Key Takeaways

  • West Virginia ranks 50th in the AARP Long-Term Services and Supports (LTSS) Scorecard, with nearly every category rated at the lowest tiers nationally.
  • Over 750,000 people are currently on Medicaid Home and Community-Based Services (HCBS) waitlists nationwide – in the states below, those waits can stretch 8 to 20 years, or in Kentucky’s case, a projected 168 years.
  • Federal Medicaid funding reductions now pose a serious threat to disabled adults in these states, which are the most exposed to cuts.
  • HCBS are optional under federal Medicaid law, meaning they are historically the first services cut when federal funding drops – a pattern already documented in Texas, Florida, and Tennessee.

The ten states in this ranking are home to millions of disabled adults who love where they live, have deep community roots, and navigate daily life with real resilience. The problems described here are not a reflection on those individuals. They are a reflection on decades of policy decisions – funding choices and legislative priorities – that have left disabled residents with insufficient support. The goal of naming these gaps plainly is to equip, not discourage.

Why Federal Medicaid Cuts Will Hit These States Hardest

Ongoing federal Medicaid funding reductions present a serious and immediate risk to disabled adults who rely on home and community-based services. HCBS are optional services under federal law, unlike nursing home care, which states are required to cover. Research published in Health Affairs shows that every time states have faced reductions in federal Medicaid funding historically, HCBS have been the first services cut.

The ten states ranked below were already underfunding HCBS before the latest round of federal pressure. States with less resilient systems have less room to absorb new reductions without cutting services outright.

How These States Were Identified and Ranked

AARP LTSS Scorecard

The AARP Long-Term Services and Supports Scorecard is the most respected national evaluation of state long-term care infrastructure available. It scores every state across five dimensions: Affordability and Access, Choice of Setting and Provider, Safety and Quality, Support for Family Caregivers, and Community Integration. States rated Tier 4 or Tier 5 in Choice of Setting and Community Integration have systems that structurally push disabled adults toward institutional care rather than supporting independent living at home.

HCBS Waitlists as a Severity Signal

Waitlist size and wait time were used alongside AARP scores to gauge real-world impact. A state can score poorly on paper but still move people through its system in a reasonable timeframe – or it can have a waitlist so large that services are effectively out of reach for most applicants. Both dimensions matter. Nationally, over 750,000 people are waiting for HCBS waiver services. In the states below, that statistic has a human face: someone waiting to get help bathing, dressing, or managing medication – often for years.

The 10 Worst States for Disabled Adults, Ranked

West Virginia: Near Last in the Nation Across Nearly Every AARP LTSS Category

West Virginia ranks 50th in the AARP LTSS Scorecard. Nearly every category is rated Tier 4 or Tier 5, with its worst scores in Choice of Setting and Provider and Community Integration – the two dimensions that most directly measure whether disabled adults can live at home rather than in institutions. The state has among the highest disability rates in the country, driven by industry decline, poverty, and rural geography, yet one of the weakest support infrastructures. Per 2023 KFF data, West Virginia reported a waitlist for seniors and adults with physical disabilities, meaning the situation is worsening. The state has also proposed HCBS reductions in response to declining federal funding.

Alabama and Mississippi: Among the Highest Disability Rates, Weakest Infrastructure

Alabama (49th) receives its worst AARP scores in Choice of Setting and Provider and Community Integration – both Tier 5. The state has one of the highest percentages of adults with disabilities nationally, driven by poverty, chronic disease, and occupational injury rates. HCBS waitlists carry multi-year delays, and rural areas face acute provider shortages even when waiver slots technically exist.

Mississippi (47th) ranks in Tier 5 for Safety and Quality and Community Integration. Its ID/DD waiver waitlists run between 2,496 and 2,772 people – smaller in raw numbers than Texas or North Carolina, but served by a provider infrastructure so limited that shorter lists still translate to years of waiting. Mississippi has not expanded Medicaid under the ACA, leaving many disabled adults without consistent coverage access.

Texas: More Than 180,000 People Waiting – With a Documented History of Deep Waiver Cuts

Texas has the largest HCBS interest list in the nation – over 180,000 people. The wait for the Home and Community-based Services (HCS) waiver runs 5 to 15 years depending on region. A 2022 Texas study found that of 18,649 people who reached the top of the STAR+PLUS Waiver interest list, only 6.7% actually enrolled – and over 8% had died while waiting. Texas is also one of five states that do not screen for eligibility before waitlist placement, meaning those 180,000+ numbers are inflated, though the genuine eligible backlog remains enormous. According to documented state records, during previous Medicaid funding pressure, Texas cut IDD waivers by 42% and personal care services by 16% — among the most severe such cuts on record. – among the most severe IDD waiver cuts in the historical record. That history makes the state’s exposure to current federal cuts especially significant.

Kentucky: A Waitlist Analysis Projecting 168 Years to Clear the Backlog

An analysis of Kentucky’s Michelle P. Waiver – which serves adults with physical disabilities who need personal care support to remain in the community – found it would take 168 years to serve everyone currently on the list at the current funding pace. The waitlist stands at 13,026 people, with reported wait times of 8 to 10 years. Kentucky’s overall AARP ranking is 41st, below the national median on every evaluated dimension. The state has a very high disability rate driven by poverty, occupational injury, and chronic disease, and a support system that has been consistently underfunded relative to that need.

Florida, North Carolina, Louisiana, Tennessee, and Oklahoma

North Carolina (42nd) operates the Innovations Waiver for people with intellectual and developmental disabilities – and families who enroll a child today may realistically wait 20 years before receiving services. The state’s population is growing faster than its waiver capacity.

Florida (43rd) is the most complex entry: services are genuinely strong in some counties and severely lacking in others. What places it here is a specific set of structural failures – non-screened waitlists, a history of among the deepest IDD waiver cuts on record (25% during prior Medicaid pressure), late ACA Medicaid expansion, and severe rural-urban inequality in service access.

Louisiana (44th) carries a 14,586-person developmental disability waiver waitlist (per 2023 KFF data), proportionally among the largest in the country relative to population. The state does not publish wait time estimates – itself a warning sign. Louisiana also has one of the highest poverty rates nationally, ranking second in the U.S. as of 2023, and the poverty-disability overlap compounds both financial and service gaps simultaneously.

Oklahoma (45th) has a documented history of Medicaid underfunding relative to disability need and is one of five states that does not screen for waiver eligibility before waitlist placement. Per-capita HCBS investment has been consistently below national averages.

Tennessee (46th) has documented prior cuts during Medicaid funding pressure – 8% reductions to HCBS waivers and 9% to personal care services. Its AARP Tier 4 rating in Support for Family Caregivers reflects a state where formal services are thin, and family members fill the gap by necessity. The ECF CHOICES program for people with intellectual and developmental disabilities is a genuine bright spot, recognized nationally for its employment-focused model – but it exists within a system that remains structurally underfunded overall.

What You Can Do Right Now in Any of These States

Apply for Every Waitlist Today – Delay Compounds

Waitlist position is determined by application date. An 8-year wait that begins today ends 8 years from now. An 8-year wait that begins next year does not. Apply to every applicable HCBS waiver program immediately, and document the application date carefully. If a crisis situation exists – caregiver loss, housing instability – request emergency prioritization in writing.

Know Your Medicaid State Plan Entitlements

Even without a waiver slot, Medicaid state plan services, including home health, are an entitlement – not a waitlisted service. If you qualify for Medicaid, you have a legal right to home health services. These are more limited than a full waiver, but they are not subject to enrollment caps. Check whether your state participates in Community First Choice (CFC), which offers personal care services without waiver enrollment limits for eligible Medicaid recipients.

Contact Your State Protection and Advocacy Organization

Every state has a federally funded Protection and Advocacy (P&A) organization that provides free legal assistance to disabled people. These organizations can help with appeals, emergency placements, and advocacy for legal rights when services are improperly denied or delayed. Key contacts by state:

  • West Virginia: Disability Rights West Virginia
  • Alabama: Alabama Disabilities Advocacy Program (ADAP)
  • Mississippi: Mississippi Disability Rights (MDR)
  • Texas: Disability Rights Texas (DRTx)
  • Kentucky: Disability Rights Kentucky
  • Florida: Disability Rights Florida
  • Louisiana: Disability Rights Louisiana
  • North Carolina: Disability Rights NC
  • Tennessee: Disability Rights Tennessee (DRT)
  • Oklahoma: Disability Rights Oklahoma (DRO)

These Gaps Are Policy Failures – Not Personal Ones. Act Before Cuts Worsen Them.

The waitlists in these states exist because of funding caps – not because services don’t work or people don’t need them. The funding caps exist because state legislatures have not invested enough, and because federal Medicaid cuts are now reducing the matching funds that made even inadequate systems possible. Living in a state that ranks poorly on disability support is the result of decisions made over decades at the legislative level – decisions that can still be changed through sustained advocacy, family voices, and organized community pressure.

Diamonds of Disability

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