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HCBS Workforce

Written by Dr. Rieka Yu
Published on February 2, 2024
Research Highlights

All 50 states have reported shortages for any type of Home and Community Based Services (HCBS) worker.


Several states have enacted legislation to increase home care workers’ wages.


Increasing home care workers’ wages can benefit both workers and the economy.

All 50 states have a shortage of home care workers.

HCBS include medical and support services to help people with daily living (KFF 2023a). HCBS are available for adults with Medicaid or those who are Medicaid eligible (MO Department of Health and Senior Services (DHSS)). HCBS are categorized as long-term services and supports and is allowed by waivers so that an individual can receive care at home (PHI). In MO, HCBS is provided through DHSS.


HCBS involves multiple aspects of home care, provided by different types of home care workers (KFF 2023b).

  • Personal care aides help with daily living activities.
  • Direct support professionals have a broader range of care than personal care aides and help with things like employment support.
  • Home health aides/certified nursing assistants provide clinical care in community settings and daily living activities.
  • Independent providers (“self-directed services”) are directly employed by and follow a scope of practice determined by the people receiving HCBS.


All 50 states in the U.S. have shortages in HCBS providers (KFF 2023b).


Multiple states have taken measures to increase home care worker wages.

Forty-eight states have adopted various strategies of increasing provider payment rates, which includes permanent and temporary pay increases and payment formulas to increase rates with the cost of living (KFF 2023b; Figure 1).


HCBS workers paid by Medicaid. The Centers for Medicare & Medicaid Services (CMS) proposed a rule in 2023 that would require states to report HCBS payment rates for transparency (CMS 2023). For certain services, the state would also need to show that payment rates are high enough to allow the HCBS workforce to provide appropriate services. States must show at least 80% of total payments for HCBS are compensation for home care workers, as a portion of the payment rate also goes toward overhead costs (Economic Policy Institute 2022, personal communication Terrell). States would also need to report the number of people on waiting lists, the number of hours initially approved, and the number of care hours provided.

  • Nationally, a bill was proposed requiring states to address insufficient payment rates and to update payment rates at least every two years, but this did not pass (S. S.2210).


ME and MD have commissioned studies on home care workforce issues. ME recommended that home care worker wages be at least 125% of the minimum wage and the Governor appropriated money to comply with the recommendations. MN requires that home care provider agencies use at least 73% of Medicaid reimbursements for home care worker wages and benefits.


All HCBS workers. CO and IA  used funds from The American Rescue Plan to raise HCBS payment rates. CA and NC have increased minimum wage to $15/hour for home care workers and certain businesses, and the Mayor of Los Angeles, California set a minimum wage of $25/hour for healthcare workers (Ordinance No. 187566). WI and NY are increasing hourly worker wages every year.


In some states, the state or county governments can create home care authorities that serve as the employer of record and this allows workers to collectively bargain better wages, benefits, and training (New America 2021).


Wage increases can help the home care workforce.

Nationally, 15% of home care workers live in poverty, and 44% live in low-income households (PHI). Across all long-term care workers, the majority are women and non-Hispanic black individuals (KFF 2020). It is unclear if these statistics include unpaid home care workers.


Many home care workers provide care for family or friends without compensation because of unmet needs for Medicaid services (Caldwell 2022). Seventy-eight percent of family caregivers have out-of-pocket expenses for caregiving averaging more than $7,000/year for each person (Caldwell 2022). About half of family caregivers reported that these expenses have led them to take on debt, miss bills, and stop saving (Caldwell 2022).

  • Low wages among home care workers contribute to poor workforce retention leading unpaid family members to provide care in these gaps (KFF 2021, Caldwell 2022).


Although not in a home environment, pay satisfaction positively influences intrinsic job satisfaction of nursing assistants in nursing homes (Decker et al. 2009). In ME, higher wages for home care workers were a predictor of longer job tenure (Butler et al. 2013).

  • One estimate found that every dollar invested into home care would boost the economy by more than one dollar due to greater labor force participation and growth (Zandi & Yaros 2021).


Figure 1. Strategies taken by states to address the HCBS workforce shortage. Data shows the number of states to take a specific strategy to increase the HCBS workforce. Figure from KFF 2023b.



AB 56. (Wis. 2019). https://docs.legis.wisconsin.gov/2019/related/acts/9.pdf.

Better Care Better Jobs Act, S.2210. 117th Congress. (2021). https://www.congress.gov/bill/117th-congress/senate-bill/2210/all-actions-without-amendments?s=1&r=42.

Butler SS, Brennan-Ing M, Wardamasky S, & Ashley A. (2013). Determinants of Longer Job Tenure Among Home Care Aides: What Makes Some Stay on the Job While Others Leave? Southern Gerontological Society. 33(2), 164-188. https://journals.sagepub.com/doi/abs/10.1177/0733464813495958.

CA Department of Industrial Relations. (n.a.). Minimum Wage Frequently Asked Questions. Accessed February 1, 2024. https://www.revisor.mn.gov/statutes/cite/256B.0659.

Caldwell J. (2022). Reducing Costs for Families and States by Increasing Access to Home- and Community-Based Services. The Heller School for Social Policy and Management. https://heller.brandeis.edu/community-living-policy/images/reducing-cost-hcbs.pdf.

Centers for Medicare & Medicaid Services. (2023). CMS-2442-P. https://www.federalregister.gov/documents/2023/.

CO Department of Health Care Policy & Financing. (2021). ARPA Spending Plan for Home and Community Based Services. https://www.revisor.mn.gov/statutes/cite/256B.0659.

Decker FH, Harris-Kojetin LD, & Bercovitz A. (2009). Intrinsic Job Satisfaction, Overall Satisfaction, and Intention to Leave the Job Among Nursing Assistants in Nursing Homes. The Gerontologist. 49(5), 596-610. https://academic.oup.com/gerontologist/article/49/5/596/640695?login=false.

HF2578. (Iowa 2022). https://www.revisor.mn.gov/statutes/cite/256B.0659.

KFF. (2021). Voices of Paid and Family Caregivers for Medicaid Enrollees Receiving HCBS. https://www.kff.org/medicaid/issue-brief/voices-of-paid-and-family-caregivers-for-medicaid-enrollees-receiving-hcbs/.

KFF. (2023a). Pandemic-Era Changes to Medicaid Home- and Community-Based Services (HCBS): A Closer Look at Family Caregiver Policies. https://www.kff.org/medicaid/issue-brief/pandemic-era-changes-to-medicaid.

KFF. (2023b). Payment Rates for Medicaid Home- and Community-Based Services: States’ Responses to Workforce Challenges. https://www.kff.org/medicaid/issue-brief/payment-rates-for-medicaid.

Leading Age. (2022). States Legislatures Taking Steps to Address Direct Care Wages. Accessed January 30, 2024. https://leadingage.org/states-legislatures-taking-steps-to-address-direct-care-wages/.

LAMC § 187.5 (2022). https://wagesla.lacity.org/sites/g/files/wph1941/files/2022-07/Healthcare%20Workers%20Minimum%20Wage%20Ordinance.pdf.

Main. (2020). Commission to Study Long-term Care Workforce Issues. https://legislature.maine.gov/doc/3852.

Min. Rev. § 256B.0658. (2023). https://www.revisor.mn.gov/statutes/cite/256B.0659.

MO Department of Health and Senior Services. (n.a.). Home/Community Based Services Provider Information. Accessed February 1, 2024. https://health.mo.gov/seniors/hcbs/info.php.

National Conference of State Legislatures. (2022). Supporting Direct Care Workers: Recruitment and Retention Strategies. Accessed February 1, 2024. https://www.ncsl.org/health/supporting-direct-care-workers-recruitment-and-retention-strategies.

New America. (2021). Valuing Home and Child Care Workers: Policies and Strategies That Support Organizing, Empowerment, and Prosperity. https://www.newamerica.org/new-practice-lab/reports/valuing-home-child-care-workers/.

New York Assembly. (2023). SFY 2023-24 Budget Includes $2.4 Billion for Distressed and Safety-Net Hospitals, Medicaid Rate Increases and Wage Increases for Home Health Care Workers. https://nyassembly.gov/Press/.

PHI (n.a.) Caring for the Future: The Power and Potential of America’s Direct Care Workforce. https://www.phinational.org/caringforthefuture/.

Zandi M, & Yaros B. (2021). Macroeconomic Impact of Home and Community-Based Services Expansion. Moody’s Analytics. https://www.moodysanalytics.com/-/media/article/2021/.

SB105. (N.C. 2021). https://www.revisor.mn.gov/statutes/cite/256B.0659.

SB238. (Colo. 2019). https://leg.colorado.gov/sites/default/files/2019a_238_signed.pdf.

SB440 (Md. 2022). https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/SB0440?ys=2022RS.


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