The families counting on home-based care can't wait any longer
Rep. Justin Fleming November 6, 2026 | 2:43 PM
Six-year-old Scarlotte Sell has an extraordinarily rare genetic condition that requires kidney dialysis and a feeding tube. She depends on around-the-clock skilled nursing care from Angels of Care to stay in the comfort of her own home.
A few weeks ago, I spent an afternoon with Scarlotte and her father, Brandon, an HVAC technician, in their home in south-central Pennsylvania, and it was easy to see what that care means to their family.
For the Sells, Private Duty Nursing services monitor Scarlotte’s dialysis, manage her feeding tube, and let Brandon go to work to support his family. But finding those nurses is getting harder. Medicaid reimbursement rates for Private Duty Nursing and Personal Assistance Services have not received increased investment in recent years.
Pennsylvania’s rates now trail every neighboring state by 25% to 75%, and nurses and caregivers are leaving for better pay, sometimes in another state entirely.
The consequences show up directly in Scarlotte’s life. When a nurse can’t be found, she may miss school, and Brandon may miss work. During one prolonged gap in care, he nearly lost the family’s home. This problem is not unique to the Sells. Nearly 29% of authorized nursing hours in Pennsylvania go unstaffed, and more than 112,500 home care shifts sit unfilled every month, leaving families to patch together care or go without it entirely.
In 2025, two independent studies were commissioned by the state and found that stabilizing the system requires a Medicaid reimbursement rate increase of roughly 23% — more than $800 million. An investment in home-based care is critical if we want to preserve Pennsylvanians’ right to live and age at home.
That investment also makes fiscal sense. Care at home is significantly less expensive than long-term institutional care. Pennsylvania has spent years building policy to move care to the most cost-effective home-based setting. Nearly 78% of Pennsylvanians who receive Medicaid long-term care now receive it at home.
Sustaining that progress requires a home-based care system that can meet that need. When home-based care isn’t available, people get pushed into hospitals and institutions that cost taxpayers far more.
The Pennsylvania General Assembly has taken some steps to address the home-based care crisis. This year’s budget delivered the first meaningful bump to home health nursing rates in more than two decades. But it reached only a narrow slice of the workforce, leaving Private Duty Nursing and Personal Assistance Services untouched.
As Pennsylvania prepares its next budget, lawmakers should ask not just what it costs to invest in home-based care, but what it will cost if we don’t. A meaningful rate increase would let agencies recruit and keep the nurses and caregivers that families depend on, so parents like Brandon can keep working, so older Pennsylvanians can stay in the homes they’ve spent a lifetime building, and so Scarlotte can keep growing up surrounded by her family instead of in an institution. Pennsylvania already knows that home is where people want to be. It’s time our budget reflected that.