Care of the elderly is the poor, neglected stepchild in the debate over health reform. Although Americans are living longer than ever and studies show that two out of every three Americans who reach the age of 65 will need long-term care services or support, Congress is showing little inclination to consider the needs of a rapidly aging population as it grapples with the complex challenge of reining in health care costs and expanding coverage to the uninsured. Lawmakers should take a broader look at health to include ways of keeping seniors out of costly nursing homes as they age — unless the nursing home is the most appropriate option.[IMGCAP(1)]In response to consumers making clear their preference for alternatives to nursing homes, Medicare and Medicaid, in recent years, have become flexible enough to include home- and community-based long-term care options such as assisted living. Indeed, the fastest growing long-term care option in the United States is assisted living, a community-based, resident-centered option that is not a nursing home. When Congress created Medicaid and Medicare 40 years ago, nursing homes were the only viable long-term care option. Medicaid became the de facto funder of nursing homes. Today, half of the entire Medicaid budget pays for nursing home beds for the elderly. Neither Medicaid nor Medicare pay for any assisted living services except in very limited circumstances. Yet assisted living often provides exactly what frail seniors need and want, a residential setting and support in the activities of daily life, such as bathing and dressing. Lawmakers must recognize how much has changed in senior living in the last 40 years. Not only are Americans living longer — in some cases decades longer than they ever expected or planned — but they are healthier and more active. Life-saving drugs allow millions to manage chronic health conditions that may have required hospitalization or nursing home care in the 1960s. Advances in pharmacology allow seniors to remain in their own homes longer or to move into assisted living communities for the support that they need to age with grace, independence and dignity. Home care is a viable option for those who can afford it. But many seniors in need of care are restricted to their homes because of limited mobility. Seniors with limited social contact are subject to unnecessary depression and a poor and limited quality of life. Although many assisted living residents are initially reluctant to leave the family home, our experience shows that the quality of life for frail elderly residents dramatically improves after they move into an assisted living community. They eat better and flourish surrounded by new friends and supportive caregivers. Knowing mom or dad is living in a safe, nurturing, wholesome environment also provides peace of mind to family members. Sadly, the fear of institutional forms of care and ignorance about assisted living as a life-enriching alternative often intersect to immobilize frail seniors with sometimes tragic consequences. We don’t dispute the need or value of nursing homes for people who need a very high level of medical care. Studies show that the nursing home population is sicker than ever underscoring the ongoing need for skilled nursing for those who are very ill. However, normal aging is not a disease. And the elderly are not helpless children. A bedrock principle of assisted living is consumer choice. Seniors know how they want to live and what they need. The government should not be prematurely pushing 85-year-old widows into nursing homes because of some misguided paternalistic notion that it knows what is best for frail elderly seniors. Assisted living providers do not want to become dependent on federal money, but it is very clear that consumers do need some help in planning and financing long-term care. The Assisted Living Federation of America strongly supports efforts such as Sen. Edward Kennedy’s (D-Mass.) CLASS Act, which would establish a new voluntary long-term care insurance program that would give all Americans access to an important safety net as they age.Frail seniors do have special needs and sometimes need help in the basic activities of daily life — but they don’t always need the 24/7 nursing care of institutional settings where the costs are double that of assisted living. The mix of long-term care options continues to evolve beyond the traditional nursing home because the marketplace responds to changing consumer preferences, needs and demands. We urge Congress to consider all the long-term care options and avoid stereotyping seniors as unable to make their own choices about how and where they want to live. Richard Grimes is president and CEO of the Assisted Living Federation of America.