From Coverage to Care: Structural Barriers In Hcbs Access for Older Immigrants In New York State

Background and Purpose: Home- and Community-Based Services (HCBS) are central to U.S. long-term care policy supporting aging in place. Yet, older immigrants experience persistent inequities in access to care. Prior research has often relied on insurance coverage as a proxy for access, with comparatively limited attention to the processes that translate coverage into actual service use. This gap obscures where and how inequities emerge. Grounded in a structural vulnerability perspective and a policy pathway framework, this study examines how structural barriers are configured across the transition from Medicaid coverage to HCBS utilization. Focusing on New York State, it identifies where breakdowns occur along the access pathway and how policy design contributes to inequities in care among older immigrants.

Methods: This study employed a mixed-methods design integrating three components. First, weighted logistic regression analyses of the 2019–2023 American Community Survey (ACS) Public Use Microdata Sample (PUMS) examined the association between nativity and Medicaid coverage among adults aged 65 and older in New York State. Second, a structured policy analysis evaluated New York State HCBS-related initiatives across four stages of the access pathway: outreach, eligibility, enrollment and service delivery, and sustainability. Third, a system-level analysis assessed the alignment between HCBS service capacity and the geographic distribution of structurally vulnerable populations across 62 counties in New York State. Measures included provider supply (Licensed Home Care Services Agencies, LHCSA), service utilization (Certified Home Health Agencies, CHHA), and county-level indicators such as older immigrant share and limited English proficiency.

Results: Nativity was not significantly associated with Medicaid coverage, indicating that coverage is not the primary barrier to HCBS access. Instead, structural factors—limited English proficiency, disability status, and income—were strongly associated with coverage outcomes. Policy analyses showed that barriers accumulate along the HCBS access pathway: although outreach and eligibility have expanded, administrative complexity and fragmented policy design constrain enrollment, service progression, and continuity of care. County-level analyses further revealed a mismatch between capacity and utilization. Provider supply (LHCSA) was positively associated with the concentration of older immigrants, whereas service utilization (CHHA) and home-based service use (CHHA) showed no, or only weak, corresponding increases. This divergence suggests that structural barriers suppress service use even where service capacity exists.

Conclusions and Implications: These findings shift the focus of HCBS equity from coverage disparities to pathway-level failures in translating coverage into care. They highlight the importance of care coordination, system navigation, and continuity as critical intervention points. Policy reforms should move beyond eligibility expansion to redesign HCBS systems that address fragmentation and support sustained engagement. In particular, investing in bilingual and culturally competent care coordination, strengthening the role of family caregivers as integrated actors within care systems, and implementing place-based strategies to align services with community needs are essential. Advancing equitable aging in place requires not only coverage but also systems capable of translating coverage into accessible and continuous care.