Hundreds of thousands of older adults and younger people with disabilities are living in nursing homes only because that is where Medicaid drives them. They have no clinical need for skilled nursing care, and, if better options were available, many could be living in other settings, including their own homes.

Medicaid—the joint state/federal health care program for the very poor—sends frail older adults to nursing homes even though they often are the most expensive and least appropriate option. And, as covid-19 has taught us, they can be a high-risk setting for many. The Kaiser Family Foundation reports that as of Aug. 20, more than 70,000 residents and staff of long-term care facilities (including nursing homes and some assisted living facilities) have died from the pandemic.

This is a complicated story, so let’s unpack it by first describing Medicaid long-term supports and services (LTSS) and then looking at nursing homes.


States must provide people who have few financial assets, very low incomes, and high levels of personal care needs with long-term care. But Medicaid is required to provide care only in nursing facilities.

States can apply for one of many special waivers that allow for care in the community. And every state has at least one. Indeed, more than half of Medicaid LTSS dollars are spent on care in settings other than nursing homes. But the level, quality, and definition of that care varies widely among the states.

Many states provide only a few hours a day of personal care.  For frail older adults without a capable caregiver to navigate a complex medical and long-term care system, staying at home is difficult, if not impossible. And many of those who want care at home often cannot get it at all. in 2017, more than 185,000 older Medicaid beneficiaries were on waiting lists for home-based care.

Not every frail older adult can—or should—live at home. And there are many options besides nursing homes, such as assisted living, group homes, and other forms of congregate care.

But Medicaid pays for room and board in only in nursing homes. In theory, an older adult could move into subsidized low-income housing, but only about 6 percent of rental housing for older adults in the US is subsidized, and many of those apartments are inappropriate for someone with physical limitations.

Nursing homes

That leaves many frail low-income seniors with only one choice. They can stay at home, try to pay their own housing costs (not just rent but utilities and other expenses), and hope for Medicaid home care support. Or move to a nursing home. For many, it is no choice at all.

Nursing homes often are two very different businesses operating in the same building.

They provide short-term skilled nursing care, often to patients just discharged from a hospital, and mostly paid by Medicare. And they provide a home for about 700,000 long-stay residents—most of whom will remain until they die. About 80 percent of long-stay residents are on Medicaid. While the program’s daily payment varies widely from state to state, it averages about $200.

What is the clinical benefit of living in a nursing home? In theory, it is because it can provide skilled medical care for those who need it—a much higher level of care, for example, than an assisted living facility.  But do residents need that level of care?

About half have dementia or some cognitive impairment. Many need help with activities such as bathing or eating.  But while those residents need a high level of personal care, they don’t need regular treatment from a doctor or an RN.

Skilled care

In a 2017 report, AARP found that about 11 percent of nursing home residents had a low level of personal care needs. And in states such as Kansas, Missouri, and Oklahoma, 20 percent or more required only this modest assistance.

And far fewer need skilled nursing care. A 2018 report by Charlene Harrington and coauthors for the Kaiser Family Foundation found that, for example, just 1.6 percent required intravenous therapy, 4.5 percent required tube feeding, and 5.7 percent had a catheter. Only one in five needed injections.

Far more needed help with bowel or bladder incontinence or required some form of rehabilitation. But many of those services could be provided by a well-trained aide, therapist, or licensed practical nurse. They do not require an RN in a nursing home.

Even for those who need higher levels of treatment, nursing homes rarely have sufficient skilled nursing staff available. Harrington found that in 2016, RNs were available for an average of less than 1 hour per resident day. The government requires that an RN director of nursing be on site for only eight hours a day.

The reality is that hundreds of thousands of frail older adults are living in nursing homes only because that’s where Medicaid sends them. Today, few have better options. But regulatory and payment reforms and a fundamental redesign of Medicaid LTSS could change that.