Every week at the Blog, we analyze various reports and articles featuring dire predictions regarding the long-term health of Medicare and Medicaid. These updates often leave us asking a critical question: When will our nation’s policy-makers finally come to grips with this mounting crisis?
A few months ago, we encountered an insightful 2025 article from NextAvenue, written by social policy expert Robert Espinoza. His sobering observation highlights that we are undermining the long-term security of seniors who rely on Medicaid by failing to support the frontline workers providing their care.
Espinoza describes the caregiving workforce as “growing yet beleaguered,” asserting that failing to reform Medicaid policy will result in a heavy price for all of us. This commentary explores Espinoza’s observations and his proposed solutions for a more sustainable system.
How Medicaid Spending Cuts Impact Families and Care Workers
“For many of us in the long-term care field, the recent passage of President Trump’s Big Beautiful Bill Act was profoundly big but far from beautiful,” Espinoza begins. “Reducing Medicaid (and CHIP) spending over the next 10 years by nearly $1 trillion will devastate families who rely on this program for both health and long-term care.”
Espinoza notes that significant data is often missing from popular analysis regarding the harm these cuts inflict on the direct care workforce. This group consists of over 5 million home care workers and nursing assistants who support older adults in residential and community settings.
“Dramatically reduced Medicaid funding will mean fewer dollars for the entire long-term care system, and that includes money to improve jobs for this growing yet beleaguered workforce,” Espinoza writes. “A system that lacks enough properly paid and trained workers will affect all of us, regardless of our income level.”
Medicaid as the Primary Funding Source for U.S. Long-Term Care
As the primary payer of long-term care in the United States, Medicaid accounts for 57 percent of total care spending. Espinoza explains that the system functions as a “means-tested program,” requiring recipients to meet specific income and asset limits to qualify.
Beyond financial requirements, applicants must also meet functional criteria, such as needing help with daily activities like bathing or eating. The financial burden on the system is disproportionate to the number of seniors enrolled.
He writes, “Data from 2023 shows that over 7 million Americans aged 65 and older are enrolled in Medicaid. Many rely on the program for what are termed long-term services and supports (LTSS). In total, seniors account for about 10 percent of all Medicaid enrollees, but – because of the cost of long-term care – they account for roughly 20 percent of total Medicaid spending.”
Rising Longevity and the Surging Demand for Medicaid Services
The demand for long-term care is predicted to balloon as the Baby Boomer generation continues to age. Espinoza reports that the population requiring Medicaid assistance is expected to grow from 6.3 million in 2015 to roughly 15 million by 2050.
“In addition,” he writes, “we’re witnessing growing numbers of people with disabilities of all ages, and these demand figures don’t include an estimated 16 million middle-income older adults who can’t afford high long-term care costs yet don’t qualify financially for Medicaid. Already, too many people are left behind.”
The current statistics are already staggering, with hundreds of thousands of eligible people sitting on waiting lists for home-based services. Espinoza notes that the average wait time is nearly 40 months due to a lack of provider capacity and a massive workforce shortage.
Recognizing the Essential Role of the Direct Care Workforce
The direct care sector is larger than any other occupation in the country, with workers serving in private residences, nursing homes, and assisted living communities. Strengthening this workforce is a massive challenge because care workers encompass a wide variety of roles and skill levels.
“A home care worker might help with bathing, dressing, household chores and companionship,” Espinoza explains. “A more advanced worker might help with medication management or helping a person transition from the hospital to their community. And they are rightfully considered by many as the ‘eyes and ears’ of our care system — observing, recording and reporting changes in a client’s condition to ensure they remain healthy and safe.”
He emphasizes that anyone who has experienced the support of a dedicated caregiver knows that their value to a family is immeasurable.
Economic Pressures Driving the Exodus of Long-Term Care Workers
Despite their essential role, care workers suffer from a lack of investment, earning a median wage of $16 per hour. This low compensation leaves approximately one in three workers living near poverty, often relying on Medicaid for their own healthcare.
“More than anyone else, they are the living embodiment of Medicaid in the U.S.; workers who toil in necessary yet low-wage jobs, relying on this program to both resource their job sector and ensure they can see a doctor,” Espinoza writes.
Many skilled workers eventually leave the profession to seek better pay in the retail or fast-food sectors. When these professionals exit the field, older adults and their families are left without the vital support they need.
Recent Progress and the Threat of Policy Reversals
“Between 2021 and 2024, largely due to funding from the American Rescue Plan Act, federal and state leaders invested nearly $37 billion in additional Medicaid home and community-based services funding for the direct care workforce across all 50 states,” Espinoza writes.
States used these funds to improve provider reimbursement rates, leading to higher hourly wages, better training, and improved recruitment efforts. However, Espinoza warns that these modest gains are in peril as federal legislation continues to stall.
“While a few states lead the way on this workforce, the vast majority have a long way to go in advancing policies that help workers fare well in today’s economy,” he writes. “Dramatically reduced Medicaid spending will not only stall this modest progress but take us back several steps.”
A Path Forward: Competitive Wages and Policy Reform
Espinoza outlines several clear suggestions for improving the long-term care landscape. He suggests that leaders must defer to the advice of policy experts who advocate for a framework of competitive wages, improved training, and career advancement.
“Second,” he writes, “we must adopt a range of financing reforms in long-term care that make these services and supports more affordable to people — and improve the quality of direct care jobs. Protecting and expanding Medicaid remains the most common policy option, yet there are other possibilities related to expanding public coverage and the private market.”
Building Political Will for Long-Term Care Reform
As his article concludes, Espinoza reiterates that meaningful change requires broad public and political support. He notes a concerning lack of awareness among the general public regarding the realities of long-term care costs.
“Alarmingly, while nearly one in two voters support increased funding for Medicaid, the rest are indifferent or opposed,” he observes. “Such thinking underscores how many people neither understand nor have experienced not being able to afford long-term care coverage.”
He concludes with a vision for the future, stating that we can create a system that is properly resourced for everyone’s benefit. However, he warns that the current legislative direction suggests we are still far from achieving that goal.
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The post Medicaid at 60: How the Long-Term Care System Is Failing Workers and Seniors appeared first on Home.
