The Issue

The long-term care (LTC) ecosystem in the United States is facing a growing set of challenges driven by demographic shifts, workforce shortages, and systemic financing issues. As the population ages—particularly the Baby Boomer generation—the demand for long-term services and supports is rapidly increasing. Many individuals prefer to age in their homes or communities, but the infrastructure and workforce necessary to support this shift have not kept pace. Nationally and in Washington, DC, the strain on caregivers—both paid and unpaid—is mounting, creating gaps in the quality, availability, and consistency of care.

A major challenge is the long-term care workforce crisis. Direct care workers—home health aides, personal care aides, and nursing assistants—are often underpaid, lack benefits, and face high levels of burnout. In DC, recruitment and retention of these essential workers are particularly difficult due to the city’s high cost of living and competition from other sectors. Without sufficient investment in training, career pathways, and compensation, the sector will struggle to meet growing needs.

Medicaid, which funds the majority of long-term care services for low-income individuals, poses additional challenges. While DC has made progress in expanding home- and community-based services, the Medicaid reimbursement rates often fail to cover the true cost of care, limiting provider capacity and innovation. The complexity of eligibility and service delivery also creates barriers for families seeking support. Together, these issues underscore the urgent need for policy reform, sustainable investment, and community-based solutions that reflect the values of dignity, independence, and equity for all who need long-term care.