The number of home care providers billing Medicaid has grown in recent years – but new research has found that the number of beneficiaries has increased even faster, exacerbating concerns about access to Medicaid home care.

Participant growth outpacing provider growth is one key finding from the Medicaid Home Care Chartbook 2026, a new annual report co-authored by  The National Alliance for Care at Home (the Alliance) and the Research Institute for Home Care (the Institute). 

“In 2019, there were roughly 59 participants in Medicaid using home care for every provider enrolled in Medicaid delivering home care,” Damon Terzaghi, vice president of Medicaid and home care policy at the Alliance, said on a recent webinar focused on the chartbook’s findings. “By 2023, that grew to 65.6 – almost 66 participants – per provider. So even though we saw growth in providers, we saw faster growth in participants.”

Chartbook researchers leveraged Medicaid claims data, focusing on people receiving home care services – including personal care, private duty nursing, home health aids and respite care. They identified 3.3 million people with home care claims in 2023. Of this population, 45% were dually eligible for Medicare. 

While the number of home care participants continues to grow, the One Big Beautiful Bill Act (OBBBA) is expected to negatively affect enrollment among home care users. The OBBBA drew a “bullseye” on Affordable Care Act (ACA) expansion, Terzaghi said, so the bill’s impact on home care is focused on the ACA expansion population, but the bill’s impacts reverberate beyond that population.

“The expectation is that by 2034 we will see roughly 300,000 fewer home care users than was previously expected … because of OBBA,” Terzaghi said. “Remember, this is trended forward with expected inflationary growth. So this is really 300,000 fewer than would have been enrolled without the law.”

Some of the OBBA’s new policies that may impact eligibility include more frequent redeterminations, restrictions on retroactive Medicaid eligibility criteria, limits on home equity and work requirements.

Impacts from the bill varied from state to state. States including Rhode Island, Alaska, Hawaii, Colorado and Connecticut are expected to lose relatively significant proportions of their overall home care population. Meanwhile, non-expansion states, including Texas, Florida, Georgia and Mississippi, are expected to be impacted to a lesser degree.

The OBBBA will also cause a “substantial” number of individuals enrolled in Medicaid who receive home care services– 75,381 – will be subject to mandatory cost sharing.

“If you recall the OBBA, among the many changes it made, it did require states to charge cost-sharing for individuals enrolled in that ACA expansion population,” Terzaghi said. “The law requires individuals enrolled in the ACA expansion group with incomes above 100% of the federal poverty level to be subject to mandatory cost-sharing for services.”

The chartbook also found that personal care was the most commonly used home care service, accounting for 62.7% of claims. According to the chartbook, this is unsurprising because personal care is the most provided home- and community-based service across the country, and because personal home care is a flexible, person- centered service that addresses a wide range of limitations.