The affordability of private pay services is an important component of long-term services and supports system performance. This Insight on the Issues presents data on private pay affordability for every state and more than 400 markets in the United States. There is wide variation in affordability between states and markets. Private pay nursing home care is not affordable for middle-income families anywhere. While less costly than nursing homes, home health care is still unaffordable for middle-income older people at typical levels of use.