Biden Home Care Plan Could Fail Without at Least $250 Billion


September 17, 2021 5:30 am

Labor, aging, and disability advocates are fighting to get lawmakers to put at least $250 billion toward a plan to expand home and community-based care for the elderly and disabled and improve conditions for the poorly paid workers that tend to them.

The plan, which the White House wants funded at $400 billion over eight years, could fail, though, if Congress ultimately approves an amount that’s less than what states deem adequate. In that case, states could choose not to take the money and leave their Medicaid programs running as is.

“In order for states to take that on, they need to know that the funding will be there, and the funding will be robust enough to allow them to both set up the infrastructure and to deliver the services and the improved wages,” Ai-jen Poo, co-founder and executive director of the National Domestic Workers Alliance, said.

The proposed cash infusion into Medicaid’s Home and Community Based Services program has two goals: reducing waiting lists for support for older and disabled Americans who want to stay in their homes rather than go into assisted living facilities or other institutions, and raising pay for home health care’s largely female, minority workforce.

Medicaid is the largest payer of long-term support services such as home care for the elderly, but states are not required to participate in the home and community-based program.

Home care, though, is much cheaper, overall. The yearly average cost, per person, of a nursing home to Medicaid is $90,000 compared with $26,000 for home care workers, according to Poo.

And although home health workers are one of the fastest-growing segments of the labor market, they typically earn about $17,000 per year, often without benefits, Poo said.

Boosting the program “would be the single largest direct investment in the creation of good jobs for women and women of color in the history of the country,” she said.

Budget Number

The home care initiative began to draw attention when then-candidate Joe Biden put it on his campaign platform. He’s proposed the $400 billion as part of his $2 trillion infrastructure proposal known as the American Jobs Plan.

Advocates, worried after hearing that just $150 billion would be included for the program in the House’s $3.5 trillion budget reconciliation package, succeeded in getting the amount bumped up to $190 billion before the provision was approved by the House Energy and Commerce Committee, said Nicole Jorwic, senior director of public policy at The Arc, a nonprofit that advocates for people with intellectual and developmental disabilities.

“I was really concerned when some people were putting the number 150 on it. That was a level where we wouldn’t be confident we could do it right,” Sen. Robert Casey (D-Pa.) said in an interview. The Congressional Budget Office told Casey’s office that, based on its experience with Medicaid expansion under the Affordable Care Act, states won’t expand their HCBS program unless they get enough funding.

“You have to make sure you build something where you’re going to both increase services, but you have enough resources to build wages also,” said Casey, the chief architect of the plan and lead sponsor of the legislation behind it.

“When budgets are tight, states lean towards services as opposed to raising wages, and it’s always the workers who get left behind,” Poo said.

It’s possible that funding came in at $190 billion in the House bill because multiple committees have jurisdiction over health-care funding, Jorwic said.

She said she was “hopeful” that, ultimately, the program would be funded at a higher level when the reconciliation bill goes to the Budget and Rules committees. Groups that work on the issue say the White House, Speaker Nancy Pelosi (D-Calif.), and Senate Majority Leader Chuck Schumer (D-N.Y.) all appreciate the importance of providing enough funding to get states on board, she added.

$400 Billion Push

Although advocates are fighting for $250 billion, the program really requires $400 billion to deal with “the scale and scope of the problem,” and to allow the U.S. to “turn home care jobs into good living wage jobs and expand access to care,” Mary Kay Henry, president of the Service Employees International Union, said. SEIU represents about 740,000 home-care workers.

SEIU doubled its ad campaign Tuesday in support of the home care plan, spending another $3.5 million to call on Congress to support ample funding. $400 billion would fuel 1.4 million direct and indirect jobs, and expand access to care for 3 million people, Henry said.

“The additional money gives us a fighting chance at the state level to make these poverty jobs living wage jobs” with sick leave and medical benefits, she said.

Meanwhile, the urgency underscoring the issue stems not just from a need to expand access to home services and improve wages but by the fact that 10,000 people are aging into retirement per day, Poo said.

“What we’re hearing is that the vast majority of Americans, 88%, want to age at home and in the community. And we just are not prepared for that,” Poo said.

The current access crisis “could become a catastrophe if we don’t invest in home and community-based care,” she said.