Home- and Community-Based Services Spending and Living Arrangements Among Older Adults.

Abstract

The US population is aging rapidly, increasing the future demand for assistance with aging in place. To examine the association between higher state allocation of long-term care spending to home- and community-based services (HCBS) and the likelihood of group quarters residence, coresidence with adult children, Medicaid enrollment, and migration among older adults with and without independent living difficulties. This repeated cross-sectional study used state-year fixed-effect models of American Community Survey microdata to analyze how changes in states' allocation of long-term care spending to HCBS was differentially associated with aging-in-place indicators and Medicaid enrollment among older adults with vs without independent living difficulties. The study was conducted and data were analyzed between October 2025 and April 2026. Share of state's long-term services and support budget on HCBS from 2008 to 2020. Medicaid enrollment, group quarters residence, coresidence with adult children, within-state migration, and out-of-state migration. Of the 7.35 million older adults in the sample, 17.1% had independent living difficulties. Those with independent living difficulties were older (mean [SD] age, 80.44 [8.73] vs 73.38 [6.80]), more likely to be female (66.7% vs 53.9%), less likely to be married (33.9% vs 59.6%), and less likely to be born in the US (83.9% vs 86.3%). Regression results indicated that a 20-percentage point increase in state HCBS share was associated with a 2.6-percentage point lower likelihood of group quarters residence (95% CI, -3.23 to -1.87), 0.8-percentage point lower likelihood of coresidence with an adult child (95% CI, -1.11 to -0.49), a 1.0-percentage point higher likelihood of residential continuity (95% CI, 0.64 to 1.29), 0.8-percentage point lower likelihood of within-state migration (95% CI, -1.08 to -0.43), and 0.2-percentage point lower likelihood of out-of-state migration (95% CI, -0.28 to -0.14) among older adults with independent living difficulties compared with those without. The results of this cross-sectional study suggest that higher shares of HCBS spending are associated with a higher likelihood of aging in place among older adults with independent living difficulties without markedly increasing Medicaid enrollment, supporting the targeted expansion of HCBS services.