Over the past 18 years, aging and disability services have undergone profound transformation—shaped by demographic change, policy evolution, innovation, and an increasingly clear commitment to person-centered systems. During this time, I have had the privilege of serving as Executive Director of ADvancing States, working alongside state leaders and partners as these systems have evolved.

Policy has moved steadily toward greater integration and flexibility. Medicaid home and community-based services expanded significantly, reflecting a shared commitment to supporting people in their homes and communities rather than institutions. Indeed, in 2008 approximately 37 percent of older adults were served in their homes and communities and 67 percent were served in institutional settings.  As of 2023, that number has reversed and 64 percent of older adults are now served in HCBS settings and 36 percent are served in institutional settings.

One way of gauging the interest in HCBS programming is the growth in interest in the annual HCBS Conference.  When I started in 2008, we were thrilled if 400 people attended the event.  The conference focused solely on Medicaid waivers leaving out the critical role that the Aging Network can play to provide a smaller set of services that are designed to also keep people in their homes.  As of last year, we had over 1700 attendees from every state and three territories in attendance and 90 sponsors.

Along the way, states navigated major federal changes—from the HCBS Settings rule, the Affordable Care Act, to new authorities supporting managed LTSS, value-based purchasing, and integrated care models. At the same time, the Older Americans Act evolved to strengthen caregiver supports, develop no wrong door systems, promote evidence-based programming, improve nutrition services, and develop community-based infrastructure.

The role of states has grown more complex and more central. Agencies increasingly serve as system integrators—aligning aging, disability, Medicaid, housing, public health, and behavioral health systems. Cross-agency collaboration, once aspirational, is now essential.  In recognition of this, early in my tenure as Executive Director, the membership overwhelmingly voted to change the name of the association to the National Association of States United for Aging and Disabilities (NASUAD) in recognition of the populations that aging agencies were increasingly serving both older adults and individuals with disabilities.  At the same time, we offered our services for the state staff who administer the home and community-based waiver for these populations.  The name was changed again in 2019 to ADvancing States to better reflect the goals of the association—to ADvance programs, policies, and services for individuals who are aging, who have a disability and their caregivers so that they can live independently in their homes and communities for as long as they choose.

The workforce crisis has become one of the defining challenges of this era. Persistent shortages of direct care workers, exacerbated by the COVID-19 pandemic, have forced states to confront longstanding issues related to wages, training, career pathways, and job quality. The pandemic itself reshaped the field—revealing both deep vulnerabilities and extraordinary resilience, accelerating innovation, and underscoring the essential role of LTSS systems in public health and emergency response.

Technology and data have also transformed practice. From electronic case management and quality measurement to remote service delivery and enabling technologies, states are using new tools to improve access, accountability, and outcomes—while grappling with equity, privacy, and implementation challenges.

Perhaps most importantly, the past 18 years have brought a stronger, clearer voice to people who use services and their families. Self-direction, lived experience, cultural competence are no longer peripheral concepts; they are central to how success is defined.

In recognition of the need to continue to grow a strong state workforce, we created an Alumni Leadership Network so that members who have served in key roles can continue to provide valuable guidance and mentorship to newer leaders.  We also created the Next Gen program five years ago to develop a new cohort of HCBS leaders.  Over my 18 year tenure, I have been blessed to have worked alongside some of the most visionary leaders in government.

The years ahead will demand even greater adaptability—but they will also offer new opportunities to build systems that are more responsive and centered on the dignity and preferences of every person they serve.

Sincerely,

Executive Director, ADvancing States