Long-Term Care at Home

Home health care worker helping older woman.
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Experts discuss how to improve home and community-based services.

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The majority of older Americans want to stay in their homes as they age. Why then do so many face barriers to receiving long-term care at home?

Home and community-based services (HCBS) encompass a wide array of medical and social services, such as home health aides, meal deliveries, and transportation services. By allowing people to remain in their homes and communities, HCBS provide an important alternative to nursing home care. HCBS programs are especially vital in light of the Supreme Court’s Olmstead v. L.C. decision, which held that unnecessary institutionalization of people with disabilities constitutes illegal discrimination.

But Medicaid—the largest single payer of long-term care in the United States—has a structural bias toward institutional care. Although Medicaid requires states to cover nursing home care, HCBS coverage remains largely optional. States that wish to cover HCBS can do so by requesting a waiver of Medicaid’s rules on long-term care or by amending their state plans. States are permitted to limit the scope of these benefits and restrict their availability to only certain subsets of the Medicaid population.

All states, however, offer some form of HCBS to at least some individuals, and the programs are growing increasingly popular. In fact, the majority of long-term care spending under Medicaid now goes toward HCBS rather than institutional care. Still, demand outpaces supply. As of 2020, over 600,000 individuals were on waiting lists for HCBS in their state. Demand rose even more sharply during the pandemic, as individuals in nursing homes sought to transition to home care.

The U.S. Congress attempted to alleviate some of the strain on HCBS programs through the American Rescue Plan Act, which temporarily increased federal funding for Medicaid HCBS by 10 percent. But more substantial investment remains elusive, as the Biden Administration has yet to deliver on its proposal to increase HCBS spending by $400 billion.

In this week’s Saturday Seminar, we feature the work of scholars who discuss the regulatory landscape of HCBS.

The Saturday Seminar is a weekly feature that aims to put into written form the kind of content that would be conveyed in a live seminar involving regulatory experts. Each week, The Regulatory Review publishes a brief overview of a selected regulatory topic and then distills recent research and scholarly writing on that topic.