The number of Medicaid home care recipients has grown significantly faster than the supply of providers available to serve them — a widening gap now threatening access to care for millions of Americans, according to a new national report.
The National Alliance for Care at Home and the Research Institute for Home Care released the findings Monday in their inaugural 2026 Medicaid Home Care Chartbook, the first comprehensive analysis of the Medicaid Home and Community-Based Services (HCBS) user population, workforce trends, organizational changes, and economic contributions of home care providers across the United States.
The report’s central finding: the ratio of HCBS participants to providers climbed from 59-to-1 in 2019 to 65.65-to-1 in 2023 — an 11.3% increase in just four years. More people need home care services. Fewer providers exist to deliver them.
Among Medicaid enrollees, older adults represent 10.5% of those receiving HCBS home care, while individuals with disabilities account for 12.3%. Personal care services — which include assistance with bathing, dressing, and activities of daily living — make up 62.7% of all Medicaid HCBS home care claims, the largest single category by volume.
Federal Policy Changes Could Deepen the Shortfall
The chartbook arrives as federal legislation is poised to reshape who qualifies for Medicaid home care. The report projects that eligibility changes under the One Big Beautiful Bill Act — signed into law on July 4, 2025 — could result in an estimated 311,879 fewer individuals qualifying for Medicaid home care coverage by 2034.
The Congressional Budget Office has separately estimated that the law’s health provisions could result in 11.8 million people losing health coverage overall by 2034. Home care advocates say the specific impact on HCBS participants could hit communities that are already underserved especially hard.
The chartbook is the first resource of its kind designed to give policymakers, researchers, and advocates a baseline data set to track how the Medicaid home care system evolves over time — and where it faces pressure.
A Workforce Already Under Strain
The provider shortage documented in the chartbook reflects deeper workforce pressures that have built steadily for years.
Approximately 800,000 older Americans are already on waiting lists for subsidized home care because there are not enough workers to serve them, according to the Home Care Association of America. An estimated 59% of home care agencies report operating with insufficient staffing, and one in four individuals who need home care are turned away.
Worker retention remains a persistent challenge. The sector’s turnover rate stands at nearly 80%, and data suggest roughly 70% of newly hired caregivers leave within their first 100 days. Federal labor projections estimate more than 6.1 million home care job openings between 2024 and 2034 — the second-largest projected opening category among all U.S. occupations.
Harvard T.H. Chan School of Public Health projects that 4.6 million home care positions could go unfulfilled by 2032 if current recruitment and retention trends continue.
A March 2026 report from the Medicaid and CHIP Payment and Access Commission reinforced the connection between pay and provider capacity. MACPAC concluded that “HCBS workforce shortages reduce Medicaid’s ability to serve people with long-term care needs in the home or community” and recommended that the federal government require states to report hourly wages paid to HCBS workers — a step it said would help states set effective payment rates to attract and keep direct care staff.
Beginning in 2026, states are required under a 2024 CMS rule to publish average hourly fee-for-service HCBS rates for key service categories including home health aide, personal care, and homemaker services.
What the Chartbook Covers
The 2026 Medicaid Home Care Chartbook examines HCBS data at both the state and national level, covering user demographics, provider organizational trends, and the economic footprint of Medicaid home care across the country. The Alliance and the Research Institute for Home Care describe it as the first report of its kind to consolidate this data into a single accessible resource.
The chartbook is intended to serve as a recurring reference point for tracking the trajectory of the Medicaid home care system as enrollment demographics, federal policy, and workforce conditions continue to shift.
Why This Matters for Home Care
As the gap between home care recipients and available providers continues to grow, more families are taking on direct care responsibilities at home — often without adequate professional support. For those caring for aging or seriously ill loved ones, having the right equipment in place becomes essential: SonderCare home hospital beds are designed to support both the person receiving care and the family caregiver managing it.
