Demographic trends forecast greater racial and ethnic diversity among America’s growing older adult population (ACL, 2021). America’s older adults are also living longer, making them more likely to need long-term services and supports (LTSS). Within LTSS, the essential services that help people age in place by delivering care in people’s homes and communities are commonly known as home and community-based services (HCBS). Generally, people with LTSS needs prefer HCBS over care delivered in institutional settings.

With support from Arnold Ventures this project set out to explore whether the HCBS system is prepared to meet the needs of this growing and increasingly diverse aging population. More specifically, whether the system is prepared to meet the needs of an aging dually eligible population from communities of color. A population who are most impacted by poverty, have greater levels of unmet needs and often the most complex health statuses. Our project was guided by two research questions:

•  What disparities in access to home and community-based services (HCBS) exist for dually eligible beneficiaries of color?
• How can we mitigate the disparities through policy change?

In order to answer these questions we used multiple study methods including: a comprehensive literature review; quantitative data analysis of Health and Retirement Study (HRS); key informant interviews; and focus groups with older adults of color who are dually eligible for Medicare and Medicaid.

Key findings across this research include:

• Demonstrated disparities with respect to HCBS spending, access, and outcomes among communities of color. These disparities include increased unmet LTSS needs; a lack of help from either unpaid care sources (i.e., family or friends) or from HCBS; limited access to HCBS; poorer health outcomes; and lower HCBS utilization and expenditures.
• Limited access to culturally and linguistically appropriate HCBS services.
• Limited access to information, training, and support for caregivers and care recipients
• Ongoing impacts of systemic and interpersonal racism including inequities in the supply of community level resources and provider bias.
• Usual source of care as a key element in reducing racial and ethnic disparities in HCBS utilization and reported unmet need, but limited access to managed care among communities of color.

Using these findings, we developed policy recommendations which we believe will help address racial and ethnic disparities within HCBS services by enhancing a combination of: (1) access; (2) quality of care delivery; (3) cultural responsiveness; (4) workforce quality, and (5) data practice.

Our top policy priorities include:

• Connect beneficiaries with a usual source of care: A usual source of care, as operationalized by the HRS, is a medical provider or health care location (such as a doctor’s office, clinic or health center) that an individual will usually go to if they are sick or in need of guidance related to their health.
• Strengthen the HCBS workforce: A robust workforce that is high-quality, culturally and linguistically competent, and equipped to meet beneficiaries’ needs is essential to reducing disparities in care.
• Engage Beneficiaries, Family, and Caregivers: Engagement should be a key ingredient in all phases of policy creation and service provision including design, dissemination, and implementation.

The policy section of the report includes recommendations on how to advance each of the above policy priorities, as well as targeted approaches to improve access, quality of care delivery, cultural responsiveness, workforce quality, and data practices within HCBS services. Additionally, the report provides a high-level summary of the research that informed our policy recommendations.