HCBS Utilization Has Grown Significantly, But The Workforce Hasn’t

Workforce growth has not kept pace with the growth of utilization in home- and community-based services (HCBS), a new study found.

From 2013 to 2019, the number of home care workers per 100 HCBS participants declined by 11.6%. Preliminary estimates suggest that a decline in that ratio continued post-2020.

“When you look over time, we actually found that the number of home care workers was increasing, which we were initially a little bit surprised about,” Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, told Home Health Care News. “At the same time, the number of people who were enrolled in Medicaid and receiving home care services through the HCBS benefit was increasing at a much faster rate.”


Using data from the American Community Survey and the Henry J. Kaiser Family Foundation, Werner and her colleagues found that the home care workforce grew from about 840,000 caregivers to 1.22 million between 2008 and 2013.

After 2013, growth slowed, ultimately reaching 1.42 million workers in 2019.

From 2008 to 2020, the number of Medicaid HCBS participants steadily grew, with “accelerated growth between 2013 and 2020,” the study found.

Source: Leonard Davis Institute of Health Economics at the University of Pennsylvania

The discrepancy is significant, given the fact that HCBS are the predominant approach to long-term services and supports (LTSS) in the U.S. Medicaid, the primary payer for LTSS, has also expanded HCBS coverage.

“There appears to be an insufficient number of home care workers to keep up with the growth in this program,” Werner said.

Knowing there is no silver-bullet solution, Werner believes the conversation should at least start at compensation. That, in turn, becomes a conversation about Medicaid funding.

Source: Leonard Davis Institute of Health Economics at the University of Pennsylvania

“Many home care workers — including home health aides — are often paid at minimum wage, live below the poverty line and actually they themselves are enrolled in some social services,” Werner said. “So wages are clearly, in my view, insufficient and need to be raised for home care workers. I think it’s hard to do when you talk to home health agencies because Medicaid pays, people are reporting, at too low of a rate.”

For now, improving workplace culture, including career ladders and having routine and reliable scheduling are other recommendations proposed by Werner and her colleagues as a way to close the widening gap.

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