Skip to main content

    Leer en español

    The people who help

    The people who help: Better pay and training for the people who make a life at home possible.

    About 649,900 people are on waiting lists for Medicaid help at home, most of them with intellectual and developmental disabilities. The workers who give that help are paid little, and more than a third of them leave each year.

    Try it in the sliderTalk to Ryan

    Ryan K. Hertel · heyitskenton

    The problem

    What we're up against.

    • Years on a waiting list.

      649,900 people were on waiting or interest lists for Medicaid home care in 2026. People with intellectual and developmental disabilities made up 72% of them, and waited 38 months on average.

    • Short of workers almost everywhere.

      Direct support professionals were the shortage states reported most, in 48 states, and 41 states saw home care providers close for good within a year.

    • Low pay, fast goodbyes.

      Agencies paid direct support professionals a median $18.39 an hour in 2024, and 37.1% of them left within the year. Nearly two in three who left had been there less than a year, and only one state pays these workers a median wage at or above a living wage for one adult.

    • Turnover reaches the people being helped.

      In one state's study, people whose support workers kept changing had more emergency room visits, more injuries, and more abuse and neglect.

    • Not even counted.

      Federal job statistics have no category of their own for direct support professionals, so the country can't say how many there are.

    What works

    Proven, and ready to grow.

    • Better pay keeps people.

      When San Francisco raised home care pay and benefits, the share of new workers still in the job a year later rose from 39% to 74%. In Oregon, as pay rose, turnover fell from 50.2% to 33.3%.

    • Training, with a mentor.

      In a randomized trial, sites that gave workers competency-based training and mentoring saw turnover fall 13.51%, while turnover at the other sites rose 2.85%.

    • Health insurance, not bonuses.

      Across agencies, lower wages and no health insurance went with higher turnover, and agencies offering signing or referral bonuses had higher turnover, not lower.

    • A pair of eyes, any time.

      Be My Eyes connects blind and low-vision people with sighted volunteers by video, free, and 1 million users have signed up. In a survey of blind and low-vision workers, 83.1% of those who answered used it in daily life.

    What a family could fund

    Where the money goes furthest.

    • A raise that reaches workers.

      A dollar an hour more, over a full-time year of 2,080 hours, costs $2,080 a worker. Home health and personal care aides earn a median $35,800 a year.

    • Training that stays.

      Competency-based training and mentoring across a network of providers: the approach that cut turnover in the trial.

    • Health insurance for the people who help.

      Coverage for support workers where agencies can't offer it, since its absence went with higher turnover.

    • Trained eyes on call.

      Aira's trained visual interpreters cost a person $26 a month on its smallest plan, and are free to use at places that pay for them, which an initiative could do for a whole town.

    Honest limits

    What money can't promise.

    • Medicaid pays most of the bill.

      Medicaid paid 61% of the country's long-term care, 47% of it for care at home, and 48 states raised their payment rates to fight shortages. Private money can't replace that.

    • Raises can fade.

      Oregon's own report warns that turnover may rise again now that pandemic pay boosts have ended.

    • Pay alone isn't a sure thing.

      In Ontario, a minimum wage for home care workers raised their pay without significantly changing turnover.

    • The lists overstate the need.

      Most people on the waiting lists live in states that add people without checking whether they qualify.

    • Less federal money ahead.

      A federal law passed in 2025 is estimated to reduce federal Medicaid spending by $911 billion over the next decade.

    Hard questions

    Asked and answered.

    1. You might ask

      Isn't this the government's job?

      Ryan

      Mostly, yes. Medicaid pays for most of this care, and states set the rates. Private money does the most good where Medicaid doesn't reach: training, health coverage, and proving what works so states can copy it.

    2. You might ask

      Won't a raise end when the money does?

      Ryan

      It can, and Oregon's report says so. A grant can be tied to a state's rate increase, and from 2030 a federal rule sends at least 80% of designated home care payments to workers' pay.

    3. You might ask

      Why pay people when volunteers do it free?

      Ryan

      For a quick look at a label or a sign, volunteers are wonderful, and Be My Eyes is free. But daily, hands-on support is a job, and it already leans hard on 63 million family caregivers.

    4. You might ask

      Wouldn't signing bonuses fix it cheaply?

      Ryan

      The data says no: agencies offering pay incentives and referral bonuses had higher turnover, while wages and health insurance went with workers staying.

    In the slider

    See what your fortune could do here.

    The people who help

    The slider prices this cause with these numbers:

    • A dollar an hour more, over a full-time year of 2,080 hours, costs $2,080 a worker.
    • The whole need is the 4.7 million home health and personal care aide jobs, where most direct support workers are counted, since there's no national count of direct support workers alone.
    • Before payroll taxes, and a raise paid privately ends when the money does unless states raise their rates, as their own reports warn.
    Try it in the sliderTalk to Ryan

    More of the Blueprint

    Keep reading.

    Back to Keep 100

    Sources

    Every number in this chapter, and where it came from.

    1. Source 1: A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2026 (opens in a new tab)

      KFF, 5 October 2026. Checked 22 October 2026.

      Some states add people to their lists without checking eligibility, so not everyone listed would qualify.

    2. Source 2: NCI State of the Workforce for IDD: 2024 Survey Report (opens in a new tab)

      National Core Indicators-Intellectual and Developmental Disabilities, December 2025. Checked 22 October 2026.

      Agencies in the states that took part, not a national count.

    3. Source 3: Payment Rates for Medicaid Home Care Ahead of the 2025 Reconciliation Law (opens in a new tab)

      KFF, 5 January 2026. Checked 22 October 2026.

    4. Source 4: State of the Workforce for IDD 2024: At a Glance (opens in a new tab)

      National Core Indicators-Intellectual and Developmental Disabilities, December 2025. Checked 22 October 2026.

    5. Source 5: The Impact of Direct Support Professional Turnover on the Health and Safety of People with Intellectual and Developmental Disabilities (Friedman) (opens in a new tab)

      Inclusion (American Association on Intellectual and Developmental Disabilities). Checked 22 October 2026.

      One state's random sample, observational: it shows a link, not proof of cause.

    6. Source 6: Message Sent: DSPs Count (opens in a new tab)

      Institute on Community Integration, University of Minnesota, August 2024. Checked 22 October 2026.

    7. Source 7: Living Wages and the Retention of Homecare Workers in San Francisco (Howes) (opens in a new tab)

      Industrial Relations, January 2005. Checked 22 October 2026.

      One county, two decades ago, and not a randomized study.

    8. Source 8: Stability of the Direct Support Professional Workforce Providing Residential Supports to Adults with I/DD in Oregon in 2022 (opens in a new tab)

      Oregon Department of Human Services and OHSU, 2024. Checked 22 October 2026.

      Pay and turnover moved together; the report doesn't test cause.

    9. Source 9: Reducing Worker Turnover in IDD Services By Using Competency-Based Training: Results of a Group Randomized Controlled Study (opens in a new tab)

      Society for Social Work and Research, 17 January 2015. Checked 22 October 2026.

      A conference abstract; the study was later published in the Journal of Intellectual Disability Research.

    10. Source 10: Incentives, Wages and Retention Among Direct Support Professionals: National Core Indicators Staff Stability Survey (opens in a new tab)

      Intellectual and Developmental Disabilities, 1 April 2022. Checked 22 October 2026.

      A snapshot across agencies: it shows links, not proof of cause.

    11. Source 11: About Be My Eyes (opens in a new tab)

      Be My Eyes. Checked 22 October 2026.

    12. Source 12: Remote Sighted Assistance App Use and Thoughts About 'Sighted' Assistance from Artificial Intelligence (opens in a new tab)

      American Foundation for the Blind, AccessWorld, 2024. Checked 22 October 2026.

    13. Source 13: Occupational Employment and Wage Statistics: Frequently Asked Questions (opens in a new tab)

      U.S. Bureau of Labor Statistics. Checked 22 October 2026.

    14. Source 14: Occupational Outlook Handbook: Home Health and Personal Care Aides (opens in a new tab)

      U.S. Bureau of Labor Statistics, 27 August 2026. Checked 22 October 2026.

    15. Source 15: Personal Aira Subscriptions (opens in a new tab)

      Aira, 1 March 2026. Checked 22 October 2026.

    16. Source 16: 5 Key Facts about Medicaid's Share of National Health Spending (opens in a new tab)

      KFF, 3 September 2025. Checked 22 October 2026.

    17. Source 17: Exploring the Results of the Ontario Home Care Minimum Wage Change (opens in a new tab)

      Healthcare Policy, August 2020. Checked 22 October 2026.

    18. Source 18: Caregiving in the US 2025 (opens in a new tab)

      AARP and the National Alliance for Caregiving, 24 July 2025. Checked 22 October 2026.