recommendations regarding the conceptual framework and provisional design for these two studies or for a single, comprehensive study. A planning committee was convened in July to explore the topic.

This report represents the culmination of the committee's work, which was informed through a number of processes. These involved a thorough review of the relevant literature; presentations given at an invitational workshop held by the committee that included input from consumers, leading researchers, and state officials; and the actual deliberations of the committee and a discussion of members ' expert opinions.

OVERVIEW OF HOME AND COMMUNITY-BASED LONG-TERM CARE

As detailed in Chapter 2, more than 10 million Americans of all ages currently need some type of LTC to remain in their own homes or in other community-based settings (compared with only 2 million persons in institutions such as nursing facilities or chronic care hospitals). Contrary to most stereotypes, only a little more than half of the total population of home and community-based LTC users are elderly individuals (ages 65 and older). Most of the rest (two-fifths) are working-age adults; children under age 18 represent a very small segment of the total population of these LTC users.

Estimates of the number of residential care settings vary a great deal—from 18,000 to more than 65,000 settings serving 1 million residents, depending on the way in which such settings are defined. Several recent studies have found serious levels of disability among residents and suggest that the population is aging and experiencing profound levels of chronic disease, functional impairment, cognitive impairment, and chronic mental illness. Again, however, this varies according to the definition being used.

Each year, billions of dollars are paid for LTC through a variety of funding sources. Along with substantial contributions from the recipients themselves and their families, more than 100 federal programs provide support of some sort for LTC. Several major government programs finance the majority of such care, however, including Medicare, Medicaid, OAA programs, Social Services Block Grants, the Supplemental Security Income and Social Security Disability Insurance programs, and a variety of state programs that are funded through individual states' general revenues.

In recent years, several changes have been proposed for financing LTC. As this report is being written, Congress is considering major legislation to reform both the Medicaid and the Medicare programs. Changes to the Medicaid program include block granting the program to the states, allowing eligibility to be defined and determined by the individual states, and increasing the use of managed care. Medicare proposals also call for increasing the use of managed



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