By NextBestFitOther health, residential & personal care
Home- and community-based services (HCBS) become an entitlement instead of a capped Medicaid waiver with waiting lists (about 700,000 people were on HCBS waiting lists in 2023). Rates rise 5% to raise direct-care worker pay. Non-medical help (housekeeping) stays out of pocket.
Result
$353.5B
$320.5B → $353.5B
Per resident, per year
$1,036
÷ 341.1M people
Per household
$2,674
÷ 132.2M households
Range
$347.5B–$365.6B
Lean and costly scenarios.
How it's calculated
| # | Step | Arithmetic | Value |
|---|---|---|---|
| 1 | 2024 spending on this service (CMS NHE Table 4) Sources: CMS Office of the Actuary (2025) | $320.5B | |
| 2 | Private health insurance paid $21.1B at 1.10× the reference price → volume Sources: CMS Office of the Actuary (2025) | $21.1B ÷ 1.10× | $19.2B |
| 3 | Medicare paid $4.6B at 1.00× the reference price → volume Sources: CMS Office of the Actuary (2025) | $4.6B ÷ 1.00× | $4.6B |
| 4 | Medicaid paid $199.8B at 1.00× the reference price → volume Sources: CMS Office of the Actuary (2025) | $199.8B ÷ 1.00× | $199.8B |
| 5 | Out-of-pocket spending in 2024 Sources: CMS Office of the Actuary (2025) | $11.2B | |
| 6 | Stays out of pocket (items UHP excludes: 30%) | $11.2B × 30% | $3.4B |
| 7 | Covered out-of-pocket converted to reference-price volume | ($11.2B − $3.4B) ÷ 1.10× | $7.1B |
| 8 | Care UHP takes over, valued at 2024 prices | $233.3B | |
| 9 | Same care valued at the reference price (Average 2024 Medicaid waiver rates) | $230.7B | |
| 10 | Re-priced at UHP rate 1.05× | $230.7B × 1.05× | $242.2B |
| 11 | Price effect (same care, new prices) | $242.2B − $233.3B | $8.9B |
| 12 | Utilization multiplier 1.10× | $242.2B × 1.10× | $266.5B |
| 13 | Utilization effect (more care) | $266.5B − $242.2B | $24.2B |
| 14 | UHP spending on this service | $266.5B | |
| 15 | Plus spending that stays out of pocket | $3.4B | |
| 16 | Plus Other insurance programs (CHIP, DoD, VA) (continues unchanged) | $3.8B | |
| 17 | Plus Other third-party payers & programs (continues unchanged) | $79.9B | |
| 18 | Total national spending on this service under the plan | $266.5B + $3.4B + $83.7B | $353.5B |
| 19 | Change from 2024 | $353.5B − $320.5B | $33.0B |
Trade-off: Prices rise $8.9B (to raise access or wages) and patients receive $24.2B more care.
Sources: CMS Office of the Actuary (2025); KFF (2024)