Recognizing the Overlooked Middle:
California's LTSS Financing and Affordability Initiative
Who Are the Overlooked Middle?
The “Overlooked Middle” are a population of older adults and adults with disabilities who are unable to sustain the costs of long-term services and supports (LTSS) when needed without jeopardizing their daily living expenses, and yet they are too wealthy to qualify for Medicaid coverage.
Generally, they are a diverse group of adults ages 50 and older with incomes between 139% and 500% of the Federal Poverty Level. In 2024 dollars, this amount ranges from a low of about $21,000 to a high of $102,000, depending on household size.
The Overlooked Middle is an understudied yet significant group of aging adults who do not qualify for Medicaid, yet if they need paid LTSS they could not afford it without compromising basics living needs.
About This Initiative
California’s Long-Term Services and Supports (LTSS) Financing and Affordability Initiative, led by the California Department of Aging in partnership with the LeadingAge LTSS Center @UMass Boston, gathered national experts to study and better understand older adults and people with disabilities who fall into the Overlooked Middle.
As part of California’s Master Plan for Aging, this research describes:
• Current needs of California’s Overlooked Middle, and likely changes by 2050.
• What they say about their needs and preferences today and for tomorrow.
• Policy and program options in other states that support aging in community, expand service delivery, and stabilize their financial security.
For more information, please see the LTSS Initiative webpage at the California Department of Aging.
Three Research Questions Addressed in This Initiative
Population Analytics: Who are the older adults and people with disabilities in California’s Overlooked Middle population now and how will their socio-demographic and health outlook change in the next 25 years?
Consumer Perspectives: What do California’s Overlooked Middle say about their own needs, values, and preferences for accessing and financing ongoing care and support?
Policy Analysis: What are policies and programs that exist across the nation to serve these individuals, and how might these examples be valuable to meet the unique and changing needs of California’s Overlooked Middle?
Key Demographics and Attitudes of California’s Overlooked Middle
Size and Growth
In 2024, there were 5.5 million Californians ages 50 and older in the Overlooked Middle.
By 2050, this population is projected to grow to 6.9 million, and those 75 years and older will nearly double.
Affordability Risk
Roughly half of California’s Overlooked Middle cannot fully afford to pay for their basic living needs if moderate LTSS costs arise (i.e., about 4 hours of paid care per day, every day).
The risk is higher for women, Black and Hispanic older adults, and those at lower income levels.
LTSS Need Growth
There were 571,000 people in California’s Overlooked Middle who had LTSS needs in 2024. By 2050, this number is projected to reach 1.08 million – an 89% increase.
By 2050, all California counties will see significant growth in the Overlooked Middle with LTSS needs, ranging from 18%
to 148%.
Housing and Home Equity
About two thirds of households in California’s Overlooked Middle own a home. Their median home equity that could be tapped while remaining in their home is about $350,000.
However many worry that using their home’s equity will limit future housing and LTSS choices later, and they do not see tapping home equity as a viable option to pay for LTSS should the need arise.
Consumer Perspectives
California’s Overlooked Middle prioritizes near term basic living needs over planning for future LTSS.
They want programs that protect financial security, preserve choice and control, and help navigate systems.
What We Heard: Voices of the Overlooked Middle
• Low awareness of LTSS risk and coverage options.
• Strong preference to age in their community with autonomy and social connection.
• Homeownership serves as a longevity asset but is not a first choice for financing care; many would only use home equity as a last resort.
What We Found: Policy & Program Options Across the Nation
• Over 200 programs and policies address basic living needs, caregiver supports, transportation, housing, service navigation, and others for aging in community.
• Several programs help the Overlooked Middle make high-value choices and delay rapid spending to Medicaid eligibility.
• Evolving Concept: CDA partnered with ATI Advisory and Milliman to develop a Medicare home- and community-based benefit that combines navigation and community care in a cost-effective way.
Data Spotlight Across California’s 58 Counties: 2023-2050
California’s county level projections show wide variation – the growth of people 50 years and older ranges from –3% to 78% by 2050.
People age 50 years and older with LTSS needs will grow from 24% to 147% across counties by 2050.
Nearly every California county will have at least 13% of its 50 years and older population with LTSS needs fall within the Overlooked Middle.
California LTSS Financing and Affordability Initiative Product List
Final Report
Evaluating the Needs, Preferences, and Potential Avenues of Care Support for California’s Overlooked Middle: Final Report for California’s LTSS Financing and Affordability Initiative
Marc Cohen (UMass Boston) & Gretchen Alkema (Wolf Eagle Enterprises)
This Final Report describes the background and context for California’s LTSS Financing and Affordability Initiative, summarizes additional reports that address the three research questions, and provides reflections on lessons learned.
Population Analytics
Too Much to Qualify for Help, Yet Too Little to Afford Care: Defining Older Adults in the Overlooked Middle.
Marc Cohen (UMass Boston) & Gretchen Alkema (Wolf Eagle Enterprises)
Long-Term Services and Supports in California’s Overlooked Middle Assessing Needs and Affordability.
Richard Johnson & Damir Cosic
Urban Institute
This report provides the conceptual definition of the Overlooked Middle and how it defines the main population focus for California’s LTSS Financing and Affordabilty Initiative.
Using the Dynamic Simulation of Income Model (DYNASIM) with the Overlooked Middle definition, this report identifies California’s current population of middle-income adults 50 and older with LTSS needs and future projections in 2050.
County-by-County Projections for California Populations Age 50+ 2023-2050: Tableau.
Claire Wickersham, Jane Tavares, Marc Cohen (UMass Boston) & Damir Cosic (Urban Institute)
Housing Wealth and In-Home Care: Opportunities and Obstacles to the Use of Home Equity for LTSS in California’s Overlooked Middle.
Jennifer Molinsky & Samara Scheckler
Joint Center for Housing Studies of Harvard University
This data visualization shows the size and projected growth of the Overlooked Middle across California’s 58 counties.
This report analyses housing and home equity trends of California’s Overlooked Middle, summarizes homeowner perspectives on home equity, and offers perspectives on how home equity can be a resource to address LTSS needs.
Consumer Perspectives
Voices from California’s Overlooked Middle: Challenges and Opportunities in Long-Term Care. Findings from Consumer and Stakeholder Engagement Sessions on Aging and LTSS.
Collaborative Consulting & Community Catalyst
The Concerns and Financial Readiness of California’s 50+ Population: Considerations for Long-Term Services and Supports Financing.
Lisa Shugarman & Meg Hefferon
NORC at the University of Chicago
This report summarizes in-person and virtual conversations with California’s Overlooked Middle, family caregivers, and service providers to better understand the top issues, and concerns facing those with LTSS needs in the community.
This report describes results from a survey of Californians ages 50 and older on issues and challenges of meeting LTSS in the community.
Voices from California’s Overlooked Middle: Challenges and Opportunities in Long-Term Care. Findings from Stakeholder Engagement Sessions.
Collaborative Consulting & Community Catalyst
The Program and Policy Preferences of California’s 50+ Population: Considerations for Long-Term Services and Supports Financing.
Lisa Shugarman & Jared Sawyer
NORC at the University of Chicago
This report summarizes virtual conversations with California’s Overlooked Middle and family caregivers to better understand how they might prioritize key solutions to address LTSS needs.
This report describes results from a survey of Californians ages 50 and older focused on potential solutions that prioritize and address LTSS needs in the community.
Policy Analysis
Beyond Medicaid: Innovative Approaches to Support Aging in the Community for the Overlooked Middle.
ATI Advisory
Insights from State Medicaid Innovations to Enhance LTSS Access: Compendium of Long-Term Services and Supports (LTSS) Related Medicaid Waivers
Claire Wickersham, Jane Tavares, & Marc Cohen
UMass Boston
This report identifies various LTSS care models and policies from across the nation that could be considered for California’s Overlooked Middle.
Excel Compendium for ATI Report “Beyond Medicaid”
This report reviews Medicaid LTSS laws and policies used by other states to consider solutions for meeting the LTSS needs of the Overlooked Middle, with case studies of programs in Oregon and Vermont.
Excel Compendium For UMass Boston Report
Pilot Concept: Medicare Advancing Home and Community Care (MAHCC) Model
Advancing Solutions for the Overlooked Middle: A Concept for Accessing Home and Community-Based Care in Medicare.
ATI Advisory
Cost and Savings Analysis for Proposed Medicare Advancing Home and Community Care Model Prepared for California Health and Human Services Agency.
Josh Wingfield, Nick Johnson, & Chris Giese
Milliman
This report explores whether a Medicare-based home- and community-based services (HCBS) benefit, referred to as the Medicare Advancing Home and Community Care (MAHCC) model, could deliver targeted HCBS to the Overlooked Middle, while improving outcomes in a cost effective way.
This report summarizes an analysis of costs and risks projections to pilot the Medicare Advancing Home and Community Care (MAHCC) model.
Meeting the Long-Term Services and Supports (LTSS) Needs of California’s Overlooked Middle: Implications for Policy and Programs – A Synthesis of Stakeholder Engagement and Policy Research.
Eileen J. Tell & Claire Wickersham
UMass Boston
LTSS Survey Question Databank
Claire Wickersham & Eileen J. Tell
UMass Boston
This report summarizes key findings from focus group and surveys of California’s Overlooked Middle and how their priorities align with various programs and services available across the states.
This tool provides a repository of items used in multiple LTSS-related surveys in California and nationally over the last decade.
California LTSS Financing and Affordability Initiative Product List
Final Report
Evaluating the Needs, Preferences, and Potential Avenues of Care Support for California’s Overlooked Middle: Final Report for California’s LTSS Financing and Affordability Initiative
Marc Cohen (UMass Boston) & Gretchen Alkema (Wolf Eagle Enterprises)
This Final Report describes the background and context for California’s LTSS Financing and Affordability Initiative, summarizes additional reports that address the three research questions, and provides reflections on lessons learned.
Population Analytics
Too Much to Qualify for Help, Yet Too Little to Afford Care: Defining Older Adults in the Overlooked Middle.
Marc Cohen (UMass Boston) & Gretchen Alkema (Wolf Eagle Enterprises)
This report provides the conceptual definition of the Overlooked Middle and how it defines the main population focus for California’s LTSS Financing and Affordabilty Initiative.
Long-Term Services and Supports in California’s Overlooked Middle Assessing Needs and Affordability.
Richard Johnson & Damir Cosic
Urban Institute
Using the Dynamic Simulation of Income Model (DYNASIM) with the Overlooked Middle definition, this report identifies California’s current population of middle-income adults 50 and older with LTSS needs and future projections in 2050.
County-by-County Projections for California Populations Age 50+ 2023-2050: Tableau.
Claire Wickersham, Jane Tavares, Marc Cohen (UMass Boston) & Damir Cosic (Urban Institute)
This data visualization shows the size and projected growth of the Overlooked Middle across California’s 58 counties.
Housing Wealth and In-Home Care: Opportunities and Obstacles to the Use of Home Equity for LTSS in California’s Overlooked Middle.
Jennifer Molinsky & Samara Scheckler
Joint Center for Housing Studies of Harvard University
This report analyses housing and home equity trends of California’s Overlooked Middle, summarizes homeowner perspectives on home equity, and offers perspectives on how home equity can be a resource to address LTSS needs.
Consumer Perspectives
Voices from California’s Overlooked Middle: Challenges and Opportunities in Long-Term Care. Findings from Consumer and Stakeholder Engagement Sessions on Aging and LTSS.
Collaborative Consulting & Community Catalyst
This report summarizes in-person and virtual conversations with California’s Overlooked Middle, family caregivers, and service providers to better understand the top issues, and concerns facing those with LTSS needs in the community.
The Concerns and Financial Readiness of California’s 50+ Population: Considerations for Long-Term Services and Supports Financing.
Lisa Shugarman & Meg Hefferon
NORC at the University of Chicago
This report describes results from a survey of Californians ages 50 and older on issues and challenges of meeting LTSS in the community.
Voices from California’s Overlooked Middle: Challenges and Opportunities in Long-Term Care. Findings from Stakeholder Engagement Sessions.
Collaborative Consulting & Community Catalyst
This report summarizes virtual conversations with California’s Overlooked Middle and family caregivers to better understand how they might prioritize key solutions to address LTSS needs.
The Program and Policy Preferences of California’s 50+ Population: Considerations for Long-Term Services and Supports Financing.
Lisa Shugarman & Jared Sawyer
NORC at the University of Chicago
This report describes results from a survey of Californians ages 50 and older focused on potential solutions that prioritize and address LTSS needs in the community.
Policy Analysis
Beyond Medicaid: Innovative Approaches to Support Aging in the Community for the Overlooked Middle.
ATI Advisory
This report identifies various LTSS care models and policies from across the nation that could be considered for California’s Overlooked Middle.
Excel Compendium for ATI Report “Beyond Medicaid”
Insights from State Medicaid Innovations to Enhance LTSS Access: Compendium of Long-Term Services and Supports (LTSS) Related Medicaid Waivers
Claire Wickersham, Jane Tavares, & Marc Cohen
UMass Boston
This report reviews Medicaid LTSS laws and policies used by other states to consider solutions for meeting the LTSS needs of the Overlooked Middle, with case studies of programs in Oregon and Vermont.
Excel Compendium For UMass Boston Report
Pilot Concept: Medicare Advancing Home and Community Care (MAHCC) Model
Advancing Solutions for the Overlooked Middle: A Concept for Accessing Home and Community-Based Care in Medicare.
ATI Advisory
This report explores whether a Medicare-based home- and community-based services (HCBS) benefit, referred to as the Medicare Advancing Home and Community Care (MAHCC) model, could deliver targeted HCBS to the Overlooked Middle, while improving outcomes in a cost effective way.
Cost and Savings Analysis for Proposed Medicare Advancing Home and Community Care Model Prepared for California Health and Human Services Agency.
Josh Wingfield, Nick Johnson, & Chris Giese
Milliman
This report summarizes an analysis of costs and risks projections to pilot the Medicare Advancing Home and Community Care (MAHCC) model.
Meeting the Long-Term Services and Supports (LTSS) Needs of California’s Overlooked Middle: Implications for Policy and Programs – A Synthesis of Stakeholder Engagement and Policy Research.
Eileen J. Tell & Claire Wickersham
UMass Boston
This report summarizes key findings from focus group and surveys of California’s Overlooked Middle and how their priorities align with various programs and services available across the states.
LTSS Survey Question Databank
Claire Wickersham & Eileen J. Tell
UMass Boston
This tool provides a repository of items used in multiple LTSS-related surveys in California and nationally over the last decade.
LTSS Initiative Partners
California Department of Aging
| Under the umbrella of the California Health & Human Services Agency, the California Department of Aging (CDA) provides statewide leadership, oversight, and funding for programs and services that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the State. Through California’s aging network, CDA supports Californians in accessing services and resources that promote dignity, choice, and connection. CDA is the principal state partner in implementing the Master Plan for Aging.
For more information, visit www.aging.ca.gov |
 |
LeadingAge LTSS Center @UMass Boston
| The LeadingAge LTSS (long-term services and supports) Center @UMass Boston strives to conduct applied research that will serve as a foundation for government policies and provider actions to improve the quality of care and quality of life for vulnerable older adults. The LTSS Center’s primary mission is to translate research into policy and practice.
For more information, visit www.ltsscenter.org |
 |
Wolf Eagle Enterprises, LLC
| Wolf Eagle Enterprises, LLC is a strategic engagement firm that delivers clear-eyed insights and resource-conscious solutions to health, aging, and care delivery industries. |  |
Learn more at www.wolfeagleenterprises.com
ATI Advisory
| ATI Advisory is a healthcare research and advisory services firm that helps decision-makers across the healthcare ecosystem reduce complexity, control costs, and improve how care is delivered.
Learn more at www.atiadvisory.com |
 |
Collaborative Consulting
| For over 16 years, Collaborative Consulting has worked with community-based organizations, government entities, multi-sector coalitions, foundations, and health systems to do three things: envision better futures, chart actionable courses, and create the conditions to improve lives. |  |
Learn more at www.collaborativeconsulting.net
Community Catalyst
| Community Catalyst advances health justice by helping communities shape the health systems that affect their lives and economic security.
Learn more at www.communitycatalyst.org
|
 |
Joint Center for Housing Studies of Harvard University
| The Joint Center for Housing Studies of Harvard University strives to improve equitable access to decent, affordable homes in thriving communities. We conduct rigorous research to advance policy and practice, and we bring together diverse stakeholders to spark new ideas for addressing housing challenges. Through teaching and fellowships, we mentor and inspire the next generation of housing leaders.
Learn more at www.jchs.harvard.edu |
 |
Milliman
| Milliman leverages deep expertise, actuarial rigor, and advanced technology to develop solutions for a world at risk. We help clients in the public and private sectors navigate urgent, complex challenges so they can meet their business, financial, and social objectives.
Learn more at www.us.milliman.com |
 |
NORC at the University of Chicago
| NORC at the University of Chicago conducts research and analysis that decision-makers trust. As a nonpartisan research organization and a pioneer in measuring and understanding the world, we have studied almost every aspect of the human experience and every major news event for more than eight decades. Today, we partner with government, corporate, and nonprofit clients around the world to provide the objectivity and expertise necessary to inform the critical decisions facing society.
Learn more at www.norc.org |
 |
Urban Institute
| The Urban Institute is a nonprofit research organization founded on one simple idea: To improve lives and strengthen communities, we need practices and policies that work. For more than 50 years, that has been Urban’s charge. By equipping changemakers with evidence and solutions, together we can create a future where every person and community has the opportunity and power to thrive.
Learn more at www.urban.org |
 |
LTSS Initiative Partners
California Department of Aging
| Under the umbrella of the California Health & Human Services Agency, the California Department of Aging (CDA) provides statewide leadership, oversight, and funding for programs and services that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the State. Through California’s aging network, CDA supports Californians in accessing services and resources that promote dignity, choice, and connection. CDA is the principal state partner in implementing the Master Plan for Aging.
For more information, visit www.aging.ca.gov |
|
LeadingAge LTSS Center @UMass Boston
| The LeadingAge LTSS (long-term services and supports) Center @UMass Boston strives to conduct applied research that will serve as a foundation for government policies and provider actions to improve the quality of care and quality of life for vulnerable older adults. The LTSS Center’s primary mission is to translate research into policy and practice.
For more information, visit www.ltsscenter.org |
|
Wolf Eagle Enterprises, LLC
| Wolf Eagle Enterprises, LLC is a strategic engagement firm that delivers clear-eyed insights and resource-conscious solutions to health, aging, and care delivery industries. | |
Learn more at www.wolfeagleenterprises.com
ATI Advisory
| ATI Advisory is a healthcare research and advisory services firm that helps decision-makers across the healthcare ecosystem reduce complexity, control costs, and improve how care is delivered.
Learn more at www.atiadvisory.com |
|
Collaborative Consulting
| For over 16 years, Collaborative Consulting has worked with community-based organizations, government entities, multi-sector coalitions, foundations, and health systems to do three things: envision better futures, chart actionable courses, and create the conditions to improve lives. | |
Learn more at www.collaborativeconsulting.net
Community Catalyst
| Community Catalyst advances health justice by helping communities shape the health systems that affect their lives and economic security.
Learn more at www.communitycatalyst.org
|
|
Joint Center for Housing Studies of Harvard University
| The Joint Center for Housing Studies of Harvard University strives to improve equitable access to decent, affordable homes in thriving communities. We conduct rigorous research to advance policy and practice, and we bring together diverse stakeholders to spark new ideas for addressing housing challenges. Through teaching and fellowships, we mentor and inspire the next generation of housing leaders.
Learn more at www.jchs.harvard.edu |
|
Milliman
| Milliman leverages deep expertise, actuarial rigor, and advanced technology to develop solutions for a world at risk. We help clients in the public and private sectors navigate urgent, complex challenges so they can meet their business, financial, and social objectives.
Learn more at www.us.milliman.com |
|
NORC at the University of Chicago
| NORC at the University of Chicago conducts research and analysis that decision-makers trust. As a nonpartisan research organization and a pioneer in measuring and understanding the world, we have studied almost every aspect of the human experience and every major news event for more than eight decades. Today, we partner with government, corporate, and nonprofit clients around the world to provide the objectivity and expertise necessary to inform the critical decisions facing society.
Learn more at www.norc.org |
|
Urban Institute
| The Urban Institute is a nonprofit research organization founded on one simple idea: To improve lives and strengthen communities, we need practices and policies that work. For more than 50 years, that has been Urban’s charge. By equipping changemakers with evidence and solutions, together we can create a future where every person and community has the opportunity and power to thrive.
Learn more at www.urban.org |
|
LeadingAge LTSS Center @UMass Boston
Contact: Marc Cohen, Co-Director of the LeadingAge LTSS Center @UMass Boston
Media Inquiries: Jennifer McGivney, jennifer.mcgivney@umb.edu
California Department of Aging
More Information: LTSS Financing and Affordability Initiative webpage
LeadingAge LTSS Center @UMass Boston
Contact: Marc Cohen, Co-Director of the LeadingAge LTSS Center @UMass Boston
Media Inquiries: Jennifer McGivney, jennifer.mcgivney@umb.edu
California Department of Aging
More Information: LTSS Financing and Affordability Initiative webpage