An aging U.S. population and the yearslong trend away from inpatient care is moving long-term care and support out of institutions and into the home. But a new study in the May Health Affairs and supported by the National Institute on Aging indicates that the supply of workers is not increasing rapidly enough to meet the growing demand for home care services.

Researchers used data from the American Community Survey (an annual household survey from the Census Bureau) to estimate the number of home health care workers each year in the United States from 2008 to 2020. These workforce numbers were then compared with data from the Kaiser Family Foundation on the number of people in each state who received care through Medicaid's home and community-based services programs over the same period. (Medicaid is the largest payer of long-term home health care services in the United States.)

During this 12-year period, the estimated number of home health care workers increased from 840,000 in 2008 to 1.42 million in 2019. Over the same period, however, the number of Medicaid-covered patients seeking home care rose from just over 2 million in 2008 to more than 3.37 million in 2019. While workforce growth began to slow in 2013, growth in demand for home health care under Medicaid accelerated slightly. The result: between 2013 and 2019, the ratio of workers to home care participants dropped by 11.6%.

There are no national data on the actual unmet needs for home health care. Some people can't afford to pay for these services out of pocket but are not eligible for Medicaid, and the coverage itself varies from state to state. The researchers note that it's likely they have underestimated the true growth in the need for home care.

Significant long-term and multipronged investments in this critical workforce are needed, including realistic wages and benefits, incentives to states to standardize training, reform of federal and state reimbursement models, and consideration of new approaches such as employment-based Schedule A visas for foreign home health workers. Without intense efforts in the near future, at-home care will become increasingly unavailable, and family members and friends will be scrambling to fill the widening gap between workforce and need.-Betsy Todd, MPH, RN