The Affordable Care Act and recent health care reform proposals neglected a key health policy issue – long-term services and supports (LTSS). If left unaddressed, the health care system will struggle to meet the needs of an aging population. By 2050, one-fifth of the total United States population will be 65 years or older, and approximately 15.4 million people are estimated to need LTSS. National spending on LTSS is projected to increase from 1.3 percent of gross domestic product (GDP) to 3.3 percent. States face the challenge of meeting increasing LTSS needs while undergoing fiscal pressure since Medicaid delivers the majority of LTSS.