During the pandemic, most states allowed some form of payment to family caregivers whose loved ones were receiving Medicaid home- and community-based services. As those payments dry up, workforce shortages could be exacerbated, according to a KFF analysis published Tuesday.

More than 4 million people rely on Medicaid HCBS, according to the health policy analysis firm formerly known as the Kaiser Family Foundation or the Henry J. Kaiser Family Foundation.

“Medicare generally does not cover HCBS and in 2020, Medicaid spent $162 billion on HCBS — a majority of the $245 billion in total HCBS spending,” according to the brief.

As states wind down payments to family caregivers and remove other pandemic-era policies, this “could complicate ongoing workforce shortages and create new challenges for enrollees,” according to a survey of state Medicaid HCBS officials from KFF. The 50-state survey was conducted between May and August.

“With ongoing workforce shortages, families may have difficulty finding paid workers to take over their responsibilities when the policies expire,” noted authors Alice Burns, associate of director of KFF’s Program on Medicaid & Uninsured; Maiss Mohamed, research assistant at the program; and Molly O’Malley Watts, owner and principal at Watts Health Policy Consulting.

Twelve states are ending payments to family caregivers who are legally responsible for the person for which they are caring, and five states will be ending payments to other types of family caregivers.

The authors noted that states have generally been more generous with family caregivers being paid even if they were not legally responsible for the person receiving care and if the person receiving care was enrolled in an HCBS waiver. Among the 50 states with HCBS waivers that responded to the survey, 41 states allow payments to spouses, parents of minor children, and other legally responsible relatives; and 49 states allow payments for other family members and friends.

“Payments to legally responsible relatives are more likely to end after the [public health emergency] authorities expire than are payments to other family and friends,” according to the analysis. 

Payments that were allowed for legally responsible relatives under the PHE will be ending for people in seven states who are aged 65 or more years or who have physical disabilities.

“Beyond administrative hurdles, the end of the PHE authorities may place further strain on the HCBS workforce and on family caregivers who provide HCBS. Many of the PHE authorities were enacted in response to HCBS workforce shortages that were exacerbated by the COVID-19 pandemic,” the authors said. “As the pandemic era ends, employment in the long-term services and supports sectors continues to remain below pre-pandemic levels and it is unclear whether HCBS workforce shortages will become worse.”