As Massachusetts marks the 250th year of American independence, we face a profound contradiction. We celebrate the ideals of life, liberty, and the pursuit of happiness while those ideals slip further from reach for the commonwealth’s most vulnerable residents: older adults, people with disabilities, and those who care for them.
This assessment draws from “The State of the Commonwealth as Viewed by Older Adults, People with Disabilities, and Caregivers,” a comprehensive policy statement endorsed by 31 participants in Dignity Alliance Massachusetts, a broad coalition dedicated to transformative change in long-term care.
Here in Franklin County, the demographic shift is particularly rapid. While roughly 17,000 residents — 24% of the population — are now over 65, by 2030 that figure will reach 34%, far exceeding the statewide average of 22%. With more than half our county’s residents living in rural communities, the barriers to aging with dignity are especially acute. When sidewalks are broken, public transportation is limited, and home care workers must travel long distances, rural elders face compounded isolation and vulnerability.
Statewide, nearly one in five Massachusetts residents is now over 65, with those over 85 projected to grow by more than 30% in the coming decade. We boast the nation’s second-best longevity rate and highest insurance coverage. Yet longevity collides with affordability in devastating ways: one-third of older households fall below the Elder Index, unable to meet basic needs and age in place with dignity. For those living alone, the crisis is starker — nearly 57% of adults 65 and older cannot afford even a no-frills lifestyle.
Now federal cuts threaten to deepen this crisis. The “One Big Beautiful Bill Act” of 2025 is expected to slash $1.75 billion from MassHealth beginning this fiscal year. State officials warn this will force “very difficult choices” and could leave tens of thousands without adequate coverage. These are not abstract numbers — they represent neighbors who will lose home care, medications, and the support that keeps them independent.
The commonwealth’s response to aging has been shaped by decades of institutional inertia and industry influence. While Massachusetts has earned national recognition for its commitment to home and community-based services, particularly through the Personal Care Attendant program, a deeper problem persists: our anachronistic commitment to maintaining nursing home “heads in beds.”
This institutional bias restricts choice and violates the principle established by the Supreme Court’s Olmstead decision — that people with disabilities have the right to receive services in the least restrictive setting. When a widow who could thrive in assisted living is instead funneled into a nursing home simply because Medicaid will pay for one but not the other, we have failed her and our values.
Massachusetts remains a national outlier in refusing to offer a robust Medicaid-funded assisted living option. For decades, MassHealth has maintained a posture overly deferential to the nursing home lobby. Assisted living is less expensive and often more appropriate than nursing home care, yet thousands are denied this choice because of industry influence over policy.
Pending legislation — H.791/S.474, An Act Relative to Assisted Living and the Frail Elder Waiver — would direct MassHealth to create an assisted living alternative priced at no more than 80% of nursing home costs. This reform is essential to restoring dignity and autonomy in long-term care. The question is whether our legislators will prioritize people or industry profits.
The barriers to aging with dignity extend far beyond institutional care. The Massachusetts Rental Voucher Program remains overwhelmed, with waiting lists stretching for years. For older adults living alone — many financially eligible but unable to access support — independence is deferred indefinitely. The Home Modification Loan Program offers zero-interest loans up to $50,000, but funding lags far behind need. With 80% of low-income seniors lacking sufficient assets, even modest accessibility investments become impossible without public support.
Community infrastructure tells another story of neglect. Broken sidewalks, inaccessible pedestrian signals, and costly public transportation undermine independent living. Many municipalities still fail to provide hybrid access to public meetings, effectively silencing older adults and people with disabilities from civic participation.
For nursing home residents, the indignity is measured in dollars and cents. The Personal Needs Allowance for MassHealth-funded residents remains frozen at $72.80 per month —unchanged for decades despite soaring costs. A grandmother cannot afford basic toiletries. This is not a budget detail; it is a moral failure.
Behind every statistic is a life diminished: the man with disabilities waiting years for a rental subsidy, the older adult denied behavioral health support until crisis forces hospitalization, the facility unable to staff a social worker because regulations written in the 1970s no longer meet modern needs.
These are not isolated tragedies. They are systemic failures shaped by deliberate policy choices. Industry lobbyists secure billions for facilities while families wait months or years for home care services. National associations resist staffing standards. Developers profit from assisted living while MassHealth refuses to fund it. The state continues to fund institutional care without tying dollars to measurable quality outcomes.
Dignity Alliance Massachusetts brings together nursing home resident advocates, disability rights organizations, legal service entities, mental health organizations, health policy experts, faith-based groups, and labor organizations to advance policies that revolutionize long-term care. The path forward requires more than incremental adjustments. We must honor consumer choice by ensuring long-term care settings reflect individual preference and willingness to accept risk. We must install community-first gatekeepers to review nursing home admissions with a bias toward community living. We must adopt the Medicaid-funded assisted living benefit, expand rental subsidies, fund accessibility improvements, raise the Personal Needs Allowance, and modernize social work regulations.
This is not simply about budgets — it is about values. Affordability is dignity. Independence is dignity. Civic participation is dignity.
The founders of Massachusetts envisioned a “city on a hill,” a model society where neighbor helps neighbor, where the vulnerable are cared for, and where every citizen sustains the common good. That vision was not meant to be a relic of history but a living promise.
As we mark 250 years since our nation’s founding, we are called to renew that promise. To show that Massachusetts can be an example of justice, compassion, and shared responsibility. A commonwealth where sidewalks are safe, homes are accessible, care is affordable, and civic life is open to all.
Together, we can build that commonwealth. Together, we can ensure that dignity, independence, and participation are not privileges, but rights. That is the legacy we must leave — worthy of the ideals of 1776 and the generations who entrusted us with their vision of liberty and justice for all.
James A. Lomastro, PhD, is 78, resides in Conway and is a member of Dignity Alliance.