For Home Care Providers, HCBS Operating Environments Still Vary Greatly From State To State

More than three years after the start of the COVID-19 pandemic, the U.S. is still seeing major gaps in long-term care for seniors, according to a new AARP report.

“We know that some states are taking steps to innovate or put new policies in place, such as paid leave for family caregivers, or a payroll tax credit for family caregivers, but state action is generally falling short of what the aging populations in these states need, so that people can live their final years or even decades in dignity with access to the best care possible,” Susan Reinhard, senior vice president of AARP Public Policy Institute, said during a Thursday press call.

The report found that 53% of Medicaid long-term services and support spending for seniors and adults with physical disabilities went to home- and community-based services.


Plus, 12 states spent the majority of Medicaid long-term services and support funding on home- and community-based services. This is an increase from seven states in 2009.

Family caregivers were also a big focus area of the AARP report.

“No.1 is prioritizing family caregivers — 48 million family caregivers who really are the backbone of the long-term care system,” Reinhard said. “They are providing more than $600 billion in unpaid care. They need help – paid sick leave, tax credits and other mechanisms to address the family caregivers’ health and financial needs, so that they can stay on the job, frankly.”


The report concluded that states that had policies meant to support family caregivers needed to maintain their policy framework, but also make sure that those policies were effectively implemented. It also found that states with strong family caregiver supports in place tended to have better overall long-term services and support systems.

The report also dug into the home- and community-based care infrastructure.

“It’s important to address a whole infrastructure, such as increasing support and training for home health aides for home visits, supporting the ability to access and use medical devices and equipment, and most important is updating key Medicaid regulations and payment models,” Reinhard said.

AARP found that between 2018 and 2020, 21 states improved their Medicaid spending balance by 10% or more, while 6 other states declined by at least 10% during that time period.

The report found that 23 states saw a 10% or more increase in home care costs. Inflation, growing demand and consumer preference for home care over nursing homes are some of the contributing factors to these higher costs.

Additionally, 16 states saw a 10% or more decrease in home health aide supply, while 18 states saw a 10% or more increase.

Ultimately, Reinhard stressed the importance of enhancing long-term care support and services for seniors.

“It’s really critical that we improve the aging experience for all Americans across the country,” she said. “Our ability to get this right largely depends on our ability to care for our loved ones … that requires providing both humane and holistic long-term care support and services.”

State scorecard

As part of the report, each state was ranked and placed in one of five long-term services and supports performance tiers based on factors like affordability, safety and more. The first tier are the states that are the strongest performers, and the fifth tier states are the worst.

“We can get a vivid picture of states that can be a model for improvement, as well as states that deserve far greater attention from their leaders to better support their residents in their states,” Reinhard said.

Tier 1

1. Minnesota

2. Washington

3. District of Columbia

4. Massachusetts

5. Colorado

Tier 2

6. New York

7. Oregon

8. Hawaii

9. Vermont

10. New Jersey

11. California

12. Rhode Island

13. Connecticut

14. Maryland

15. Wisconsin

16. Maine

Tier 3

17. Delaware

18. Nebraska

19. North Dakota

20. New Mexico

21. Pennsylvania

22. Arizona

23. Iowa

24. New Hampshire

25. Illinois

26. Alaska

27. Indiana

28. Virginia

29. Utah

30. Kansas

31. Michigan

32. Ohio

33. Montana

34. Texas

35. Idaho

Tier 4

36. South Dakota

37. Arkansas

38. Missouri

39. Georgia

40. Wyoming

41. North Carolina

42. Kentucky

43. Florida

44. Nevada

45. Louisiana

46. Oklahoma

Tier 5

47. Tennessee

48. Mississippi

49. South Carolina

50. Alabama

51. West Virginia

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