“Within a little over two weeks he’d lost 20 pounds and went into a coma,” says Mark Kosieradzki, who was the Cole family’s attorney. Dean Cole was rushed to the hospital, says Kosieradzki, “and what was discovered was that he’d become totally dehydrated. They did get his fluid level up, but he was never, ever able to recover from it and died within the month.”

Kosieradzki says that Virginia Cole had signed a stack of papers when her husband was admitted to the nursing home. As is often the case, one of the forms was a binding agreement to go to arbitration if she ever had a claim against the facility. So instead of taking the nursing home to court, her claim for wrongful death was heard by three private arbitrators. They charge for their services.

“The arbitration bill for the judges was $60,750. That was split in half between the two parties,” says Kosieradzki.

“No one should be forced to accept denial of justice as a price for the care their loved ones deserve,” says Henry Waxman, a former congressman from California. Arbitration agreements keep the neglect and abuse of nursing home residents secret, Waxman says, because the cases aren’t tried in open court and resolutions sometimes have gag rules.

“None of the systemic health and safety problems that cause the harm will ever see the light of day,” he says.

The would require nursing homes to explain these arbitration agreements so that residents or their families understand what they’re signing. It would also make sure that agreeing to arbitration is not a requirement for nursing home admission.

, which represents most nursing homes, is against this proposed change in the rules. Clifton Porter II, the AHCA’s senior vice president for government relations, says that’s because “they’re prescribing us to do things that we, frankly, already do.” Porter acknowledges, however, that practices vary from facility to facility, depending on state law.

Arbitration agreements, he says, are common throughout the health care industry — in hospitals, surgery centers and doctors’ offices. “Why aren’t rules being promulgated to eliminate arbitration in those settings?” he asks.

In any case, Porter says arbitration is more efficient for both sides than going to court would be.

“It actually allows consumers to get an expedited award,” he says. “And you have the benefit of not having to use the courts and go through the entire process.”

But that expedited award is about 35 percent lower than if the plaintiff had gone to court. That’s one conclusion of a commissioned by Porter’s organization in 2009.

If the federal government does regulate or ban the signing of arbitration agreements for new nursing home residents, Porter says the American Health Care Association will probably fight the move in court.

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In just 12 years, the oldest members of the huge baby-boom generation will turn 80. Many will need some kind of long-term care. A new study from says that care could vary dramatically in cost and quality depending on where they live.

The was motivated by a simple fact: The number of available is declining. In 2010, there were potentially seven for each person 80 years old or older. By the time baby boomers reach that age, there will be only four potential caregivers for each of them. And those numbers are expected to continue declining. Chalk it up to longer lives and smaller families.

, a senior vice president at AARP, says the study can show states where they need to improve. “The gradual pace of improvement has to pick up,” she says. “We don’t have the time to get ready for the demographic imperative that is before us.”

The study looked at 26 different variables in each state, from affordability and access to whether care is delivered in private homes or more expensive nursing homes. Reinhard says states that encouraged more care at home got higher marks. “It’s a philosophy, it’s a value that states have and they work hard to make that happen,” she says.

AARP calls its study a . So, if you’re keeping score, the state with the highest marks was Minnesota, followed by Washington, Oregon, Colorado and Alaska. Bringing up the rear were Indiana, Tennessee, Mississippi and Alabama, with Kentucky coming in last.

Nevertheless, Reinhard says that all the states improved in some ways from the previous study in 2011. For example, it’s become increasingly common for family members to perform some medical tasks like giving injections or treating wounds. But in the past couple of years, 13 states have also allowed nurses to train paid caregivers to perform such tasks in the home. That means that “the family caregiver doesn’t have to run home from work and do it,” says Reinhard.

While the states are the generators of public policy related to long-term care, there’s also a role for the federal government, says . He’s CEO of the SCAN Foundation, one of the co-sponsors of the study, and was also recently chair of the Federal Commission on Long-Term Care. (Note: SCAN helps fund KHN’s coverage of aging and long-term care issues.)

It would be good to have national standards for training workers, Chernof says. “We can help make sure that that training is good and adequate. In California, for example, you need more training to be a cosmetologist to cut hair than you need to be a home care worker.”

The costs of care — whether at home or in a nursing home — varied widely across the states. But there wasn’t one where care was affordable for most middle-class families. The study found that home care services on average would consume 84 percent of the income of a typical older middle-income family. For nursing home care, it was 246 percent of income.

That’s why the study gave high grades to states that had adopted measures to improve the circumstances of family caregivers. Because with the high costs of long-term care, older adults will continue to rely on family caregivers, even as their numbers dwindle.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).