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How Western States Are Expanding Home Care

As her father’s health began to decline three years ago, Dana Ward decided she would care for him herself with the assistance of a California home-care program that trains family members how to care for loved ones and pays them an hourly wage to do so.

She didn’t want to put Barry S. Ward Sr. in a nursing home, where he’d have to get used to caregivers — and those caregivers would have to cope with his dementia and Parkinson’s disease, says Ward, 34, of Petaluma, California. She wanted to help keep her father, now 72, safe. And she hoped to get closer to him. “I wanted to build a better relationship with my father than I had in my youth,” she says.

She completed the In-Home Supportive Services mandated orientation as well as a background check. She began to change her father’s diapers, to pick him up when he fell and to take him to doctor’s appointments. She responded to his calls for help in the night.

For all that, she was paid $15 an hour. “It should pay more,” Ward says. “It’s a real job.”

Ward was able to tap into one of several programs that California has to support in-home and community care. It’s part of a nationwide trend — particularly prevalent in the West — for states to boost spending and programs for care in home, not institutional, settings.

That’s according to new data from AARP’s most recent Long-Term Services and Supports State Scorecard, which uses 50 spending, quality and access indicators to rank each state’s long-term care system. The Scorecard shows that for the first time since AARP began publishing the information in 2011, more than half of Medicaid’s long-term care dollars for older adults and people with physical disabilities went to home- and community-based services (HCBS) instead of nursing homes or other facilities.

“This is a big deal. We are seeing a breaking point,” says Susan Reinhard, senior vice president of AARP’s Public Policy Institute, which published the Scorecard in September.

EXPLORE: AARP Long-Term Care Scorecard

That shift to home- and community-based services comes as demand for such care has increased, fueled in part by a pandemic that took a horrific toll on nursing home residents. Polls have consistently shown that most older Americans want to age in place.

But with America’s population of older adults growing, the chasm between the demand for HCBS and access to such services is poised to widen.

“We’re going see a dramatic increase in the 80-plus and 85-plus population” as the boomer generation gets older, says Robert Applebaum, a senior research scholar at Miami University’s Scripps Gerontology Center in Ohio. “So the demand for long-term services ... is going to be tremendous.”

Western states rank high

Three Western states — California, Washington and Oregon — were among the highest in the nation in providing state support for HCBS. The Scorecard also grouped states according to their overall performance levels; Washington was one of five states in the top group.

Graphic by Nicolas Rapp

In Washington, 76 percent of Medicaid long-term care spending goes to HCBS, the second-highest rate in the nation. Cathy MacCaul, advocacy director for AARP Washington, says the state Legislature worked with the Department of Social and Health Services to make that happen. Only 12 percent of home-health patients end up with a hospital admission — the lowest rate in the country.

What’s lacking in Washington: access to adult day care services; the state ranks 48th nationally on that measure.

California has also taken steps to widen care options. In 2021, the state released its Master Plan for Aging, which prioritized aging-at-home options and higher wages for caregivers. In addition, the state will eliminate asset limits for receiving Medi-Cal — the state’s Medicaid program — on Jan. 1, 2024. A bill to raise the minimum wage for health care workers to $25 an hour was signed by Gov. Gavin Newsom (D) in October. On the AARP Scorecard, California ranks first in the nation in the percentage of Medicaid’s long-term care spending going toward HCBS — 83.2 percent. But the Golden State faces the same challenge as others: finding and compensating a long-term care workforce. It ranks 48th on worker wage competitiveness.


“We’re shy hundreds of thousands of workers,” says Nina Weiler-Harwell, associate director of advocacy and community engagement for AARP California. She’s heard of direct-care workers leaving the health care sector for jobs at In-N-Out Burger because they pay better and are less stressful.

The challenge is also acute in Alaska, which has 20 nursing homes statewide and a strong need for at-home and community care. “It’s obviously a very vast geography, and so it’s even more imperative that we’re successful in helping people age at home,” says Marge Stoneking, associate state director of advocacy for AARP Alaska; AARP would like to see more robust self-directed care options.

Competition for workers intense

In Hawai‘i, the health care system competes with tourism for certain employees, such as home health aides. And housing costs are the highest in the nation. Hawai‘i did rank first in the nation in safety and quality of care in all long-term care settings, including nursing homes, according to the Scorecard. The state-funded Kupuna Care program for older adults pays for community-based services for those who can’t afford private care but make too much to qualify for Medicaid.

“Our families really want to keep their loved ones at home,” says Audrey Suga-Nakagawa, advocacy director for AARP Hawai‘i. “But they can’t do it without some help.”

Wannette Gaylord, who operates five community facilities in Hawai‘i, says staffing is the number one problem. “Once I fill one position, the hotels steal another employee and I have to fill another,” she says. “Hotels can give higher pay and they can give full benefits.”

In California, Ward doesn’t regret the three years spent caring for her dad, who has gone to a short-term facility. Though she wishes the compensation had been better, more than a paycheck was at stake.

“Work doesn’t stop if you’re supporting a loved one,” she says. “There’s no clocking in and clocking out.”

Barbara Kingsley-Wilson, based in Long Beach, California, has reported for publications in California, Ohio and New York, and for AARP since 2020.

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