Creating a sustainable system to effectively support our aging population is critical. Roughly 11,200 people a day are turning age 65 in the U.S. By 2034, it is projected that there will be more older adults than children in the country for the first time in U.S. history. Medicaid is the primary public source of coverage for long-term services and supports (LTSS), funding over half of these services in 2020. The Older Americans Act is an important funding source for states, but it is not keeping pace with today’s senior population. The American Rescue Plan Act (ARPA) increased federal funding for home- and community-based services (HCBS), but most of the pandemic-related funding is now expiring. States are implementing creative initiatives to continue to support the health-related needs of this growing aging population.

• Innovations: States are using both remote technology and in-person education to better serve older adults while stretching limited dollars. The New York State Office for the Aging has partnerships with more than 20 technology companies to increase services and improve the health and well-being of older adults and caregivers. New York added social isolation and technology screening questions to its comprehensive assessment so older adults can be connected to digital solutions such as robotics, online courses, and virtual senior centers, when appropriate. In North Dakota, the state conducts LTSS Options Counseling for all Medicaid individuals over age 21 who are referred for a long-term stay in a nursing home. The state sends staff to meet with individuals and provide education on the types of care options available to them, from nursing home care to in-home care. Nearly 5,000 visits were completed in 2023, in which more than 1,000 referrals were sent to HCBS case managers.

The U.S. will need more new direct care workers than any other occupation. The direct care workforce of aides and nursing assistants will add more than 1 million new jobs by 2031, which is more new jobs than any other occupation. At the same time, nearly 9.3 million total direct care jobs will need to be filled.

• Innovations: The pandemic and correlated funding to states has resulted in investments in the direct care workforce, as 40 of the states included at least one workforce-related item in their HCBS ARPA spending plans. New York has encouraged counties to hire personal care aides directly as county employees, giving them access to a full-time living wage, health and retirement benefits, and county transportation. To date, 14 counties are either directly hiring their own aides or contracting with a licensed home care agency to have aides specifically assigned to their county. The state is seeing a reduction in waiting lists and overall turnover of the aides. North Dakota issued 23 grants of up to $50,000 — provided by Money Follows the Person (MFP) and ARPA funds — to develop or expand access to in-home care providers in rural and Tribal communities. Sixty new in-home care agencies have enrolled since 2022. North Dakota is also developing a direct care careers online provider registry to help individuals and their caregivers find in-home care, similar to the New York State Home Care Registry.
• At the federal level, ACL’s Direct Care Workforce Strategies Center was launched to create a centralized place for best practices, guidance, and resources. The center is providing technical assistance to six states as well as 14 additional states in a learning collaborative.

Family caregivers are shoring up the workforce. With the direct care workforce shortage, 53 million family caregivers are providing $600 billion of unpaid care annually. When they do not have support and time for self-care, their health and well-being can suffer.

• Innovations: Many states have taken action to support family caregivers, including expansion of Medicaid reimbursement for their services, increased access to respite care, and the creation of additional supports in communities such as training and educational resources. For example, the New York State Office for the Aging (NYSOFA), in partnership with the New York State Department of Labor, launched the Working Caregiver Initiative to address the unique stresses faced by employees who are juggling work and caregiving responsibilities. The initiative helps businesses, both public and private, and their human resources departments, understand and plan for the impact of caregiving on employees and foster a supportive workplace culture. As part of this initiative, NYSOFA provides the ARCHANGELS’ Caregiver Intensity Index (CII) free to all caregivers in New York state. The CII provides caregivers with an intensity score that validates their caregiving experience and connects them to resources. NYSOFA has also partnered with Trualta to offer a free online evidence-based training and education platform to any caregiver in the state.
• The National Strategy to Support Family Caregivers provides a first-of-its-kind roadmap for a coordinated strategy for helping caregivers. It contains 500 actions, 150 of which can be implemented by states, communities, and others. A 2024 Report to Congress found that nearly all of the 350 federal actions were completed or are in progress, and a new progress report showcases the early impact on states and communities.

People first need housing to receive home- and community-based services. By 2035, 1 in 3 householdswill be headed by someone 65 or older. With rising demand for housing that can meet the needs of older adults and people with disabilities, the lack of both affordable and accessible housing will be barriers to aging in place for many Americans.

• Innovations: While states are broadly working to increase access to housing, some are specifically targeting aging populations in these efforts. In North Dakota, MFP recipients receive transition supports as they are discharged from a nursing home, including a housing coordinator, through the MFP Housing Program. This program helps find safe, affordable housing for persons who are MFP qualified and wish to transition out of institutions or nursing facilities and back into the community.
• Launched in 2021, the Housing and Services Resource Center is a partnership with the U.S. Department of Housing and Urban Development and ACL that highlights best practices and helpful resources. The Housing and Services Partnership Accelerator is supporting eight states in developing or expanding innovative housing-related supports and services for Medicaid-eligible people with disabilities and older adults who are experiencing or at risk of homelessness.

Rural areas need specific solutions. Rural areas have higher concentrations of older residents than urban areas. These rural, older adults can have access to fewer resources, experience more complex health conditions, and be more affected by provider shortages and service gaps. Care for people with LTSS needs in rural and frontier areas is challenging.

• Innovations: Several states are focusing on better supporting older rural residents to age in place. For example, in North Dakota, 50 percent of people live in rural areas, and only nine cities have a population of more than 15,000 people. The state allows spouses and other family members to receive Medicaid payment for providing care. The state Medicaid program also pays a higher rate to aides who are willing to travel to provide services in rural areas. Providers are not paid for travel time; the rural differential rate is paid for time spent providing services. The rates are based on the number of miles per round trip that a provider travels to serve an individual.

Partnerships and interagency coordination are crucial for states to serve older adults. Aging is both impacting and is impacted by health care, transportation, housing, technology, and workforce. All levels of government and agencies need to plan well.

• Innovations: Multisector Plans for Aging are being developed in many states, including as New York and North Dakota. Modeled after the state efforts, the Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities, authorized by the Older Americans Act and led by ACL, is working to improve coordination across federal agencies to promote healthy aging and age-friendly communities. In summer 2024, it released a Strategic Framework for a National Plan on Aging.

It is estimated that more than half of people turning 65 today will need some LTSS during their life courses, and over 4.1 million people will turn 65 in 2024 alone. Women, people with lower incomes, and people with poorer health are more likely to need LTSS and need it for longer periods of time. It is time to modernize the state of care for older adults across federal, state, and local governments in partnership with communities. State leaders are taking action through legislation, regulation, and investments. NASHP remains committed to supporting state policymakers to improve the health and well-being of older adults.