Advancing rural aging policy in California: recommendations for state policy on housing, long-term services and supports, and health care access

Rural communities are aging faster than urban and suburban areas and bear a higher burden of disability and chronic conditions, intensifying demand for long-term services and supports (LTSS), accessible housing, and health care (Cohen & Greaney, 2023; Monnat, 2025). This demand collides with longstanding structural constraints: geographic isolation, workforce shortages, chronic underinvestment, and thin service infrastructures that disadvantage low-density regions where distance and limited capacity make uniform policy models less feasible (Bennett et al., 2019; Rhubart et al., 2021). Together, these cross-domain challenges define a persistent rural aging equity gap. California’s Multisector Plan for Aging (MPA), known as the Master Plan for Aging, is a model now adopted or explored by 37 states, offering a pivotal platform to coordinate across sectors (West Health, 2024). However, translating statewide frameworks into equitable outcomes for rural communities requires intentional engagement and policy adaptation. In 2022, The SCAN Foundation launched the Rural MPA Initiative, supporting coalitions across three rural regions spanning seven counties. Grounded in collective impact and community-engaged research principles (National Academy of Medicine, 2022), regional coalitions convened cross-sector advisory committees and engaged residents historically underrepresented in planning and policy processes. Over three years, 227 community members and professionals provided qualitative input through focus groups, listening sessions, and interviews. This input was coupled with secondary data to identify barriers and develop locally grounded action plans. Translating statewide frameworks into equitable outcomes for rural communities requires intentional engagement and policy adaptation. In 2025, community-identified challenges and recommendations from the three regions were synthesized and refined through iterative consultation with 82 state and local experts, including advocacy organizations, government agencies, and rural providers, resulting in the Rural Aging in California: Policy Brief Series focused on long-term services and supports (LTSS), housing, and health care access (DeLange Martinez et al., 2025a). This article describes the cross-domain challenges identified by rural older adults, caregivers, and providers and presents corresponding implementation-oriented policy recommendations codeveloped with state and local experts and adapted for other states. Although grounded in California, this approach provides a replicable model for ensuring that state MPAs reflect unique local needs, resulting in more inclusive plans. Long-term services and supports (LTSS) encompass the spectrum of paid and unpaid assistance such as personal care, medication management, and specialized housing or community programs that people with disabilities and chronic conditions need over time. LTSS includes home and community-based services (HCBS), institutional facilities, and caregiver support. In rural California, these services are fragmented and difficult to navigate, placing an immense burden on older adults, individuals with disabilities, and family caregivers. A significant disconnect exists between formal policy language describing LTSS and the lived experiences of rural community members. Three structural barriers are particularly salient: insufficient support for family caregivers, complex and difficult-to-navigate systems, and an unstable direct care workforce. Limited awareness of available programs and services, uncertainty about eligibility, and cultural norms of self-reliance reduce service use even when programs exist. Low wages, long travel distances, limited training, and high turnover among direct care workers reinforce service instability and caregiver burden, leaving many rural older adults to rely solely on informal networks or to forego care altogether. Table 1 summarizes the structural barriers shaping rural LTSS challenges and the corresponding state policy recommendations developed to address them. Some recommendations could apply to more than one challenge (see also DeLange Martinez et al., 2025b). Long-term services and supports: challenges and policy recommendations. Expand Older Americans Act (OAA) caregiver support programs (respite, education, counseling) Conduct targeted outreach to help caregivers self-identify Expand Medicaid Home- and Community-Based Services (HCBS) options that allow payment of family caregivers, with rural-specific training and navigation supports Simplify enrollment and recertification processes Strengthen Aging and Disability Resource Connections (ADRCs) as single points of entry Fund case management for individuals just above Medicaid eligibility Support enrollment across Medicaid and state-funded HCBS Fund benefits counseling and caregiver education Pilot bridge supports and relocation assistance for near-eligible households Identify new revenue sources to fund a statewide long-term care benefit Establish a statewide direct care workforce registry, beginning in rural areas Establish tiered wage scales for specialized certifications and higher-acuity care (e.g., dementia, behavioral health) Reimburse travel time and mileage, including travel from workers’ to clients’ homes Align Medicaid and non-Medicaid HCBS reimbursement rates with the true cost of rural service delivery Establish competitive, tiered wages that reflect the complexity of care provided Expand benefits (health care, paid leave, retirement) Offer retention incentives Develop portable benefits that paid workers retain across employers and care settings Invest in rural workforce stabilization funds Establish career advancement pathways with compensated peer mentorship and training roles Establish statewide direct care worker advisory councils with meaningful rural representation Scale modular training through rural community colleges and workforce partnerships Fund stipends, tuition, and device/connectivity support for family caregivers Expand rural access to dementia- and disability-specific training These challenges echo established research indicating that rural LTSS are often fragmented and rely heavily on families (Coburn & Lundblad, 2017; Henning-Smith & Lahr, 2018). Family caregiving is more prevalent in rural areas and frequently occurs without support from formal systems (Miller et al., 2023). Geographic isolation, limited transportation, and workforce shortages constrain access to paid home care, intensifying reliance on community and church networks (Dill et al., 2023; Miller et al., 2023; Patano et al., 2024). Direct care workforce shortages are more severe in rural settings, where high turnover and limited training undermine HCBS delivery (Kallas et al., 2023). The policy recommendations in Table 1 emphasize scaling and adapting established programs and tools such as Medicaid HCBS, Older Americans Act programs, and workforce investments to account for rural geography and capacity constraints. Prioritizing adaptation and integration of existing programs enhances feasibility in rural settings, where long travel distances, limited infrastructure (including public transportation), and workforce instability directly affect service delivery and reliability. Housing functions as a foundational determinant of rural older adults’ ability to age safely and remain in their communities. Housing is inextricably linked to health outcomes and caregiving capacity; instability after an illness or disaster can trigger a cascade of crises for older adults and their caregivers. The rural housing system is under strain: fixed incomes are outpaced by rising costs, accessible homes are scarce, navigation barriers are complex, and vulnerability to displacement from disasters or eviction is acute. Furthermore, distance and transportation constraints dictate which housing options are feasible, and gaps in services and case management make it harder to remain safely housed when care needs increase. Table 2 summarizes the primary community-identified challenges within the housing domain and the corresponding state policy recommendations developed to address them through affordability, supply, housing quality, navigation, and cross-system coordination (see also DeLange Martinez et al., 2025c). Housing stability for rural older adults: from community-identified challenges to policy recommendations. Target housing and homelessness resources to older adults Require local housing plans to address the needs of low-income older adults and require local jurisdictions to allocate dedicated funding for adults 55+ Expand flexible housing pools to braid funding across housing, aging, and health systems and stabilize housing during transitions Expand tax credits, bonds, and grants to develop and preserve affordable senior housing Increase incentives for rural landlord participation in housing vouchers Expand home-sharing programs Increase permanent supportive housing in rural areas Promote co-location of affordable housing with onsite services like adult day centers, case management, and transportation services Expand funding for home repair, accessibility, and climate-resilient retrofits Expand home modification program eligibility to include manufactured and mobile homes Fund infrastructure upgrades in Mobile Home Parks to support safe aging in place Fund flexible rural transportation models (e.g., volunteer drivers, on-demand services) Support mobility management programs Invest in community centers that co-locate services to reduce travel burden Make permanent and scale housing navigation and stabilization programs, including Medicaid-supported housing services and state-funded homelessness prevention initiatives Increase rural funding for case management, navigation, and flexible financial assistance that can be deployed quickly during transitions Strengthen rental protections and enforcement in rural areas Expand funding for eviction prevention and culturally and linguistically accessible legal aid Deploy mobile legal clinics and authorize Community Justice Workers in rural areas Reform homelessness data systems to capture hidden homelessness in rural areas Require age-disaggregated reporting across housing and homelessness programs Integrate housing data with Adult Protective Services (APS) and aging services Track outcomes by age, gender, race, ethnicity, and geography to surface rural disparities Strengthen coordination among Continuums of Care, Area Agencies on Aging (AAAs), ADRCs, APS, Centers for Independent Living, Housing Authorities, and Medicaid programs Align accountability across systems through shared protocols, referral pathways, and information sharing Fund disaster navigation for older adults Simplify disaster recovery applications Expand climate-resilient housing investments and technical assistance Support disaster preparedness through resilience hubs, mutual aid networks, and inclusion of aging and disability providers and individuals with lived experience in local emergency planning Ensure emergency transportation plans explicitly include older adults and individuals with disabilities The housing challenges elevated through the Rural MPA Initiative align with research identifying rural housing stock as older, more likely to require repairs, and less accessible, while affordable rental options remain critically limited (Oberdorfer & Wiley, 2014). Rural communities also lack a full continuum of housing options that accommodate changing care needs, and rural older adults experience higher levels of unmet accessibility needs than urban counterparts (Anarde, 2019; Lee et al., 2025). Furthermore, the homeless population is aging with predisposing personal vulnerabilities (e.g., poverty and social isolation), structural factors (e.g., the lack of affordable housing), and the absence of a safety net (e.g., inadequate health care and social service networks) (Aron et al., 2001; Henderson et al., 2023). The recommendations in Table 2 emphasize a coordinated state response that scales proven tools (e.g., vouchers, home repair and modification programs, legal aid, and disaster navigation) while strengthening data systems to make rural older adult housing instability visible to policymakers. Collectively, these recommendations reflect a prevention-oriented approach that stabilizes housing before a temporary disaster becomes a long-term crisis and that strengthens housing plus services capacity where rural options are thinnest. Long waits for appointments, the compounding burden of transportation, and a pervasive struggle to navigate care define rural health care access—barriers exacerbated for those with disabilities or limited English proficiency. Critical structural gaps include workforce availability and care continuity, specialized geriatric and dementia expertise, integrated behavioral health care support, care coordination during transitions, transportation and digital infrastructure, and culturally responsive, trusted care. A cycle emerges where delayed or foregone care increases risks, caregiver strain, and preventable institutionalization. Table 3 summarizes the primary community-identified challenges within the health care domain and the corresponding state policy recommendations developed to address them (see also DeLange Martinez et al., 2025d). Health care access for rural older adults: from community-identified challenges to state policy recommendations. Expand rural training pipelines and residencies across primary care, behavioral health, emergency medicine, caregiving, and key specialties Support team-based, interdisciplinary care models through scope-of-practice alignment and reimbursement Provide rural recruitment and retention incentives (e.g., loan forgiveness, housing support, tax credits) Stabilize rural providers through targeted Medicaid rate adjustments and supplemental payments. Expand geriatric and dementia training in primary care and postgraduate education Fund continuing education on aging, disability, dementia, LGBTQ+ care, and culturally responsive care Support dementia-capable care models and caregiver education integrated into primary care Expand single points of entry for information, behavioral health support, counseling, and care coordination Strengthen hospital–community partnerships in discharge planning Improve interoperability and shared accountability across health and social care systems and fund electronic health record (EHR) upgrades in rural safety-net clinics Develop standardized discharge protocols for unhoused and high-risk older adults Fund flexible rural transportation models, including volunteer drivers and mileage reimbursement Stabilize rural Emergency Medical Services (EMS) through targeted state funding to close critical geographic service gaps Invest in broadband availability and affordability and digital literacy for older adults Support and reimburse telehealth navigators to assist patients Protect reimbursement for clinically appropriate virtual care Fund multilingual navigators and community health workers Partner with trusted rural and Tribal organizations, senior centers, community groups, and faith-based groups to deliver health education and support These experiences reflect a broader national paradox where the health care system faces growing complexity alongside declining capacity, a strain felt most acutely in rural regions (Jones & Dolsten, 2024). Access to timely and appropriate health care is a defining challenge for rural aging, shaped by a confluence of workforce shortages, geographic barriers, and fragmented systems. The policy directions in Table 3 move beyond isolated interventions, advocating for an integrated strategy that simultaneously builds the rural health care workforce, strengthens local care coordination, and ensures enabling supports like transportation and broadband are in place. Recent federal policy changes intensify the urgency of state-level rural aging policy action. The 2025 Budget Reconciliation Act (H.R. 1) imposes significant reductions to Medicaid—a primary funder of LTSS and health care for low-income older adults. These federal cuts are disproportionately straining state budgets and rural service infrastructures, where capacity is already thin. The recommendations in Tables 1–3 offer states practical strategies to scale and adapt existing state-administered programs - including recommendations that can be implemented even within a constrained fiscal environment. Importantly, proactive investment in these policies will ultimately yield long-term state savings by preventing costly hospitalizations and avoidable institutionalization. Long-term services and supports are threatened by H.R. 1’s restrictions on Medicaid financing, which make state-level cuts to optional HCBS more likely (ATI Advisory, 2025; Justice in Aging, 2025). Given that rural older adults already face shortages of professional caregivers and insufficient HCBS capacity, further reductions would exacerbate their reliance on unsupported informal networks. At the same time, chronic underfunding of Older Americans Act programs continues to weaken local aging networks responsible for critical outreach, navigation, and caregiver support (Phillips, 2025). Proactive state investment is essential to prevent further erosion of care capacity in these high need areas. Rural housing challenges are also intensified by recent federal shifts. Proposed reductions to rental assistance and changes to federal homelessness policy may disproportionately affect rural older adults, where affordable housing options and local capacity are already limited (Duke, 2025; Sequeira, 2025; U.S. Department of Housing & Urban Development, 2025). In this context, state actions are vital to stabilize housing and preserve evidence-based navigation and prevention strategies. State-level actions around health care are urgent as H.R. 1 reduces projected federal Medicaid spending in rural areas alone by approximately $137 billion over a decade, with the majority of cuts occurring after 2030 (Kaiser Family Foundation, 2025). Although a temporary $50 billion Rural Health Transformation Fund was established for 2026–2030, its adequacy is uncertain and it sunsets just as rural aging populations surge and permanent cuts deepen (Kaiser Family Foundation, 2025). The health care recommendations provide a roadmap for states to use transitional federal funds to build resilient systems through developing the workforce, strengthening coordination, and stabilizing rural providers. The Rural MPA Initiative demonstrates a replicable pathway for translating rural lived experience into state action by pairing community listening with policy mapping and expert consultation, generating implementation-ready, cross-domain recommendations aligned with existing systems. This pathway is urgent as federal funding cuts intensify on state Tables 1–3 state policy recommendations alongside the structural barriers and community-identified challenges are to Although the policy (DeLange Martinez et al., are for California, this article the recommendations for state them within the broader rural aging and the cross-domain through which were The policy recommendations as a of state actions that can be implemented through existing This from (e.g., navigation) to targeted investments that crises like and to foundational systems changes (e.g., rate data that build long-term and can these policy recommendations by on to that rural This of cross-sector policies provides a for states to to federal funding with existing housing, aging, and workforce systems. In it to for strategies that move beyond planning that also as a federal in rural (Coburn & Lundblad, 2017; Rhubart et al., 2021). policy from the Rural MPA Services as older adults and caregivers eligibility, and services, during transitions such as housing or disaster These align with that rural caregivers and residents face and access & Lahr, et al., culturally responsive navigation capacity through aging and disability centers housing and community-based may reduce preventable crises and access to existing navigation benefits support, across systems, and flexible assistance to prevent barriers to service as a Long travel conditions, limited transportation and service were defining of rural research on geographic barriers to access et al., 2023; et al., 2025). Policy explicitly address distance by ensuring travel reimbursement rural In rural housing affordability is often distance from health care, and caregiving policy that include travel flexible transportation, and telehealth with digital literacy as a shortages were in health care, direct care, housing services, case management, and care coordination gaps across the including delayed and capacity et al., to stabilize the rural workforce, such as through wages, training pathways, and reimbursement that rural service are to rural aging Resource Rural housing caregiving strain, and access barriers are often by data systems and that and with for eligibility, and funding (Bennett et al., Rural data systems are often and rural data are communities to need than prevention resources are and response occurs after a and reporting and rural are for equitable policy state the challenges that from the Rural MPA Initiative the of beyond uniform to aging frameworks such as MPAs provide a critical rural requires and investment in local Importantly, rural communities be to adapt models without Policy in rural areas is by eligibility pathways and eligibility where service options are time for housing and long-term care and funding across housing, health, and social service systems. and the higher cost of rural service delivery is critical to providers and stabilizing households during ultimately supporting aging in place. the Rural MPA Initiative demonstrates the of community-engaged that housing, and health care system that would in research build on this approach by the and outcomes of rural aging that capture travel burden, caregiver strain, housing and service access and availability across Although grounded in California, this approach is in other states with rural include cross-sector regional intentional inclusion of historically underrepresented and a pathway from lived experience to state policy by community policy and expert consultation, the recommendations to housing, and social service systems. policies are and and rural aging rural aging equity requires housing, and health care as an integrated policy system shaped by workforce and The Rural MPA community engagement state policy recommendations that reflect rural lived This policy pathway practical for states to that aging policy is equitable and inclusive across rural rural aging equity requires housing, and health care as an integrated policy system shaped by workforce and This was by The SCAN Foundation Rural Policy The community-identified challenges and policy recommendations that this are in the Aging in Rural policy available through The SCAN Foundation (DeLange Martinez et al., 2025d).