August 11, 2026  – States across the country have made significant progress in helping older adults and people with disabilities remain in their homes instead of entering institutional care, but new research suggests continued investment will be needed to protect those gains.

A new analysis from NORC at the University of Chicago found that home- and community-based services (HCBS) now serve the vast majority of Medicaid beneficiaries who receive long-term services and supports (LTSS). According to the report, approximately 8.4 million of the nation’s 9.7 million Medicaid LTSS users received care through home- and community-based programs in 2023.

The findings highlight a dramatic shift in Medicaid over the past four decades. In 1981, HCBS represented just 1% of Medicaid long-term care spending. By 2023, that share had grown to nearly 64%, reflecting ongoing efforts by states to provide care in community settings that many beneficiaries prefer.

Much of that growth has been driven by Medicaid Section 1915(c) waiver programs, which allow states to offer services such as personal care, home health aides, adult day programs, caregiver support, home modifications, and assistive technology as alternatives to nursing home placement.

Researchers reviewed 262 active HCBS waivers across 46 states and the District of Columbia and found that nearly every state has developed programs tailored to the unique needs of different populations, including older adults, individuals with physical disabilities, traumatic brain injuries, autism, HIV/AIDS, and intellectual or developmental disabilities.

While core home-based services are widely available, the report found considerable variation in specialized supports. Services such as employment assistance, skill development, and community integration are more commonly offered through waivers serving individuals with intellectual and developmental disabilities.

Despite the expansion of home-based care, access remains uneven. Approximately 600,000 people nationwide remain on HCBS waiting lists, largely because of enrollment caps and ongoing shortages in the direct care workforce. Rural communities continue to face some of the greatest challenges in accessing home-based services due to limited provider availability.

The report also highlights innovative approaches adopted by several states to strengthen home care programs.

To preserve access to home-based care, the researchers recommend that states strengthen provider networks, invest in workforce recruitment and retention, expand supports for family caregivers, and consider incorporating more HCBS services directly into their Medicaid state plans rather than relying exclusively on waiver programs.

The report concludes that continued collaboration between states and the federal government will be critical to ensuring older adults and individuals with disabilities can continue receiving the care they need safely in their homes and communities.