Nursing home care has been described as the most troubled and troublesome segment of the American health care system. Despite the annual expenditure of billions of dollars, extensive regulation, and the emergence of an increasingly sophisticated and concentrated industry, significant problems persist. Inadequate quality of care continues to be a serious and pervasive problem. Discrimination against patients whose care is paid for by Medicaid and Medicare, as well as against those with “heavy care” or extensive needs, is rampant. Costs have escalated at a phenomenal rate and continue to represent a substantial fiscal burden, causing one state Medicaid director to refer to nursing home payments as “the black hole of state budgets.”

These circumstances are neither new nor surprising. They are, in fact, the result of rather startling failures in the public sector that are rooted in the special nature of the politics of long-term care. This article discusses the history of public policy toward nursing homes and the politics of long-term care, emphasizing problems in assuring acceptable quality of care. It also addresses the possibilities for reform during the next two years, particularly in light of new patient advocate and nursing home reform coalitions that promise to change the face of long-term care politics.