How Did we get here?

The broader reality is that the United States intentionally spent decades shifting long-term care away from large institutions and into homes and community settings.

That shift happened for several reasons:

• Many patients prefer receiving care at home rather than in institutions.

• Home and community-based care can often be less expensive than full institutional care.

• Nursing home and long-term care capacity is limited.

• America’s aging population is rapidly increasing demand for caregivers and support services.

Those policy decisions helped create an enormous home-health and caregiving economy across the country.

At the same time, caregiving industries have historically become important entry points for immigrant communities because:

• Caregiving labor is in constant and growing demand.

• Startup barriers for small agencies can be relatively low.

• Family and community support structures often align naturally with caregiving work.

• Medicaid reimbursement systems allow many smaller providers to participate in the market.

None of this automatically produces fraud. In many cases, these systems support legitimate caregiving work performed by real families, aides, nurses, and small business owners trying to serve vulnerable populations.

But when massive reimbursement systems, fragmented oversight, inconsistent technology infrastructure, and rapidly expanding provider networks collide, opportunities for abuse can emerge at scale.