Washington, D.C. — A new national report is sounding the alarm on what could be one of the most significant rollbacks in home-based care in a generation: an estimated 311,879 fewer individuals enrolled in Medicaid home care services by 2034, the direct result of eligibility changes baked into the 2025 reconciliation law.
The findings come from the inaugural 2026 Medicaid Home Care Chartbook, released by the National Alliance for Care at Home and the Research Institute for Home Care. The projections are based on government data covering approximately 3.3 million Medicaid home care recipients in 2023, run through forecasting models to estimate the impact of the new restrictions.
That’s a 9.4% reduction in home care enrollment — and the consequences won’t stop at the front door.
What the Law Changed
The One Big Beautiful Bill Act, passed in 2025, restructured Medicaid in several ways that directly affect who qualifies for home- and community-based services. The changes include more frequent eligibility redeterminations, limits on allowed home equity, community engagement requirements — better known as work requirements — and mandatory cost-sharing for certain services starting in 2028.
According to the report, roughly 75,000 individuals who currently receive home care will face those new cost-sharing requirements when they kick in.
The impact isn’t uniform. States that expanded Medicaid under the Affordable Care Act are expected to see steeper losses. Alaska and Rhode Island could see home care enrollment drop by as much as 30%, while Florida, Minnesota, Mississippi, South Dakota, and Wyoming are projected to lose less than 0.1% of their home care populations.
The Nursing Home Question
For skilled nursing operators, this isn’t an abstract policy debate. When home- and community-based care becomes inaccessible — whether through eligibility loss, cost-sharing burdens, or reduced enrollment — some of those individuals eventually turn up at nursing home doors. Whether facilities will have the capacity, staffing, or reimbursement structure to absorb that shift is an open question.
The sector is already navigating the pressures from Medicaid work requirements rolling out across states, and the chartbook adds another layer of complexity: enrollment growth in home care has already been outpacing the number of available providers, with the ratio of participants per provider climbing from 59 to 1 in 2019 to nearly 66 to 1 in 2023.
Personal care services account for 62.7% of all Medicaid home care claims, and 84% of current home care recipients live in urban areas. Rural home care — where 16% of recipients are concentrated — faces a particularly precarious situation given existing provider shortages.
What Comes Next
Jennifer Sheets, CEO of the National Alliance for Care at Home, said the chartbook is meant to give providers and policymakers a clearer picture of what’s at stake before the eligibility changes fully take hold.
“The insights gained from this report will be critical to shaping future policies that strengthen Medicaid home care services and protect the future of beneficiaries who use Medicaid HCBS,” Sheets said in a statement.
The Alliance and the Research Institute are hosting a webinar to walk through the full report’s findings. For skilled nursing facilities watching the long-term trajectory of Medicaid policy, it’s a dataset worth understanding now — before the numbers stop being projections.
