The pandemic highlighted a number of longstanding challenges in our health and long-term care systems as they strain to meet the needs of older adults and individuals living with a disability. In 2024, states will continue in their efforts to address many of these challenges by developing and strengthening policies in four key areas:
- Supporting the workforce of professional and family caregivers
- Reducing health inequities by addressing social determinants of health
- Improving access to home and community-based services
- Improving quality and accountability in nursing homes
Caregiving: Direct Care Workforce and Family Caregivers
Many states will be looking to further reinforce and support the direct care workforce in 2024. Direct care workers — such as personal care and home care aides as well as certified nursing assistants — provide care services to individuals and older adults with complex needs. During the pandemic and with the support of federal American Rescue Plan Act (ARPA) funds, many states increased Medicaid payment rates for these workers with one-time pay increases or bonuses. A NASHP analysis shows that in 2024, at least 22 states are planning to sustain these payment increases post-pandemic. The Centers for Medicare & Medicaid Services (CMS) also issued a proposed rule in the spring of 2023 that requires at least 80 percent of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for these workers.
States are also likely to continue their work developing career pathways and additional training opportunities for direct care workers. For example, to help address the needs of the direct care workforce, Indiana has a direct service workforce plan on wages and benefits, training and pathways, and promotion and planning. The state will be working with managed care entities to ensure an adequate workforce as it rolls out its new Medicaid managed long-term services and supports (MLTSS) program in 2024.
Supporting family caregivers will also remain a priority for many states. The pandemic heightened the important role of caregivers and the need to update pre-COVID policies to increase access to services and supports. The National Strategy to Support Family Caregivers brought national attention to family caregiving and presented key policy priorities to support family caregivers. With encouragement from the U.S. Administration for Community Living, states are including actions to support family caregivers into their state plans on aging. For example, Arizona is prioritizing activities to support grandparents raising grandchildren and intends to expand its evidence-based training for caregivers and grandparents in its 2023–2026 state plan. Wisconsin’s 2023–2025 plan emphasizes coordinating caregiver support with employers and local communities, providing online training to family caregivers and caregiver support coordinators, and collecting data to track impact.
Health Disparities
COVID-19 has intensified health disparities and health inequities for certain populations, including historically marginalized groups. In its Framework for Health Equity, CMS outlines five priorities for advancing health equity throughout its policies and programs. States have responded to this call for action and are integrating principles of equity and inclusivity into their state plans on aging. Currently, five states have designed and implemented a multisector plan for aging and another 12 have plans in development. For example, California is taking a comprehensive approach to addressing heath disparities in its state plan by developing a caregiver equity roadmap, which includes strategies for managing the financial burdens of caregiving.
As reported in NASHP’s The Future of Aging Policy blog post, states are also tackling health disparities by increasingly emphasizing the importance of developing policies and approaches to address social determinants of health (SDOH). Specifically, states are using Medicaid state plan and waiver authorities to add non-clinical services such as case management, employment assistance, nutrition aid, and housing supports to Medicaid benefits. According to a recent Kaiser Family Foundation analysis of 1115 Medicaid waivers, 19 states had waivers approved and an additional 15 states had waivers pending with provisions to address SDOH.
States have taken advantage of these flexibilities in innovative ways. For example, New Jersey was recently approved to provide coverage for housing supports to individuals transitioning from institutions to community living and nutrition supports to beneficiaries receiving MLTSS.
Home and Community-Based Services
State policymakers will likely continue their efforts to advance benefit integration across Medicare and Medicaid to improve care delivery and encourage home and community-based care. In 2024, people with Medicare and Medicaid coverage (i.e., dual eligibles) will continue to enroll in integrated managed care special needs plans or D-SNPs (Dual-Eligible Special Needs Plans). Many dual eligibles are low-income older adults or people with disabilities. According to the Kaiser Family Foundation, the number of D-SNPs has doubled from 465 in 2019 to 851 in 2024.
D-SNPs offer the potential to improve access to home and community-based services by offering enhanced care coordination and additional benefits to support individuals who wish to receive care at home. Examples of additional or supplemental benefits commonly offered by D-SNPs include transportation to medical appointments, in-home meal delivery, caregiver supports, and home modifications. D-SNP care coordinators can also help individuals avoid or delay admissions to nursing homes and better support members transitioning from nursing homes and institutions to community living.
Nursing Home Quality and Accountability
In light of the pandemic’s devasting impact on long-term care, states are taking action to improve nursing home quality and accountability to improve the experience of nursing home residents. For example, the New Jersey Department of Human Service’s fiscal year 2023 budget includes a $1.5 million annual appropriation for interagency collaboration on long-term care integrity and oversight. New Jersey has also taken a leading role in transparency by publicly displaying nursing facility data to help consumers and their families to make informed decisions about their care. Additionally, Ohio will begin implementing recommendations outlined in its recently released Nursing Home Quality and Accountability Task Force report such as hiring more long-term ombudsmen and creating a web-based complaint platform to enable consumer to file and track complaints.
In accordance with President Biden’s Nursing Home Reform Agenda, CMS published two rules to enhance quality and improve transparency in nursing homes. In September 2023, CMS issued a proposed rule establishing minimum staffing standards in long-term care facilities, and in November 2023 CMS published a final rule requiring that nursing homes disclose additional ownership and management information to CMS on a regular basis. Due to ongoing workforce shortages, staffing will remain a challenge.
Conclusion
As the aging population continues to grow, improving the quality of care and access to services provided to older adults and individuals with disabilities will remain a priority for states in the years to come.
Federal ARPA funds have allowed states to take specific actions to improve care and services for this population, but this support is time limited as states must spend those funds by the end of 2026. States are grappling with how to continue these initiatives with sustainable funding. As noted in a NASHP June 2023 state tracker, most states plan to continue Medicaid home and community-based services flexibilities — such as payment to professional caregivers and family caregivers as well as remote and virtual technologies — through waiver amendments, legislation, and/or regulations in 2024. There are other areas where states are still determining what investments they will continue to make, recognizing the needs of this population.
NASHP is committed to supporting state policymakers in their work on caregiving, populations with health disabilities, people with serious illnesses, MLTSS, home and community-based services, and nursing home reform in 2024 and beyond.
Acknowledgements
NASHP would like to express our gratitude to The John A. Hartford Foundation, the Ralph C. Wilson, Jr. Foundation, West Health, and Arnold Ventures for their partnerships, and to the state officials who strive to improve the health and long-term services and supports for its citizens.
