Nursing home care in the USA is part of the costliest health-care system in the world, and is a heavily regulated industry still struggling to maintain quality care across the country. The modern nursing home dates back to the 1930s and the passage of the Social Security Act, with continued growth of the industry after the 1960s, when the Medicare and Medicaid programs were created. As in other industrialized countries, the elderly population in the USA is growing, and the highest growth is occurring among those older than 85. This is the group with the highest health-care costs and rates of nursing home utilization. There are two major types of care provided in US nursing homes: long-term and subacute care. In the 1980s, quality of care became an important concern, which led to major reform and passage of new regulations under the law known as OBRA-87. During this time, the Minimum Data Set (MDS), which is a comprehensive assessment tool, was introduced. It continues to be a vital tool for both payment and research. Reform also ushered in the state survey process, which scrutinizes nursing homes yearly and assesses financial penalties for substandard care. The aging of the American population will provide challenges for financing nursing home care in the future. The use of private long-term care insurance is growing, and may be an important source of payment for this type of care in the decades to come.