Our Work

A Blueprint for Reforming Medicaid Long-Term Services and Supports and Creating Good Caregiving Jobs


For many Americans, everyday activities such as driving, bathing, and cooking can be incredibly difficult due to complex medical and functional needs. Long-term services and supports (LTSS) embody a range of important services to help such individuals perform these essential daily activities, and when provided in the community as home and community-based services (HCBS), LTSS can be a lifeline to help a person live safely at home and age with dignity.

The vast majority of paid LTSS are provided through the Medicaid program, limiting coverage of these important services to the lowest income individuals in the nation and typically those who have already progressed to significant frailty. Furthermore, existing Medicaid policy and financing approaches result in a bias toward institutional care, a low-paid and under-valued direct care workforce, and restricted access and eligibility for needed services. There is an opportunity now to create good jobs and prepare our nation for the growing number of older adults with complex needs.

Our Work

With support from the Robert Wood Johnson Foundation, we have identified three key short-term and longer-term policy opportunities that, if addressed together, will increase access to HCBS, reduce the institutional bias in Medicaid, and create a strong caregiving workforce. These policy opportunities were informed by our working knowledge and in-depth experience in this space, coupled with more than 20 interviews with state Medicaid agencies, former Medicaid directors, consumer advocates, health plan executives, disability experts, previous CMS and ACL leadership, and workforce specialists.

Our view

We recommend three steps legislators and regulators can take to achieve these transformative policy goals. First, we recommend providing states with better financial support, assurances and predictability. Second, we recommend modernizing long-standing Medicaid eligibility policies. And third, we emphasize the need to invest in the direct care workforce delivering HCBS. Addressing any one of these areas exclusively risks perpetuating the instability that exists in Medicaid HCBS programs. But taken together, these approaches will expand access to HCBS in a way that is sustainable and equitable.

3 shapes coming together
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Policy Blueprint Summary

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Lack of Financial Predictability Prevents States from Expanding Access to Home and Community-Based Services (HCBS)

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Medicaid Eligibility Policy Creates an Institutional Bias

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Meeting the Challenge: Attracting and Retaining the Direct Care Workforce We Need

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