Nursing home care in the United States  As of 2017, approximately 1.4 million Americans live in a nursing home, two-thirds of whom rely on Medicaid to pay for their care. Residential nursing facilities receive Medicaid federal funding and approvals through a state health department. These facilities may be overseen by various types of state agency (e.g. health, mental health, or intellectual disabilities). Nursing homes have traditionally been large institutions. Smaller community versions were developed around the 1970s. Some "community living" (CL) groups advocated for a different type of care and funding, which resulted in the creation of assisted living facilities. Efforts to promote community-based Long Term Services and Supports (LTSS) are led by groups such as the Consortium of Citizens with Disabilities which represents over 200 national disability organizations. In the United States, the national social insurance program Medicare, was established by the U.S. federal government in 1965, which guaranteed access to health insurance for Americans aged 65 and older. This program prompted many new nursing homes to be set up in the following years, although private nursing homes were already being built from the 1930s as a consequence of the Great Depression and the Social Security Act of 1935. Medicaid, the Nation's poverty program, often funds programs such as nursing beds as residents may be "impoverished" to access the facility. In 1987, a report examined the nursing home problem in Wisconsin which involved 4,000 people, 80% under 65 years of age with an average of 110 patients per facility. 5% had developmental disabilities. They reported that 13 large institutions were certified as SNFs (skilled nursing facilities), that all were "absolutely inappropriate" placements for the developmental disabilities' clients (the federal GAO then reported a need to upgrade services in the homes, including day services), and the facilities resembled institutions of other types such as Willowbrook where abuses had been uncovered. Board and Care homes were the subject of exposés for lacking medical personnel at the time of the 1990s reviews. Nursing homes have been the subject of decades of efforts by states and at the national levels to reform health and residential care for "frail" elders, especially those with lower incomes in the US. Regulations have been added to assure that basic good care (i.e., humane, accepted good human standards) will take place in these facilities (e.g., personnel, education, activities and services, ancillary and professional services, advocacy and reviews). A major nursing home reform initiative occurred in 1996 when the Health Care Financing Administration studied its own facilities and reported to the US Congress on the effectiveness of its current system and certification of nursing homes.