Historical Mismatch Between Home-Based Care Policies And Laws Governing Home Care Workers

Health Aff (Millwood). 2019 Jun;38(6):973-980. doi: 10.1377/hlthaff.2018.05494.


Americans generally want to remain in their homes even if they develop chronic health problems or disabilities that qualify them for nursing home care. While family members or friends provide the preponderance of home-based support, millions of Americans use paid personal assistance services (PAS). Inexorable demographic trends are increasing the numbers of people who need paid home-based PAS, with this need rapidly outstripping the capacity of the paid PAS workforce. While many factors contribute to this widening discrepancy, its roots reach back more than eighty years to asynchrony among various policies affecting home-based supports for people with functional impairments and policies affecting home-based PAS workers. Finding solutions to the growing gap between demand for the services and the PAS workforce requires policies that cut across societal sectors and align incentives for consumers, workers, and other key stakeholders.

Keywords: disability civil rights; home and community-based services; home care; institutionalization; personal assistance services; workforce.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Activities of Daily Living
  • Adult
  • Aged
  • Caregivers* / economics
  • Caregivers* / legislation & jurisprudence
  • Disabled Persons / legislation & jurisprudence*
  • Disabled Persons / statistics & numerical data
  • Government Regulation
  • Health Policy*
  • Home Care Services*
  • Home Health Aides / legislation & jurisprudence*
  • Humans
  • Medicaid / economics
  • Middle Aged
  • United States