Defining the Overlooked Middle
This issue brief outlines the operational definition of the Overlooked Middle—the population of older adults who are unable to sustain the costs of long-term services and supports (LTSS) when needed without jeopardizing their daily living expenses and yet are too wealthy to qualify for Medicaid coverage. Little is known about this group of older adults, nor have they been the focus of major public policy initiatives. However, the Overlooked Middle is of key importance to local, state, and federal policy makers given the potential impact this older adult population’s LTSS needs on current and future care systems, Medicare and Medicaid financing, and family caregivers of all ages.
Developed by the LTSS Center @ UMass Boston and Wolf Eagle Enterprises, the issue brief describes the principles and method for arriving at this definition of the Overlooked Middle and uses California as an example of how this definition can be applied to a specific population of older adults.
Advancing Solutions for the Overlooked Middle: A Concept for Accessing Home and Community-Based Care in Medicare
As the population ages, California aims to support older adults and people with disabilities remain safely at home and connected to their communities. Californians in the "Overlooked Middle" lack access to affordable, accessible home and community-based services (HCBS).
The Overlooked Middle population includes Medicare beneficiaries who are at an increased risk of:
- Hospitalization
- Institutionalization
- Financial strain
- Caregiver burnout due to a lack of support options
The California Department of Aging partnered with ATI Advisory and Milliman to explore whether a Medicare-based model could deliver targeted HCBS to the Overlooked Middle, while improving outcomes and reducing and/or not increasing Medicare costs over time. The resulting Medicare Advancing Home and Community Care (MAHCC) model demonstrates the feasibility of designing a targeted, community-based Medicare intervention that can support individuals’ functional needs in a cost-effective way.
Download the MAHCC Model - Advancing Solutions for the Overlooked Middle: A Concept for Accessing Home and Community-Based Care in Medicare report and analysis (2026)