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A landmark snapshot of America's long-term care landscape compiled by the Centers for Medicare & Medicaid Services (CMS) reveals that far fewer people, just 1.5 million, received institutional services like nursing home care in fiscal year 2023, compared to 8.4 million who benefited from home and community-based services (HCBS). This data, detailed in CMS's October 17, 2025, LTSS Rebalancing Brief, shows that HCBS now accounts for 87.1% of Medicaid long-term services and supports (LTSS) users, a clear sign that the tide is turning toward care that allows people to stay in their homes and communities rather than in facilities.
For readers of the Aging-in-Place Planning and Elderlaw Blog, this represents validation that aging in place is not only preferred by seniors but increasingly supported by the health care system as a safer and less expensive alternative. As we've championed in "The High Value of Home Health Care" and in our Smart Home Toolkit, HCBS empowers independence at home, saving 42% compared to facilities. This article explains CMS statistics in plain terms, zeroes in on Ohio's ranking, and explores what it means for those seeking to age in place, offering hope amid ongoing challenges such as waitlists and quality concerns.The National Picture: A Dramatic Tilt Toward HCBS
The CMS brief, analyzing FY 2023 data from all 50 states and D.C., paints a picture of progress in rebalancing LTSS away from costly institutions toward flexible, community-focused options. Key highlights include:
- User Breakdown: Of the 9.7 million Medicaid LTSS users, 87.1% (8.4 million) received HCBS, while 12.9% (1.5 million) were in institutional settings like nursing homes or intermediate care facilities. This marks a 5% increase in HCBS users since 2019, driven by states' efforts to expand waivers in light of lessons from COVID.
- Spending Shift: HCBS claimed 63.8% of the $228.6 billion total LTSS expenditures ($145.9 billion), up from 58% in 2021. Institutional care took 36.2% ($82.7 billion), reflecting a $20 billion swing toward home-based options.
- Demographics: 31.7% of HCBS users were 65+, 60.5% aged 21-64, showing HCBS serves working-age disabled adults too, easing family caregiving burdens.
- State Variations: Top performers like Oregon (99.4% HCBS users) contrast with laggards like Mississippi (45.6%), highlighting policy disparities.
Missouri's Standout Performance: A Model for Aging in Place Success
Missouri deserves special attention in this national picture. The state ranks among the top performers in HCBS rebalancing, with 94.2% of its Medicaid long-term services and supports users receiving care in home or community settings, well above the national average of 87.1%. Missouri's Family to Family (F2F) waiver and consumer-directed options allow seniors and families to hire relatives as paid caregivers, providing up to 40 hours per week of attendant care, respite, and home modifications. With average funding around $1,800 per month and relatively short waitlists (typically 3 months or less), Missouri has made home-based care accessible and flexible for thousands.
For Missouri residents seeking to age in place, this strong showing means faster access to aides, therapy, and support services that help keep loved ones safe and independent at home, often at a fraction of the cost of institutional care. It also demonstrates that when states prioritize HCBS, families gain real breathing room, reducing caregiver burnout and the risk of unwanted nursing home placement due to overburden. Missouri's success story is proof that smart policy can turn the tide toward home, and it offers a blueprint for other states to follow.
Ohio's Ranking: Strong Access, But Quality Concerns LoomMissouri deserves special attention in this national picture. The state ranks among the top performers in HCBS rebalancing, with 94.2% of its Medicaid long-term services and supports users receiving care in home or community settings, well above the national average of 87.1%. Missouri's Family to Family (F2F) waiver and consumer-directed options allow seniors and families to hire relatives as paid caregivers, providing up to 40 hours per week of attendant care, respite, and home modifications. With average funding around $1,800 per month and relatively short waitlists (typically 3 months or less), Missouri has made home-based care accessible and flexible for thousands.
For Missouri residents seeking to age in place, this strong showing means faster access to aides, therapy, and support services that help keep loved ones safe and independent at home, often at a fraction of the cost of institutional care. It also demonstrates that when states prioritize HCBS, families gain real breathing room, reducing caregiver burnout and the risk of unwanted nursing home placement due to overburden. Missouri's success story is proof that smart policy can turn the tide toward home, and it offers a blueprint for other states to follow.
Ohio ranks in the top quartile nationally for its HCBS user rebalancing ratio at 93.3%, meaning 93.3% of its LTSS users receive home or community services, also far above the national average of 87.1%. This reflects Ohio's robust programs, such as PASSPORT (for those aged 60 or over), which serves more than 25,000 people with $2,000/month aides, and MyCare Ohio for dual eligibles. Per capita HCBS spending is $382 (29th nationally), showing solid but not leading investment. For Ohioans seeking to age in place, this is encouraging: High HCBS usage means shorter waitlists (average 3-6 months) and better access to aides, therapy, and mods, reducing fall risk and caregiver burden. With 25% of Ohioans over 65 by 2030 (Ohio Department of Aging 2025), it's a lifeline for staying home.
But the "high concern" rating for Ohio's HCBS fee-for-service and managed care users (CMS 2023) flags potential quality issues: Inconsistent provider oversight and understaffing in some agencies could undermine effectiveness. For families, this means vetting providers rigorously using our tips, tricks, tools, and strategies, and layering advanced directives with SDM for coordination.What It Means for Those Seeking to Age in Place: Opportunity Amid Challenges
The CMS data is a beacon for aging in place: HCBS's dominance shows the system values home over institutions, where staffing shortages heighten infection, fall, and malpractice risks. Ohio's 93.3% ratio means more seniors have access to waivers like PASSPORT, funding aides to prevent institutionalization. Nationally, HCBS spending saves per person costs compared to facilities.
Challenges persist: Waitlists (6-12 months national) and disparities (e.g., Mississippi's 45.6%) leave almost a quarter of a million seniors and their families in limbo (MACPAC 2025). Ohio's "high concern" signals the need for quality vigilance.Conclusion: HCBS as Home's Ally
CMS's data proves HCBS is winning; Ohio's ranking offers hope for aging in place. While this article has provided a thorough overview of the stats and strategies, it is by no means comprehensive. The landscape evolves rapidly. Readers must remain vigilant. By combining awareness with proactive planning, families can safeguard independence and thrive while aging in place.
