under OBRA 87 required substantial new resources. These staffing increases were apparently based on the amount legislators and industry leaders considered to be politically and fiscally feasible, because most of the costs for increased staffing would be reflected in increases in federal and state Medicaid budgets.

Since OBRA 87 was passed, federal legislation has been considered by selected congressional representatives for increased staffing beyond the OBRA requirements, but such legislation has not had the political support to proceed. States have the authority to increase their Medicaid payment rates as a means of increasing staffing standards, but the pressures on some states with rapidly growing Medicaid budgets make it unlikely that they will initiate increases in nursing home staffing requirements. The research reviewed has shown that low-quality facilities have a higher proportion of Medicaid residents, and Medicaid rates are usually lower than private-pay rates. Policymakers are faced with difficult choices involving trade-offs between quality and costs. Since the population of this country is aging and the oldest-old age group is increasing, and there is no cure in sight for chronic diseases such as Alzheimer's, the demand for nursing home care will not abate, even with the growth of alternative long-term care facilities. Funding mechanisms will have to be explored to ensure adequate staffing to care for residents with multiple chronic conditions and with special care or subacute care needs. It is clear that substantial improvements in the quality of nursing home care are not possible without the allocation of increased financial resources for additional and appropriately qualified staffing.

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