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Recently, some researchers have argued that high state rates of Centers for Medicare and Medicaid Services (CMS) Online Survey, Certification and Reporting (OSCAR) nursing facility deficiencies indicate stringent enforcement, leaving the impression of better-quality care soon to follow; others maintain that the rank ordering of states' quality of nursing facility care remains fairly constant, resting on deep-seated state characteristics that change slowly, so that short-term improvement in poor-quality care is unlikely. The authors examine change in the process and outcome quality of states' Medicare nursing facility long-term care programs across 1999 to 2005, using linear and two-stage least squares regression. They find that (1) nationally, process quality generally falls across this period while outcome quality generally increases; (2) neither a prominent enforcement stringency index nor state culture, a relatively stable state characteristic, exerts much influence on state process and outcome quality scores over time, but (3) the relative costs and benefits for CMS compliance appear to contribute to explaining change in states' quality of resident outcomes over time; and (4) states' process quality is much less stable than outcome quality, and outcome indices distinct from OSCAR deficiency data provide more reliable and possibly more valid measures of care quality. [ABSTRACT FROM AUTHOR]

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality. [ABSTRACT FROM AUTHOR]