State policy contexts and family and friend caregiving prevalence in the United States

Abstract INTRODUCTION Family and friend caregivers without market compensation provide the majority of long‐term services and supports (LTSS) in the United States, yet caregiving patterns may vary across state policy environments. METHODS We linked the AARP LTSS State Scorecard with individual‐level data from the Behavioral Risk Factor Surveillance System Caregiver Module ( N = 203,755 adults across 36 states, 2015–2017). Survey‐weighted multinomial and logistic regression examined associations between LTSS policy percentile (per 10‐point increase; higher = more supportive) and caregiving status at both Time 1 (2015–2017) and Time 2 (2021–2023). Exploratory analyses examined LTSS policy associations with Alzheimer's disease and related dementias (ADRD) caregiving characteristics and state‐level differences. RESULTS At the population level, residing in states with a more supportive LTSS policy environment was associated with a lower relative risk of both non‐ADRD caregiving (relative risk ratio [RRR] = 0.21, 95% confidence interval [CI: 0.08, 0.57]) and ADRD caregiving (RRR = 0.17, 95% CI [0.03, 0.86]). The Time 1 LTSS policy environment was associated only with non‐ADRD caregiving prevalence at Time 2 (RRR = 0.25, 95% CI [0.08, 0.78]), not ADRD caregiving. In the exploratory analyses, LTSS policy environment was also associated with caregiving characteristics. Exploratory temporal and state‐level analyses yielded largely null findings. DISCUSSION State LTSS policy is associated with the population‐level distribution of caregiving from family and friends. Longitudinal and quasi‐experimental designs are needed to clarify causal mechanisms.