Health Insurance
Arizona Is Best State for Long-Term Care in Nursing Homes and Assisted Living Facilities — Here’s How Other States Stack Up
Three years into the COVID-19 pandemic, staffing shortages continue to affect medical care facilities around the U.S., and long-term care is no exception.
ValuePenguin health care expert Robin Townsend says this and other factors are putting the quality of long-term care at risk.
"When staff is spread thin, they’re less equipped to meet a facility’s standard level of care," Townsend says. "Meanwhile, the cost of care will likely increase as the overall cost of living rises."
Despite this, some states provide better long-term care than others. According to the latest ValuePenguin study — which analyzes data from the Centers for Medicare & Medicaid Services (CMS), U.S. Bureau of Labor Statistics (BLS), U.S. Census Bureau County Business Patterns and more to assess cost, accessibility and quality of care in each state — Arizona ranks highest for long-term care.
- Key findings
- Arizona ranks highest for long-term care
- The District of Columbia is the worst state for long-term care, despite providing high-quality care
- Most states provide less than 4 nurse staffing hours per resident daily
- Long-term care is most expensive in Alaska, District of Columbia
- Top expert tips to determine the right long-term care option
- Methodology
Key findings
- Arizona is the best state for long-term care. ValuePenguin researchers used three overall metrics — cost, access to care and quality of care at each state’s nursing homes and assisted living facilities — with Arizona coming out on top. Idaho and Missouri rank second and third.
- The District of Columbia is the worst state for long-term care, even though it ranks among the highest for quality of care. The District of Columbia has a lower density of long-term care facilities and medical professionals than most states, and it’s among the most expensive states for long-term health care. However, those who can overcome these cost and access issues do well, as D.C. ranks in the top five in three of four quality-of-care metrics. Wyoming and New Hampshire are the second and third lowest-ranking states, respectively.
- Just 16 states provide four or more nurse staffing hours per resident daily. This comes amid the Biden administration’s February 2022 call to establish a minimum nursing home staffing requirement. According to a 2001 report to Congress that's still widely shared, the CMS recommended to Congress a minimum standard of 4.1 hours of nurse staffing hours per resident daily.
- In Alaska, a shared room at a nursing home costs an average of $378,140 annually or $1,036 a day — highest in the nation. Additionally, assisted living facilities in the state cost an average of $81,690 annually, second-highest in the U.S. And home health care aide workers make an average of $34,900 — fourth-highest in the nation.
- On the other hand, Texas and Missouri are the most affordable states for nursing homes and assisted living facilities, respectively. The annual average cost of a nursing home in Texas is $61,503. Meanwhile, Missouri ranks highest for assisted living facility affordability, with facilities in the state costing an average of $36,000 annually.
How did we rank long-term care?
ValuePenguin researchers used three overall metrics to rank long-term care in each state: cost, access and quality. Within each metric, researchers looked at the following:
- Cost of care: Average annual nursing home costs for a shared room, average annual assisted living facility costs and average wages among home health care aides
- Access to care: Density of home health care aides, medical professionals, nursing homes and assisted living facilities
- Quality of care: Average Quality of Patient Care Star Rating, nursing staff hours per resident daily, number of outpatient emergency department visits per 1,000 long-stay resident days and the percentage of long-stay residents whose need for help with daily activities has increased since admittance
To calculate the density-based figures, ValuePenguin researchers compared in-state to national figures. To determine the density of home health care aides, for example, we divided the rate of home health care aides in a given state by the rate of aides nationally.
The 11 metrics were evenly weighted to create a final score.
Arizona ranks highest for long-term care
Arizona tops the list for long-term care, with quality and cost playing key roles. Particularly, the state ranks eighth for nursing home costs and 16th for assisted living costs.
Arizona is also in the top 10 for several quality metrics, including its high average Quality of Patient Care Star Rating, a CMS rating system that measures Medicare claims and assessment data from home health agencies, and its low percentage of long-stay residents with an increased need for help with daily activities since admittance. The state also ranks among the top five for its density of assisted living facilities at 5.0. In other words, the rate of assisted living facilities in Arizona is five times the national rate.
Meanwhile, it’s 30th for average home health care aide wages, meaning the average aide salary is higher than most states. That ultimately leads to higher health care costs overall.
Cost of care in the best states for long-term care
Rank | State | Average annual nursing home costs | Average annual assisted living facility costs | Average wages for home health care aides |
|---|---|---|---|---|
| 1 | Arizona | $78,475 | $48,000 | $29,440 |
| 2 | Idaho | $102,200 | $46,050 | $27,130 |
| 3 | Missouri | $63,145 | $36,000 | $25,520 |
Source: ValuePenguin analysis of American Council on Aging, SeniorLiving.org and U.S. Bureau of Labor Statistics (BLS) data
While Idaho ranks second overall, Missouri — the third-best state for long-term health care — ranks higher across the three cost metrics. In fact, Missouri has the most affordable nursing homes and assisted living facilities among the top three. Residents here pay an annual average of $63,145 for nursing homes and $36,000 annually for assisted living facilities.
Missouri also ranks higher than Idaho in all but one accessibility metric. Notably, the density of nursing homes in Missouri is 3.52, while the density in Idaho is just 1.77.
Accessibility of care in the best states for long-term care
Rank | State | Density of home health care aides | Density of medical professionals | Density of nursing homes | Density of assisted living facilities |
|---|---|---|---|---|---|
| 1 | Arizona | 0.97 | 0.97 | 1.65 | 5.05 |
| 2 | Idaho | 0.97 | 0.95 | 1.77 | 3.95 |
| 3 | Missouri | 1.09 | 1.09 | 3.52 | 2.51 |
Source: ValuePenguin analysis of BLS and U.S. Census Bureau County Business Patterns data
However, Idaho ranks above Missouri across all quality care metrics. Notably, health care facilities in Idaho provide the highest number of nursing staff hours per resident daily among the top three states at 4.41, compared with 4.04 in Arizona and 3.25 in Missouri. Missouri also has a higher percentage of long-stay residents whose need for help with daily activities has increased since admittance, and a higher number of outpatient emergency department visits per 1,000 long-stay resident days.
Quality of care in the best states for long-term care
Rank | State | Average Quality of Patient Care Star Rating | Nursing staff hours per resident daily | Number of outpatient emergency department visits per 1,000 long-stay resident days | Percentage of long-stay residents whose need for help with daily activities has increased |
|---|---|---|---|---|---|
| 1 | Arizona | 3.5 | 4.04 | 0.78 | 12.77% |
| 2 | Idaho | 3.5 | 4.41 | 0.83 | 13.46% |
| 3 | Missouri | 3 | 3.25 | 1.02 | 14.77% |
Source: ValuePenguin analysis of Centers for Medicaid & Medicare Services (CMS) data
The District of Columbia is the worst state for long-term care, despite providing high-quality care
At the other end of the spectrum, the District of Columbia is the worst state for long-term care. Particularly, it consistently ranks lowest for affordability. Assisted living facilities cost an average of $83,730 a year — the highest of any state. Meanwhile, nursing homes here cost an average of $125,925 a year, placing it among the 20 most expensive.
Access to care in the District of Columbia is also difficult. Though the District of Columbia’s density of home health care aides is comparable to other states, it ranks lowest for its density of medical professionals. It also ranks second-lowest for its density of nursing homes and assisted living facilities.
Still, those who do end up in the District of Columbia’s long-term care facilities will fare well compared to those in other states — the District of Columbia has top-five rankings for all but one quality-of-care metric. The state has the lowest rate of outpatient emergency department visits at 0.35 per 1,000 long-stay resident days. Long-term care facilities provide an average of 4.77 nursing staffing hours per resident daily — the second-highest in the nation.
Take a look at how the District of Columbia’s quality metrics stack up against the other two lowest-ranking states:
Quality of care in the worst states for long-term care
Ranking | State | Average Quality of Patient Care Star Rating | Nursing staff hours per resident daily | Number of outpatient emergency department visits per 1,000 long-stay resident days | Percentage of long-stay residents whose need for help with daily activities has increased |
|---|---|---|---|---|---|
| 1 | District of Columbia | 3.5 | 4.77 | 0.35 | 17.05% |
| 2 | Wyoming | 3.0 | 3.72 | 1.15 | 15.53% |
| 3 | New Hampshire | 3.0 | 3.81 | 0.87 | 19.68% |
Source: ValuePenguin analysis of CMS data
However, the District of Columbia is among the states with the highest percentage of long-stay residents whose need for help with daily activities has increased. Overall, 17.05% of the District of Columbia’s long-stay residents need additional help with daily activities, placing it 1.82 percentage points higher than the average across the 50 states and D.C.
The disparity between the state’s low affordability and accessibility of care compared to the high quality of care may boil down to a few demographic factors. District of Columbia residents have a median annual income of $90,842 — well above the national median of $64,994. Additionally, just 0.30% of residents in the District of Columbia were in a nursing facility in 2020, putting it among the states with the lowest percentage of residents in nursing facilities.
Following the District of Columbia, Wyoming ranks second-worst for long-term care. While long-term care in the state is generally affordable — with nursing homes costing an average of $83,950 annually and assisted living facilities costing an average of $50,025 annually — it ranks among the lowest states for access to care. As far as quality of care goes, it ranks among the bottom 10 states for its high rate of outpatient emergency department visits.
Cost of care in the worst states for long-term care
Rank | State | Average annual nursing home costs | Average annual assisted living facility costs | Average wages for home health care aides |
|---|---|---|---|---|
| 1 | District of Columbia | $125,925 | $83,730 | $32,900 |
| 2 | Wyoming | $83,950 | $50,025 | $30,350 |
| 3 | New Hampshire | $131,400 | $72,630 | $30,690 |
Source: ValuePenguin analysis of American Council on Aging, SeniorLiving.org and BLS data
New Hampshire, the third-worst state for long-term care, consistently ranks lowest among most cost, access and quality-of-care metrics. The state ranks in the top 20 for just one metric — density of nursing homes (2.53). That generally aligns with the state’s percentage of residents in a nursing home, too. Of the state’s residents, 0.46% were in a nursing facility in 2020, 22nd overall.
Accessibility of care in the worst states for long-term care
Rank | State | Density of home health care aides | Density of medical professionals | Density of nursing homes | Density of assisted living facilities |
|---|---|---|---|---|---|
| 1 | District of Columbia | 0.69 | 0.69 | 0.75 | 0.71 |
| 2 | Wyoming | 0.56 | 0.89 | 1.06 | 1.65 |
| 3 | New Hampshire | 0.53 | 0.99 | 2.53 | 2.35 |
Source: ValuePenguin analysis of BLS and U.S. Census Bureau County Business Patterns data
Most states provide less than 4 nurse staffing hours per resident daily
Long-term care facilities in Alaska provide the most nursing staff hours per resident daily at 7.76. None of the remaining top-ranking states come close to providing similar staffing hours. Facilities in the District of Columbia, where nurse staffing hours are second-highest, provide 4.77 nursing staffing hours per resident daily.
States that provide the most nursing staff hours per resident daily
Rank | State | Nursing staff hours per resident daily |
|---|---|---|
| 1 | Alaska | 7.76 |
| 2 | District of Columbia | 4.77 |
| 3 | Oregon | 4.76 |
| 4 | Hawaii | 4.73 |
| 5 | Idaho | 4.41 |
| 6 | Delaware | 4.40 |
| 7 | Maine | 4.36 |
| 8 | North Dakota | 4.34 |
| 9 | California | 4.27 |
| 10 | Minnesota | 4.20 |
| 11 | Washington | 4.19 |
| 12 | Florida | 4.15 |
Source: ValuePenguin analysis of CMS data
Overall, just 16 states provide four or more hours of nurse staffing time per resident daily. With new potential for federal intervention, however, the remaining states may soon need to provide additional staffing. The Biden administration announced plans in February 2022 to make long-term care reforms, which include establishing a minimum nursing home staffing requirement. The last report on nurse staffing hours issued for Congress — which the CMS conducted in 2001 — recommended a minimum standard of 4.1 nursing staff hours per resident daily.
Townsend says this move is likely to positively impact long-term patient care.
"Quality of care should be high on the list of nursing home priorities," Townsend says. "While increasing the staffing time per resident would mean higher operating costs, the investment should result in better patient outcomes. Improving the staff-to-patient ratio is also good for the facility, as it helps to reduce worker burnout and decrease turnover."
Many states already have nurse staffing requirements, though most don’t come close to meeting the minimum standard set by the CMS. Of the 36 states with staffing requirements, just seven require at least 3.5 nursing staff hours per resident daily. Here’s a breakdown of the staffing requirements by state:
- 4.10 hours or more: District of Columbia
- 3.50 to 4.09 hours: California, Florida, Illinois, Massachusetts, New York and Rhode Island
- 3.00 to 3.49 hours: Arkansas, Connecticut, Delaware, Maryland, Vermont and Washington state
- 2.50 to 2.99 hours: Maine, Mississippi, New Jersey, New Mexico, Ohio, Oklahoma, Pennsylvania and Wisconsin
- 2.00 to 2.49 hours: Colorado, Georgia, Idaho, Iowa, Kansas, Louisiana, Michigan, Minnesota, Oregon, South Carolina, Tennessee, West Virginia and Wyoming
- 1.50 to 1.99 hours: Montana
- Less than 1 hour: Arizona
Staffing shortages from the COVID-19 pandemic provide an additional challenge to long-term care facilities, according to data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Of the nursing facilities that report data to the NHSN, 26% experienced health care aide shortages from mid-May 2020 through March 20, 2022, while 24% experienced nursing staff shortages in the same period.
Long-term care is most expensive in Alaska, District of Columbia
Likely due in part to staffing shortages and minimum staffing hour requirements, some states have particularly high long-term care costs. Notably, Alaska tops the list with the most costly nursing homes at an average of $378,140 annually or $1,036 daily. Additionally, assisted living facilities cost an average of $81,690 annually, second-highest after the District of Columbia.
The state’s aforementioned nursing staff hours per resident daily likely play a role in these high costs. That can also be coupled with the average health care aide wages in the state. Home health care aide workers make an average of $34,900 annually in Alaska — fourth-highest in the nation. Consequently, Alaska has the lowest percentage of residents in a nursing facility at just 0.08%. With the median household income in Alaska at just $77,790 annually, residents likely can’t afford long-term health care.
The states where long-term care is most expensive generally rank highest among health care aide wages. Connecticut ranks second-highest for nursing home costs at $165,162 annually. Meanwhile, home health care aide workers here make an average of $32,770 annually — the eighth-highest in the U.S. In New York, where nursing homes cost $153,300 annually, home health care aide salaries are sixth-highest at $33,520 annually.
States with the highest average annual nursing home costs
Rank | State | Average annual nursing home costs | Average wages for home health care aides |
|---|---|---|---|
| 1 | Alaska | $378,140 | $34,900 |
| 2 | Connecticut | $165,163 | $32,770 |
| 3 | New York | $153,300 | $33,520 |
Source: ValuePenguin analysis of American Council on Aging and BLS data
As far as assisted living facility costs go, the aforementioned District of Columbia ranks highest at an average of $83,730 annually. After the District of Columbia and Alaska, Rhode Island comes in third at $81,915 annually. Meanwhile, home health care aides make an average of $30,920 annually — 14th-highest in the U.S.
States with the highest average annual assisted living facility costs
Rank | State | Average annual assisted living facility costs | Wages for home health care aides |
|---|---|---|---|
| 1 | District of Columbia | $83,730 | $32,900 |
| 2 | Alaska | $81,960 | $34,900 |
| 3 | Rhode Island | $81,915 | $30,920 |
Source: ValuePenguin analysis of SeniorLiving.org and BLS data
Meanwhile, in Washington state, where health care aide wages are highest ($36,120), assisted living facilities cost an average of $72,000 annually and nursing homes cost an average of $113,150 annually. That ranks it among the top 10 (assisted living costs) and 20 (nursing home costs) most expensive states for long-term care, respectively.
Texas, Missouri leads for most affordable long-term care
Among the states with the most affordable long-term care, nursing homes in Texas cost the least at $61,503, or $169 a day for a shared room. Consequently, the wages for home health care aides in Texas are among the lowest at $22,620 annually.
Following Texas, nursing homes in Missouri cost an average of $63,145, or $173 a day for a shared room — making it the second most affordable state for nursing homes. Meanwhile, home health care aides in the state make an average of $25,520 annually, or 16th nationally. In Oklahoma, where nursing homes cost an average of $65,700 annually, or $180 a day for a shared room, home health care aides make $23,040 annually — sixth-lowest.
States with the lowest average annual nursing home costs
Rank | State | Average annual nursing home costs | Wages for home health care aides |
|---|---|---|---|
| 1 | Texas | $61,503 | $22,620 |
| 2 | Missouri | $63,145 | $25,520 |
| 3 | Oklahoma | $65,700 | $23,040 |
Source: ValuePenguin analysis of American Council on Aging and BLS data
Though Missouri ranks second for nursing home affordability, it ranks highest for assisted living facility affordability, costing an average of $36,000 annually. Following that, the Dakotas have the most affordable assisted living facilities. Assisted living facilities cost an average of $40,200 in South Dakota and $40,695 in North Dakota. Meanwhile, home health care aides make $28,900 in South Dakota, 27th-lowest. However, these workers make $34,150 in North Dakota — ranking it among the states with the highest home health care aide wages.
States with the lowest annual assisted living costs
Rank | State | Average annual assisted living facility costs | Wages for home health care aides |
|---|---|---|---|
| 1 | Missouri | $36,000 | $25,520 |
| 2 | South Dakota | $40,200 | $28,900 |
| 3 | North Dakota | $40,695 | $34,150 |
Source: ValuePenguin analysis of SeniorLiving.org and BLS data
Top expert tips to determine the right long-term care option
If the fact that older Americans pay higher health insurance premiums isn’t bad enough, affordable long-term health care options are few and far between. According to Townsend, the high costs of inpatient facilities and home care often prevent Americans from seeking qualified medical assistance.
"Many Americans rely on unpaid help from family and friends for their care rather than pay for a nursing home," Townsend says. "Negotiating costs is an option, but the chance of getting reduced rates for nursing home care is pretty low. Medicare and most health insurance plans don’t pay for long-term care, whether it’s in an assisted living facility, a nursing home or through an in-home care agency."
Townsend says you may be able to get help with your costs through the , Medicaid, Veteran Aid or by buying a separate long-term care insurance policy. However, she cautions that long-term care plans can be expensive, and you must purchase your policy well in advance and meet medical requirements.
If you’re unsure what Medicare and Medicaid entail, check out our guide on the key differences between these federal health insurance plans.
While Townsend says consumers may be able to reduce costs by relocating to an area where nursing homes provide quality care at cheaper rates, she recommends utilizing community resources first. The U.S. Administration for Community Living (ACL) Eldercare Locator and the Medicare Nursing Home Compare tool, for example, can often help consumers understand the extent of the options available.
After narrowing down the options, Townsend says it’s a good idea to contact the facilities you’re interested in with a list of questions ready. You’ll want to ask things like:
- Is the nursing home Medicare-certified and licensed in the state where they operate?
- What is the staff-to-patient ratio?
- Does the facility have a clear policy on reporting concerns about the care and safety of residents?
Finally, ensure the facilities you consider fit your needs or the needs of your loved one. Townsend says you should consider talking to your doctor, social worker or family throughout the entire process of selecting a long-term care option.
Methodology
ValuePenguin researchers used three overall metrics — cost of care, access to care and quality of care — to rank long-term care in each state. Within these overall metrics were 11 breakdowns:
Cost of care
- Average annual nursing home costs for a shared room (American Council on Aging, 2021)
- Average annual assisted living facility costs (SeniorLiving.org, 2022)
- Average wages among home health care aides (U.S. Bureau of Labor Statistics, 2021)
Access to care
All via U.S. Bureau of Labor Statistics, 2021, and U.S. Census Bureau County Business Patterns, 2020:
- Density of home health care aides
- Density of medical professionals
- Density of nursing homes
- Density of assisted living facilities
Quality of care
All via the Centers for Medicare & Medicaid Services:
- Average Quality of Patient Care Star Rating
- Nursing staff hours per resident daily
- Number of outpatient emergency department visits per 1,000 long-stay resident days
- Percentage of long-stay residents whose need for help with daily activities has increased since admittance
The 11 individual metrics were evenly weighted to create a final score.