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Unequal Access to Long-Term Services & Supports

Regardless of where they live, people should be able to access the care they need to live and age in good health.


Millions of Americans rely on long-term services and supports (LTSS) to manage their daily lives, yet access to these supports is hindered by strict eligibility requirements, a lack of available resources in one’s geographic area, inadequate federal and state funding, and a dearth of resources that are culturally and linguistically appropriate. While 52 percent of people aged 65 and older will require some form of long-term care in their lives, reports around the country routinely illustrate the challenges facing people who can neither afford nor access the services they need.[1]

For millions of Americans, access to LTSS is made possible through the Medicaid program. In fact, Medicaid serves as the country’s primary payer for these services, with 34 percent of the Medicaid budget directed toward long-term care. As the current presidential administration, as well as various leaders in Congress, weigh major reforms to programs such as Medicaid and Medicare, it is important to consider the impact of these reforms on America’s older adults and people with disabilities. Already, the growing direct care workforce shortage signals a crisis in paid caregiving—one worsened by state Medicaid budgets that often don’t adequately account for the real costs associated with either labor or beneficiaries with higher needs.

In addition to affordability, access to LTSS is hampered by a lack of culturally and linguistically appropriate services. Nationwide, the population of older adults, as well as people with disabilities, continues to diversify. In 2010, 20 percent of people aged 65 and older in the U.S. were people of color, a group that will more than double by 2050. Lesbian, gay, bisexual, and transgender (LGBT) people aged 65 and older will grow to at least three million in the same time period.[2] Despite the body of research demonstrating pronounced disparities in access to services as well as a lack of positive health outcomes among these populations, there are few culturally and linguistically appropriate services aimed at these diverse communities, including a lack of trained caregivers versed in their realities. Furthermore, as the country continues to diversity racially and ethnically, so too does the direct care workforce—58 percent of home care workers are people of color, and 28 percent are immigrants. Unfortunately, the heightened anti-immigrant political climate further threatens the stability of this workforce.


Medicaid should be strengthened and expanded to ensure that direct care workers and the people they serve continue to obtain health coverage and access to long-term services and supports. In the current federal debate, this means not undermining Medicaid’s financing structure through block grants or a per capita cap, which would force states to cut benefits, limit enrollment, and cut payments to providers. In addition, we should promote and fund culturally and linguistically appropriate training and services that can effectively reach communities of color and LGBT consumers. In 2010, to help address this problem, PHI developed the curriculum for SAGE’s National Resource Center on LGBT Aging, a federally funded cultural competency program that trains professionals in industries serving older adults on the unique needs of the LGBT community.


  1. U.S. Department of Health and Human Services. "Who Needs Care." Accessed February 16, 2017.
  2. Grantmakers in Aging. "Meeting the needs of elders of color and LGBT elders." Accessed February 16, 2017.

Key Takeaways

Medicaid is the primary payer for long-term care, and it should be strengthened and expanded.
People of color and LGBT older adults deserve culturally and linguistically appropriate supports.
People with disabilities should be able to access affordable and accessible services and supports.

By the Numbers: Expanding Access & Cultural Competence

$339 billion

Total U.S. spending on long-term services and supports. Source: AARP Public Policy Institute, 2017


Percentage of spending on long-term services and supports covered by Medicaid. Source: AARP Public Policy Institute, 2017


Percentage of direct care workers who are immigrants. Source: PHI, 2017

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