Yes, home attendant services face cuts before nursing-home care for dementia patients. Justice in Aging explains in its HCBS primer for older adults that federal law requires nursing-facility coverage while home-based services stay optional. Home attendant services means a paid aide helps at home with bathing, dressing, toileting, walking, and eating. FactCheck.org, summarizing federal estimates, reports in its Medicaid spending review that the 2025 law cuts Medicaid spending by about $911 billion over 10 years.
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Table of Contents
- Why nursing-home care is harder to cut
- Why home attendant care faces risk first
- What a home-care cut looks like
- What dementia families should do now
Why nursing-home care is harder to cut
States that take part in Medicaid must keep the nursing-facility benefit. They cannot drop that benefit to close a budget gap.
That rule gives nursing-home care a legal floor. A state can change payment rates or review need, but it cannot end the category itself.
Why home attendant care faces risk first
Home attendant care sits in home- and community-based services. Those services are optional for states, so they absorb pressure first when money tightens. Analysts at the Alliance for Care at Home warn that this optional status creates specific first-cut risk.
McKnight's Home Care, reporting KFF findings, describes the backlog in its report on HCBS waiting lists. In 2025, KFF found 41 states had waiting or interest lists with over 600,000 people waiting and average waits around 32 months. A waitlist works as a quiet cut. Families keep eligibility on paper but receive no aide for months or years.
What a home-care cut looks like
Rivkin Radler details the shift in its summary of New York's rule change. Effective Sept. 1, 2025, New York required new home-care applicants to need help with 3 or more daily activities.
Applicants with dementia or Alzheimer's needed supervisory help or cueing with 2 or more activities. Rivkin Radler also reports that the rule applied only to new applicants after that date. Current recipients kept coverage, while future applicants with dementia, brain injury, blindness, or fewer limits faced exclusion.
What dementia families should do now
The 2025 reconciliation law does not directly repeal home-based care. The Population Reference Bureau notes that cuts reach families only if states narrow eligibility, cap enrollment, freeze provider pay, or limit hours, with effects phased over time.
That delay gives families a window to act. Attorneys at Burner Prudenti Law advise families seeking home attendant care to apply early, document supervision needs, and watch waiver waitlists. Keep copies of doctor notes about cueing needs and every waitlist notice.
- Apply before care needs become urgent, since lists can run for months.
- Document daily supervision and cueing for bathing, dressing, toileting, walking, and eating.
- Track state waiver letters, renewal dates, and waitlist position in one folder.
