While most long-term care services are paid for through public programs such as Medicaid, people with moderate to high incomes who are not eligible for them must pay for services out of their own pocket or through private insurance—at least until they spend down their savings. A new publication explores the affordability of private pay long-term care in every state and in more than 400 U.S. markets. It finds that private-pay nursing home care is not affordable for middle-income families anywhere. While less costly than nursing homes, home health care is often unaffordable for middle-income elders. The analysis, based on Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, was produced by the AARP Public Policy Institute with support from The SCAN Foundation and The Commonwealth Fund.