Medicaid is the first payer for long-term care (LTC) in america, and pays for greater than two-thirds of the LTC delivered in home- and community-based settings. Most dwelling care (also called “dwelling and community-based providers” or HCBS) is non-compulsory for states to supply and is steadily provided by “waivers,” which permit states to cowl a variety of advantages and to decide on—and restrict—the quantity of people that obtain providers. KFF estimates that 5.1 million Medicaid enrollees use home care, and that about half of persons are utilizing dwelling care by waivers. States’ capability to cap the variety of individuals enrolled in dwelling care waivers may end up in ready lists when the variety of individuals searching for providers exceeds the variety of waiver slots accessible.
On July 4, President Trump signed the 2025 reconciliation law, as soon as known as the “One Huge, Stunning Invoice,” that features significant changes to the Medicaid program. The Congressional Funds Workplace (CBO) estimates that the brand new regulation will scale back federal Medicaid spending over a decade by $911 billion. Given the substantial share of Medicaid spending that pays for dwelling care, and the non-compulsory nature of most dwelling care packages, cuts to dwelling care packages might happen as states search for methods to reply to the reductions in federal spending. If states reduce dwelling care by decreasing the quantity of people that can obtain waiver providers, ready lists might improve. Ready lists might additionally improve on account of adjustments to immigration coverage in states that use ready lists to handle shortages of dwelling care staff, one-in-three of whom are immigrants. The Trump Administration has made notable adjustments to immigration coverage targeted on restricting entry on the border and growing inside enforcement efforts to assist mass deportation. These adjustments place elevated stress on the house care workforce, a sector that was already dealing with workforce shortages.
This information word gives new details about ready lists in Medicaid dwelling care earlier than lots of the provisions within the reconciliation regulation go into impact. Ready lists are an incomplete measure of unmet want (Field 1) and should not essentially comparable throughout states or over time. Due to these issues, the variety of individuals on ready lists might both improve or lower in response to the federal Medicaid cuts. The info come from the 23rd KFF survey of officials administering Medicaid dwelling care packages in all 50 states and the District of Columbia (hereafter known as a state), which states accomplished between April and July 2025. The survey was despatched to every state official chargeable for overseeing dwelling care advantages (together with dwelling well being, private care, and waiver providers for particular populations equivalent to individuals with bodily disabilities). All states besides Florida responded to the 2025 survey. Survey findings are reported by state and waiver goal inhabitants, though states typically supply a number of waivers for a given goal inhabitants. Key takeaways embrace:
- Forty-one states preserve ready lists or curiosity lists for individuals who want to obtain dwelling care, a quantity that fluctuated little between 2016 and 2025.
- In all years since 2016, there have been no less than 0.5 million individuals on ready lists or curiosity lists, with a complete of over 600,000 in 2025.
- In 2025, 12 states reported having no less than one new ready listing (throughout 20 waivers), and 29 states reported a rise within the variety of individuals on ready lists or curiosity lists in contrast with solely 12 states reporting a lower.
- Most individuals on ready lists or curiosity lists have mental or developmental disabilities (I/DD) and most stay in states that don’t display any individuals for eligibility previous to including them to ready lists.
- Most individuals on ready lists or curiosity lists are eligible for private care offered by states’ common Medicaid packages or for providers offered by specialised state plan dwelling care advantages.
KFF additionally just lately up to date the ready listing indicators on State Health Facts which present information by state and goal inhabitants.
Field 1. Why do ready lists present an incomplete measure of unmet want and why is it tough to match ready lists throughout states?
Ready lists present a sign of people that may have providers they aren’t receiving, however they’re an incomplete measure of unmet want for a number of causes. Ready lists mirror the populations a state chooses to serve, the providers it decides to supply, the sources it commits, and the availability of workers to supply providers. Ready lists don’t embrace individuals with unmet wants within the following kinds of circumstances:
- States don’t cowl the relevant providers (and subsequently, don’t have any ready listing),
- States enable all eligible individuals to enroll however limit service provision to handle complete spending within the waiver, and
- Eligible persons are enrolled however suppliers don’t have any extra capability (and in some instances, the house care suppliers preserve their very own ready lists).
It’s tough to match ready lists throughout states as a result of states’ approaches to managing ready lists differ in how they prioritize and display for eligibility. Some ready lists embrace solely eligible people whereas others embrace individuals for whom eligibility has not been decided. The provision of non-waiver providers for individuals on ready lists additionally varies. Though individuals could wait a very long time to obtain waiver providers—32 months on common in 2025—most individuals are eligible for different kinds of dwelling care whereas they wait.
Beginning in 2027, states will likely be required to report the variety of individuals on ready lists as required beneath a final rule on entry to Medicaid providers, however it’s unclear whether or not such reporting will handle these information limitations on ready lists. The info will embrace the variety of people who find themselves ready to enroll in a waiver program, info on whether or not the individuals on the listing have been screened for eligibility, the common period of time individuals newly enrolled within the waiver over the previous 12 months spent ready to enroll, the common size of time between approval for providers and repair begin dates, and the p.c of approved hours of care that have been offered. Though the regulation doesn’t point out curiosity lists, referral lists, or registries, the preamble to the rule signifies CMS’ intent for states to report all kinds of lists.
Regardless of the improved information states will likely be required to report, ready listing and waiver info will stay imperfect measures of unmet want. Not one of the new information will mirror how lengthy it takes for individuals to obtain dwelling care offered by the Medicaid state plan, or how complete providers are. The brand new information additionally don’t seize the variety of individuals whose approved providers are beneath wanted ranges due to hourly or greenback caps on the quantity of dwelling care they will obtain.
How Many States Have Ready Lists for Dwelling Care?
Between 2016 and 2025 the variety of states with ready lists has fluctuated between 37 and 41 and is at the moment at 41 states (Determine 1). Whereas some Inexpensive Care Act (ACA) opponents have cited waiver ready lists to argue that increasing Medicaid diverts funds from older adults and other people with disabilities, research reveals that ACA Medicaid expansion has led to features in coverage for individuals with disabilities and continual sicknesses. Ready lists for dwelling care predate the ACA Medicaid enlargement, which turned efficient in most states in 2014, and each enlargement and non-expansion states have ready lists. Waiver enrollment caps have existed since dwelling care waiver authority was added to federal Medicaid regulation within the early Nineteen Eighties.
Whereas the general variety of states with ready lists didn’t change a lot from 2024 to 2025, there have been extra adjustments in ready lists for particular kinds of waivers. Twelve states (throughout 20 waivers) reported new ready lists, with the biggest variety of new ready lists for individuals with mental or developmental disabilities (I/DD). For instance, 5 states (Illinois, Louisiana, Missouri, Utah, and Wisconsin) reported new ready or curiosity lists for waivers concentrating on people with I/DD.
A number of of the brand new ready lists mirror situations the place states undertook efforts to extend entry to care. For instance, Wisconsin has a brand new collaborative effort with counties to establish youngsters who’re eligible for however not receiving providers beneath the state’s waivers. This has resulted in an inventory of practically 9,000 youngsters who’re deemed eligible for providers however haven’t but been enrolled in waivers. Indiana established a brand new waiver for older adults that additionally resulted in a brand new ready listing of practically 8,000 individuals.
How Many Individuals Are on Ready Lists for Dwelling Care?
Between 2024 and 2025, complete enrollment in ready lists and curiosity lists elevated by 14%, and is over 600,000 in 2025 (Determine 2). General, there was a rise within the variety of individuals on ready or curiosity lists in 29 states and a lower in 12 states. A lot of the largest will increase in ready lists have been in states that reported new ready lists—typically which represented new waivers or efforts to extra proactively enroll eligible individuals, as described above. Maryland reported one of many greatest decreases in ready lists as a result of the state elevated the variety of waiver slots for his or her program serving older adults and other people with disabilities, decreasing the variety of individuals on the ready listing by over 2,000 individuals.
One issue that contributes to adjustments over time—particularly the notable decline between 2018 and 2020—is that not all states display for Medicaid eligibility previous to including individuals to ready lists and adjustments on this coverage could end in adjustments in ready listing volumes. For instance, between 2018 and 2020, the overall variety of individuals on ready lists decreased by 155,000 or 19%. Nevertheless, practically half of that change got here from Ohio’s implementation of a ready listing evaluation of waiver eligibility, which decreased the dimensions of the state’s ready listing by practically 70,000 individuals. In 2025, most states (35) with ready lists display people for waiver eligibility amongst no less than one waiver, however even amongst these states, seven don’t display for all waivers. The six states that don’t display for eligibility amongst any waivers (Florida, Iowa, Oklahoma, Oregon, South Carolina, and Texas) account for greater than half (325,000) of all individuals on ready lists.
In 2025 and earlier years, a disproportionate variety of individuals on dwelling care ready lists or curiosity lists lived in states that didn’t display individuals on ready lists for eligibility. One cause ready lists present an incomplete image of want is that not all individuals on ready lists will likely be eligible for providers. The variety of states that don’t display for eligibility on any ready lists ranged from six to eight states between 2022 and 2025, but the share of people on ready lists in these states ranged from 40% to 54%. Interviews about dwelling care ready lists discovered that when waiver providers are offered on a first-come, first-served foundation, individuals enrolled in ready lists are in anticipation of future want. That study discovered that in some states, households would add their youngsters to ready lists for individuals with I/DD at a younger age, assuming that by the point they reached the highest of the ready listing, their youngsters would have developed the instant want for providers. A lot of these waivers supply complete home care packages that embrace supported employment, supportive housing, or round the clock providers. Among the many six states that don’t display individuals for eligibility on any lists, three have solely ready lists, Texas has solely curiosity lists, and two use each. (Illinois doesn’t set up eligibility till choice however does a preliminary analysis of eligibility previous to putting somebody on the listing.)
Who Is on Ready Lists for Dwelling Care?
Most individuals on ready lists have I/DD, significantly in states that don’t display for waiver eligibility earlier than putting somebody on a ready listing. Individuals on ready lists for waivers serving individuals with I/DD (which embrace waivers particular to individuals who have autism) comprise 81% of ready lists in states that don’t display for waiver eligibility, in contrast with 55% in states that do decide waiver eligibility earlier than putting somebody on a ready listing (Determine 3). Individuals with I/DD comprise nearly three-quarters (74%) of the overall waiver ready listing inhabitants. Older adults and adults with bodily disabilities account for practically one-quarter (23%), whereas the remaining share (4%) contains youngsters who’re medically fragile or know-how dependent, individuals with traumatic mind or spinal twine accidents, individuals with psychological sickness, and other people with HIV/AIDS. People who find themselves on dwelling care ready lists are usually not consultant of the Medicaid inhabitants or the inhabitants that makes use of dwelling care. Most individuals on ready lists have I/DD, however KFF analysis reveals that folks with I/DD comprise fewer than half of the individuals served by 1915(c) waivers (the biggest supply of Medicaid dwelling care spending).
How Lengthy Are Individuals on Ready Lists for Dwelling Care?
In 2025, individuals on the ready or curiosity lists accessed providers after a median of 32 months (33 of 41 states responding), down from 40 months in 2024. Individuals with I/DD wait 37 months on common. The common ready interval for different waiver populations ranged from 15 months for waivers concentrating on older adults and other people with bodily disabilities to 63 months for waivers that serve individuals with autism. Individuals with I/DD residing in states that don’t display for eligibility wait longer for providers than individuals with I/DD residing in states that do display for waiver eligibility (49 months versus 32 months, on common).
Most individuals on ready or curiosity lists are eligible to obtain different kinds of dwelling care whereas they wait. Among the many 607,000 individuals on lists for waiver providers in 2025, residing preparations are unknown for greater than 445,000. Among the many individuals whose residing preparations are identified, 96% (154,000) stay locally and 4% (7,000) stay in institutional settings. Though most individuals on ready lists stay locally, that might not be true for all waivers. In a single California waiver for older adults and other people with disabilities, practically 5,000 of the roughly 6,500 individuals on the ready listing live in establishments.
Whereas ready for waiver providers, individuals residing locally are prone to be eligible for different dwelling care by Medicaid state plans. Of the over 5 million people who use dwelling care, KFF estimates that roughly half use providers offered by the Medicaid state plan, equivalent to private care to assist with bathing or making ready meals, therapies to assist individuals regain or purchase impartial residing abilities, and assistive know-how. States could not use ready lists to limit the variety of individuals eligible to make use of such providers and over 80% of individuals on dwelling care ready lists are eligible for private care or different state plan providers. They’d not, nonetheless, have entry to extra specialised providers equivalent to supported employment or grownup day care. Individuals on ready lists who obtain state plan providers might also have fewer hours of non-public care than they might in a waiver program, or they could not have help with a number of the actions they need assistance with equivalent to bathing, dressing, making ready meals, or managing treatment.
