Family Member Caregivers for Dual-Eligible Medicare/Medicaid Enrollees

This project examined the use of family members (e.g., spouses, children, siblings, and other relatives) to provide paid long-term care services in home and community-based settings. A handful of states have historically allowed family members to be reimbursed as personal care assistants through Medicaid Home and Community-Based Services (HCBS). The use of paid family members is growing nationally as other states expand their consumer-directed personal care programs. Many of these allow beneficiaries to choose their preferred care providers. Paying for family caregivers helps offset the significant costs and burdens of uncompensated family caregiving, and boosts the potential long-term care workforce. While this creates the possibility of the government paying for something that is often provided for “free,” the potential financial return on investment comes from reducing unnecessary admissions to nursing facilities in those cases where there is a shortage of personal caregivers and family members would not be able to provide the service without receiving a payment to support themselves. If family members can be adequately compensated for providing personal care services, this may increase the number of available personal caregivers and the options for the frail elderly to receive long-term care services outside of institutional settings. What was unknown in this approach is whether paying family members to be personal caregivers actually increases the use of HCBS that offsets nursing home admissions, and the level of payment that makes a difference. The way in which California administers its payment rates for personal caregivers in the Medicaid program creates variation in hourly payment rates across the state’s 58 counties.

This investigation provided a natural experiment to examine these questions. We examined post-discharge utilization of long-term supports and services (LTSS) among dual-eligible Californians who were discharged from an acute inpatient hospital stay from 2006-2008.

For more information, contact: Joanne Spetz, PhD, Director, UCSF Health Workforce Research Center on Long-Term Care, [email protected]+



The US is facing a major shortage of workers in long-term care, including those who provide assistance with activities such as eating, bathing, getting dressed. Personal care assistance can enable older adults and individuals with disabilities to remain in their homes and community settings. A number of factors, including long hours and low wages, contribute to the overall shortage as well as high rates of turnover among personal care workers.

In their study, California’s Medicaid Personal Care Assistants: Characteristics and Turnover among Family and Non-Family Caregivers, UCSF Healthcare Workforce Research Center authors Michelle Ko, MD, PhD, Robert Newcomer, PhD, Andrew B. Bindman, MD, Taewoon Kang, PhD, Denis Hulett, MS, and Joanne Spetz, PhD examined two policies aimed at bolstering the personal care assistant (PCA) workforce: (1) paying family members to provide personal care services; (2) paying personal care assistants higher wages. The authors analyzed the relationships between these two factors and the likelihood of turnover among PCAs in California’s Medicaid personal care program, In Home Supportive Services (IHSS). IHSS is the largest Medicaid personal care program in the nation, serving nearly 470,000 recipients in home and community settings. It is also a consumer-directed program, which allows recipients to choose any individual, including family members, to provide care and be paid for these services by Medicaid. In California, family members make up over 60% of IHSS personal care assistants.

The analysis revealed: (1) The likelihood of turnover among family member PCAs was less than half that of non-family PCAs; (2) Higher payment rates for non-family PCAs was associated with a lower likelihood of turnover; and (3) Racial and ethnic minorities with non-family PCAs experienced disproportionately higher rates of PCA turnover. The authors conclude that paying family members to provide care and paying higher wages may be keys to stabilizing the long-term care workforce and improving continuity of care. Further, elder and disabled minorities who do not have family members to provide care likely need additional support to reduce turnover among their PCAs.



Ko, M, Newcomer, R, Bindman, AB, Kang, T, Hulett, D, Spetz, J. Changing home care aides: Differences between family and non-family care in California Medicaid home and community-based services. Home Health Care Services Quarterly, 2020, 39 (1): 1-16 (online Dec 11, 2019).



In California Medicaid home-and-community-based services (HCBS), recipients’ family members receive payment as home care aides (HCAs). We analyzed data on first-time HCBS recipients to examine factors associated with the likelihood of switching HCAs within the first year of services. Those with family HCAs were less than half as likely to change than those with non-family HCAs and racial/ethnic minorities with non-family HCAs had the highest switching rates. Lower wages and local unemployment were associated with switching of non-family HCAs but not family HCAs. Policymakers can foster continuity of home care by paying family members for home care and raising worker wages.

KEYWORDS: Community and home care: staff roles, staffing patterns, staff responsibilities, policies/policy analysis, caregiving: filial, work issues, Medicare/Medicaid