More than 15,500 skilled nursing facilities (SNFs) provide care to more than 1.35 million people in the United States who need assistance with their Activities of Daily Living (ADLs), including going to the toilet, getting out of bed, getting dressed, feeding themselves, and showering, or who have cognitive difficulties, such as from dementia. Nationally, SNF use has declined as people live longer and choose home and community-based services (HCBS) over institutional care. From 2004 to 2014, the percentage of people age 65 and older in nursing homes dropped from 3.6% to 2.5%, a decrease of 24.5%. In addition, the number of people age 65 and older in nursing homes decreased 11.7% during the same time period, from 1.32 million to 1.16 million. By comparison, the number of nursing facility beds has only decreased 3.9% during the same time period. This disparity leads to overbedding, which, as I explain below, drives up Medicaid costs unnecessarily.