Uneven care across states: Disparities in Medicaid 1915(c) home and community-based services waivers for older adults in the United States

The aging population in the United States, combined with older adults' strong preference for aging in place, has driven an increased demand for home and community-based services (HCBS). Medicaid 1915(c) waivers are a critical component of the social welfare system, providing essential services such as homemaker services, personal care, and assistive technology to help economically vulnerable older adults with physical difficulties continue living in their homes. This study investigates state-level differences in the availability, accommodation, and generosity of 1915(c) waivers for older adults. Data include approved state waiver applications, Genworth State Cost of Care, Medicare-Medicaid Coordination Office reports, and the Medicaid Analytic Extract dataset. Findings reveal pronounced differences among states in these key areas. This study offers critical insights for policymakers, emphasizing the importance of expanding service variation, increasing slot allocation, incorporating participant direction more broadly, and enhancing generosity.