Every state that responded to KFF's 2025 survey of Medicaid officials reported shortages of home care workers, and direct support professionals topped the list, cited by 48 states. KFF published the findings on Jan. 5, 2026, in an issue brief on how states pay Medicaid home care providers.
The brief, by Alice Burns, Maiss Mohamed and Molly O'Malley Watts, draws on KFF's 23rd annual survey of Medicaid home care programs. State officials completed it between April and July 2025, and every state except Florida responded.
Which workers are short
After DSPs (48 states), states most often reported shortages of nursing staff (47), personal care attendants (46), case managers (44), home health aides (41), certified nursing assistants (39), community mental health workers (38) and therapists (30). KFF notes that states were not given a definition of shortage.
States blamed low reimbursement rates, a lack of qualified providers and high turnover.
Closures
In the prior year, 41 states reported home care providers closing permanently. Adult day programs were cited most often (28 states), followed by group homes (23) and assisted living and in-home providers (22 each).
What states pay
Raising payment rates was the most common state response, followed by education and training efforts. Some states also set minimum shares of rates that must go to worker pay. Still, among 34 states reporting an hourly rate for personal care, more than half paid under $20 an hour as of the survey. Where a state reported several rates, KFF used the median.
What comes next
Under the federal Medicaid access rule, states must begin reporting certain home care payment rates in July 2026, and the requirement that 80% of some payments go to worker compensation begins in 2030. Only 15 states could report all the required rates in the survey. KFF also noted that the 2025 reconciliation law is estimated to cut federal Medicaid spending by $911 billion over a decade.
Why this matters for providers and DSPs
The survey confirms that the DSP shortage is national, and that it predates the 2025 federal Medicaid cuts now taking effect. Providers can use these state-level figures when making the case for rates that match what the work demands.