2020 National Report on In-Home Care Affordability and Access

by Jennifer L. Gaskin and The Senior List Team.

Even before the coronavirus pandemic began pushing the U.S. medical system to its breaking point, Americans were spending billions on home health care — $103 Billion in 2018 alone.

By 2026, we’re expected to spend more than $170 billion covering in-home care, which doesn’t include unpaid care provided by family members, neighbors or other loved ones. Add to that projections that the supply of workers will be far short of what’s needed to keep up with skyrocketing demand (some experts have said the supply crisis will be nothing short of catastrophic), and it’s easy to see why so many families are concerned about their ability to access this care when it’s needed for their loved ones.

Key Findings

Here’s a look at the topline results from our analysis:

  • Kansas is the highest-ranked state for families and patients, followed by Missouri and Delaware.
  • New York is the No. 1 state for employment of home health and personal care aides, Rhode Island is the best state for nursing assistants, and South Dakota has the highest concentration of registered nurse jobs.
  • The District of Columbia has the highest ratio of nursing and in-home care workers per older resident (302.47 per 1,000) while Florida’s ratio is at the bottom (79.29 per 1,000).
  • Full-time in-home nursing care is a big expense everywhere, but it’s most affordable in Maryland, where a typical nursing worker makes 115.7% of what the average older adult makes per year, compared to 180.2% in California.

Table of Contents


Millions of Americans every year require help with things like housekeeping and personal care to important maintenance and monitoring of chronic medical conditions, and there are millions of people employed across the country in these jobs.

Some of these jobs are expected to surge in demand for the next several years and beyond, led by home health aides, an occupation that the U.S. Bureau of Labor Statistics says will grow by 37 percent through 2028. That compares to an overall growth rate of 5 percent for all occupations, while other jobs that often involve providing in-home health or personal care, such as registered nurses or nurse assistants, also are expected to see better-than-average growth, 12 percent and 9 percent, respectively.

At this point, we must stop and make clear that those figures represent a pre-COVID state, and continued pressure on the American healthcare system, including potentially dangerous strain on in-home care workers.

The state of in-home and nursing care is a complex one, and your view of its strengths and weaknesses likely depends largely on your perspective. After all, what’s considered ideal for, say, a personal care aide in terms of high wages may be just the opposite for the individual or family needing to access these services without breaking the bank.

Still, these services aren’t always affordable for every person or every family, and there are huge variations across the country in the expected costs of in-home and nursing care. Plus, in many places across the country, the supply of workers was dwindling long before the COVID-19 lockdown. So which states’ residents have it best in terms of access and affordability?


To understand the in-home and nursing care market, we’ve analyzed data for three major types of jobs that are most likely to be involved in providing in-home care — home health and personal care aides, nursing assistants and registered nurses — and they all do slightly different things. Understanding the distinctions can be helpful in diagnosing how well each state is handling the in-home care crunch:

  • Home health and personal care aides: Generally, home health aides complete tasks like taking a person’s temperature or blood pressure or helping administer medications, while personal care aides’ tasks are more often limited to non-medical services, like cooking, cleaning or providing social interaction. Some professionals will provide both types of service.
  • Nursing assistants: Sometimes referred to as nursing aides, nursing assistants can provide basic care like measuring and recording vital signs as well as helping with day- to-day activities like bathing and dressing.
  • Registered nurses: The most experienced of all three major in-home and nursing care jobs, registered nurses can provide the highest degree of hands-on medical care, assessing an individual’s condition, monitoring medical equipment and performing diagnostic tests.

We’re using those broad but distinct occupations to help paint the picture of which states are best for patients, individuals and families and for nursing and in-home care workers, and we’ve ranked each state from top to bottom across these areas:

  • Employment of home health and personal care aides per 1,000 jobs
  • Employment of nursing assistants per 1,000 jobs
  • Employment of registered nurses per 1,000 jobs
  • Total nursing and in-home health workers employed per 1,000 residents 65 and older
  • Unfilled nursing and in-home care jobs openings per 1,000 people 65 and older
  • Percentage of in-home care jobs unfilled for 30+ days
  • Average annual cost of in-home help as percentage of typical 65 and older income
  • Average annual cost of nursing care as percentage of typical 65 and older income

Each state was assigned a value equal to its rank in each category, and 51 was the best possible score a state could receive in a category.

Summary Rankings

Access to care is largely a two-pronged notion — being able to find compassionate, qualified professionals to provide services and being able to pay for those services. Striking this balance is a difficult notion, especially for in-home care, which is notoriously expensive and often falls outside the realm of what insurance or Medicare will cover.

Our analysis of which states are best for patients and families attempts to balance the two sides of the access equation, and it’s clear that in some states, finding and affording in-home care will be much easier than in other states.

We determined that families will have the easiest time with this mission in Kansas, followed by Missouri and Delaware. The lowest-ranked state for individuals and families, according to this methodology, is Nevada.

Category Rankings

Let’s take a closer look at state rankings in each of the eight categories that went into our ranking of access to nursing and in-home care.


The more people are employed in a given job, the more likely it is that those who need to use those services will be able to find someone qualified and compassionate, and some states have a clear advantage in certain areas.

Home health and personal care aide employment has by far its highest concentration in New York, which is likely a result of the huge concentration of population in New York City. However, South Dakota and Florida, a state well-known for its high percentage of older residents, have the lowest employment figures for home health and personal care workers.

Nursing assistant jobs are heavily concentrated in Rhode Island and North Dakota, while these services may be harder to come by in the District of Columbia and Arizona.

More registered nurses are employed per 1,000 jobs in South Dakota than in any other state, though West Virginia is fairly close. They are less prevalent in Utah and D.C.

While it’s true that in-home health and nursing workers tend to account for a smaller percentage of all jobs in D.C., when we compare them to the population most likely to need in-home nursing care and other help, residents of the nation’s capital may have the best situation overall, with about 302 workers per 1,000 residents 65 and older. Possibly due to a high ratio of older residents, Florida has the worst ratio.

The supply of qualified workers ebbs and flows as economic conditions change, and in many states, job openings for nursing and in-home care workers are going unfilled — often for more than a month. For families, this could be a signal that it will be tougher to find skilled professionals.

For example, in Massachusetts, according to data published by SimplyHired, for every 1,000 seniors in the state, there are about nine nursing and in-home care jobs that have gone unfilled for more than a month, compared to just 0.85 in Delaware.

Even focusing our attention only on in-home care jobs, which often require less training and fewer certifications, in some states, huge percentages of these jobs have yet to be filled. About three in four of these jobs posted through SimplyHired in Wyoming have been vacant for more than a month.


There’s no one arrangement for funding in-home help, and what insurance or Medicare will cover could depend on the individual person’s health status and any supplemental policies they have. But a good way of understanding how affordable these services are is to compare them to what the typical older adult earns in each state.

Our analysis, clearly though perhaps not surprisingly, shows that skilled nursing care, such as that provided by registered nurses or nursing assistants, is considerably more expensive than homekeeping services and other hands-on personal care that falls outside the scope of medical care. Additionally, it’s safe to assume our estimates are conservative. That’s because they’re

based on a formula that includes 44 hours of work per week for 52 weeks for one individual, and large home care service providers may charge clients much more than the going hourly rate.

In most states, full-time assistance in the form of in-home help is less than what the average 65 and older person makes in a year, while in one state, North Dakota, the numbers are nearly identical.

Full-time nursing care, calculated as an average of the annual wage figures for registered nurses and nursing assistants, is higher than the typical annual income of older adults in every state.

State Details


Everybody wants to believe that when they need it, qualified compassionate in-home care will be there, but that depends on states being able to attract experienced, trained individuals who can perform these services. Still, it’s clear some states are ahead of the game in balancing being places where these people want to work with ensuring this important care is affordable for families.

Data Sources

Here’s a look at the data underlying this report:

  • Annual rental cost, Zillow Rent Index, States
  • Job openings, pulled from and in April 2020
  • Employment and wages, Bureau of Labor Statistics, May 2019 publication
  • Household income and population figures, U.S. Census Bureau, most recent publications on all topics