For nearly all of her 73 years, Roselie Aiello lived on the family cattle ranch outside Mount Shasta, a rugged stretch of land she once helped run as a working butcher alongside her father. But last summer, as her body finally gave out from decades of physical labor, she and her brother John faced a decision familiar to countless California families: it was time for her to leave home.
What followed was a nine-month struggle that exposed a stark gap in how the state’s Medi-Cal program treats older adults depending on where they live — a gap that ultimately led to a new pilot program aimed at giving rural Californians more say in how and where they age.
John had moved back to the ranch to help his sister with daily tasks like bathing and dressing, but caring for her while also managing the property and his own work as a writer became unsustainable. The siblings agreed that Roselie, who qualifies for Medicaid, should transition into assisted living.
That’s when John discovered a frustrating reality: Medi-Cal does not fund assisted living care in Siskiyou County — or in 42 other counties across California. Only 15, mostly in urban areas, offer that option through what’s known as an assisted living waiver.
The disparity leaves many rural seniors with only one real alternative: a nursing home, even when their needs don’t require that level of institutional care, simply because they cannot afford to pay for assisted living privately.
“You’re wasting money by dumping somebody like my sister in a skilled nursing facility and lessening her quality of life and her chance at doing better,” John said. “By doing this, it makes no fundamental sense.”
**A statewide problem coming into focus**
California is bracing for a dramatic shift in its population — within a decade, one in four residents will be over 60. State officials have said they want to help older adults age in their own communities rather than in institutions. But whether that promise is fulfilled often depends on which managed care organization administers Medi-Cal benefits in a given county, and what services that plan chooses to offer.
Roselie is covered by Partnership HealthPlan, the dominant Medi-Cal managed care provider across a swath of Northern California, serving nearly a million residents. In 15 counties, it’s the only option available to Medi-Cal enrollees.
According to the California Department of Health Care Services, managed care organizations are “encouraged” — but not obligated — to offer optional benefits known as community supports, which can include help with the cost of assisted living, temporary rental assistance, respite care and in-home personal care. These fall under CalAIM, the state’s sweeping effort to modernize Medi-Cal. Even after related waivers expire at year’s end, these community support benefits are expected to continue.
Dustin Lyda, a spokesperson for Partnership, said the plan opted not to include an assisted living benefit due to cost concerns and a shortage of qualified facilities in the rural communities it serves. Any change, he said, would require evidence that assisted living leads to better outcomes than nursing homes. Still, he acknowledged the shortcomings.
“There’s definitely a lot more work that we need to do on our end to navigate the more rural areas,” Lyda said.
Maura Gibney, executive director of California Advocates for Nursing Home Reform, said the lack of options compounds an existing shortage in rural regions.
“There’s not a lot of options to begin with in rural counties,” Gibney said. “You take (the assisted living waiver) off a table, which already has a history of a long waiting list, and the options are pretty bleak.”
**Fighting for a place close to home**
John initially assumed his sister would have to leave Siskiyou County altogether, since it offers just one Medi-Cal-approved facility — a nursing home. Roselie had previously stayed at an assisted living facility in neighboring Shasta County and felt at home there, but Partnership doesn’t cover assisted living costs in that county either.
The plan instead offered to place Roselie in Sonoma County — roughly five hours from the family ranch. The Aiellos refused, worried the distance would cut Roselie off from the relatives she relied on for emotional support.
“If you remove her totally from a family contact, she would not be thriving right now. She needs to see family,” John said. “When there were resources available that fit her needs in Redding — that’s the closest point to her home county — why do I need to move her to Oakland, to Los Angeles, to San Diego?”
For nine months, John pushed back — sending emails, making calls, and enlisting Roselie’s doctor to advocate on her behalf, all while trying to secure her a spot at the Shasta County facility. The process took a toll on both of them.
“He was doing all of this to help me,” Roselie said. “Where was it going to end?”
**A system with built-in gaps**
Advocates say most people would rather remain in community settings than move into nursing homes, which tend to be significantly more expensive to operate. But nursing home capacity is limited and should be preserved for people who genuinely need round-the-clock medical supervision, Gibney said.
“We really try to help people look at the other options that exist for remaining in the community,” she said. “You’re going to have better health outcomes, better quality of care, if you can stay in the community and out of an institutional setting.”
Still, the picture isn’t entirely one-sided. Dr. Kenneth Lam, a geriatrician and assistant professor at the University of Colorado Anschutz Medical Campus, noted that people in assisted living are sometimes hospitalized more often than nursing home residents, which can offset some of the anticipated savings.
“The evidence suggests that it’s a trade-off,” he said.
State officials confirmed that managed care contracts aren’t competitively bid, and plans aren’t required to offer specific community supports like assisted living assistance as a condition of their contracts.
“Whether a plan chooses to provide specific community supports is not a factor in contract renewal, which focuses instead on overall compliance with state and federal performance standards,” said Tessa Outhyse, a spokesperson for the Department of Health Care Services.
Partnership’s state contract, originally set to expire in December, has been extended to 2029 after California delayed its broader process for awarding managed care contracts. Lyda said demand for community supports, including requests for assisted living help, has been rising steadily. But even in counties where such benefits exist, waitlists can stretch on for months.
Statewide, the number of new enrollees approved for an assisted living waiver actually declined at the start of 2025, even as the waitlist kept growing. By September, more people were waiting for a waiver than were actually receiving one.
Gibney said the sequence itself can be part of the problem — many Medi-Cal recipients are advised to join the waitlist before they’ve even applied for the funding, adding to the delays. Some spend months waiting only to learn they don’t qualify.
“It’s a lot of shifting sand, that’s what people are finding themselves in the middle of,” Lam said. “They’re being told that they get to choose, but it’s a complex choice.”
**A new chapter for Roselie**
In March, Roselie finally moved into Sundial Assisted Living in Shasta County — the very facility she and John had hoped for from the start. Two months earlier, Partnership had agreed to cover her care, offering her a spot in a new pilot program launched July 1 that expands assisted living access to select members of its network. There’s no formal application process; eligible members are referred through healthcare providers or can request consideration directly.
The pilot is designed to test whether expanding assisted living coverage leads to better health outcomes and lower costs overall.
“Success would also be having these individuals being able to continue to receive care within their community setting, being in their home,” Lyda said. “We know that that is more impactful to health than being completely taken out of a familiar area.”
The transition hasn’t been simple for Roselie, who has been hospitalized twice since moving to Sundial and spent a brief stint back in a nursing home. But socially, she has flourished — making new friends, teaching card games to fellow residents, and receiving visits from caretakers and neighbors during her hospital stays.
“I’m looking at it like this: It’s a new adventure,” she said.
John remains uneasy about his sister’s health and whether Sundial will be a lasting solution. He’s relieved the fight paid off, but still troubled that it took so much effort to get there.
“I don’t understand why I was the guy fighting for everybody,” he said. “I’m just one person trying to support myself, trying to take care of a family member.”
Original source: CalMatters
