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Three years after the COVID-19 pandemic hit the nation, major gaps in care for older adults and people with disabilities persist, particularly in attracting and retaining the long-term care workforce and providing access to care.

The AARP unveiled its new Long-Term Services & Supports State Scorecard on Thursday, providing a state-by-state analysis of long-term care across the country. The association ranked and measured state performances across all LTSS areas using 50 indicators across five dimensions: affordability and access, choice of setting and provider, safety and quality, support for family caregivers, and community integration.

For the first time, more than half (53%) of Medicaid LTSS spending for older adults and people with physical disabilities went to home- and community-based services — up from 37% in 2009, according to the LTSS Scorecard.

The scorecard noted that in recent years, the supply of assisted living beds has increased, but challenges remain in accessing them. Assisted living is expensive, and there is limited Medicaid coverage, which only pays for the service component of assisted living, according to the report.

Since the 2020 LTSS Scorecard, the supply of assisted living beds has increased by 15%, to 55 beds per 1,000 older adults aged more than 75 years. This indicator showed widespread improvement, with almost half (24) of the states increasing performance by 10% or more, in terms of increasing assisted living supply.

Hawaii saw the largest increase (54%) in assisted living supply relative to the last scorecard. Minnesota had the largest assisted living supply ratio, at 138 beds per 1,000 older adults, whereas New York had the smallest, at just 20 beds per 1,000 older adults.

Nineteen states showed a decline in assisted living supply, whereas five states retained the same supply as in the 2020 scorecard. 

Some assisted living communities are part of continuing care retirement / life plan communities, which the AARP said serve a “predominantly white clientele” and are “prohibitively expensive.”

“In other words, these services are not meaningfully available to most people or available in an equitable manner,” the report read.

Workforce remains a challenge

Attracting and retaining a direct care workforce continues to be a challenge across all lines of care and service, according to the AARP.

Direct care worker wages are lower than those of entry-level jobs in other industries across all states, according to the report. Those wage shortfalls occur even in the best-performing state (New Hampshire), representing a difference of more than $3,000 compared with similarly situated occupations. 

The report recommended bolstering the HCBS workforce with improved recruitment and training, increasing pay and expanding the ability of direct care workers to take on some additional aspects of care. The report also encouraged states to play a role in setting staffing standards across service lines and holding providers accountable to those standards.

The LTSS Scorecard was funded by an AARP Foundation grant with support form The SCAN Foundation, the Commonwealth Fund and the John A. Hartford Foundation. It has been updated every three years since 2011.