For two decades, New Federalism, devolution, and other challenges to the federal role in domestic health and human services policy have fundamentally shaped the structure and delivery of long-term care in the United States. Devolution evokes crucial questions concerning the future of universal entitlement programs such as Social Security and Medicare and, with them, the future of aging and long-term care policy. This article examines the implications of the “devolution revolution” for long-term care in the context of the sociodemographics of aging and the managed care movement. Central issues are the extent to which state-level discretionary policy options (1) alter priorities, services, and benefits for the elderly and disabled; (2) foster a race to the bottom in long-term care; (3) promote generational, gender, racial and ethnic, and social class trade-offs; and (4) fundamentally alter the role and capacity of nonprofit sector services that comprise a significant part of the long-term care continuum.
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