Democrats Seek to Advance Biden Home-Care Plan Via Medicaid Cash


June 24, 2021 10:38 am

Senate Democrats will release legislation as soon as Thursday to meet President Joe Biden‘s promise to expand in-home care for the elderly and disabled while boosting caregivers’ wages and unionizing opportunities, according to a draft bill obtained by Bloomberg Law.

States would implement the proposal using a major influx of federal funding through Medicaid. The bill would condition the funds on states’ ability to shift people to home-based care from nursing homes, recruit and train more home health workers, provide caregiver pay increases, and establish oversight capacity. 

The bill’s goal is to deliver on Biden’s pledge—from the “human capital” portion of his infrastructure plan—to put $400 billion toward reducing the sizable waiting lists facing those who wish to receive support in their homes instead of in institutional settings, and also to improve the quality of life for a predominantly female, minority workforce. 

Congress would initially authorize $100 billion for state grants, but the ultimate price tag may wind up much higher, depending on how many states elect to participate.

Sources briefed on the legislation said the draft is in near-final form ahead of its official introduction, tentatively planned for Thursday. It offers the first-known details of a critical piece of a package Democratic lawmakers aim to pass this year using the budget reconciliation process, which would avoid the need for Republican votes in the Senate. 

The bill was drafted with the intention of meeting reconciliation rules, but it remains to be seen whether it’s actually in compliance, as determined by the Senate parliamentarian. Reconciliation can only be used for provisions with budget effects that are more than just incidental, among other requirements.

The bill’s architect and lead sponsor, Sen. Bob Casey (D-Pa.), briefed his caucus on the details Tuesday, along with Senate Majority Leader Chuck Schumer (D-N.Y.) and Senate Finance Chair Ron Wyden (D-Ore.), said three sources familiar with the process. 

Worker Raises, Recruitment

Under the legislation, states could receive grants to create plans for expanding their home-based services and boosting worker pay. If approved, the federal government would pay up to 90% of the costs for implementing those plans.

States would have flexibility in designing their programs to revamp their home- and community-based care systems, but would need to prove they have achieved outcomes related to home-care service availability, worker raises, and recruitment and retention of enough in-home aides to meet demand. States could also get funds to continue programs to expand home health started this year using funds from a Covid-19 relief law enacted in February (Public Law 117-2).

Officials Lay Out Rules for Expanding Medicaid’s Home-Based Care

States could apply for an additional 2% bump in federal Medicaid dollars if they establish an oversight entity to administer a program for “self-directed care,” which lets those receiving care customize their plan without involving an outside employer agency. 

Among the oversight entity’s mandates: registering qualified caregivers and connecting them to beneficiaries; recruiting and training workers; and ensuring that the program policies are cooperative with home-care worker labor unions—either when it comes to bargaining with existing unions or remaining neutral in the face of a union organizing drive. 

This final prong is geared toward meeting demands of the Service Employees International Union, which represents some 740,000 home-care workers and has been lobbying for inclusion of robust home care funding in an infrastructure package. 

Congressional Negotiations

The draft is the product of months of negotiations between congressional lawmakers and a broad range of constituents in the aging, disability, and labor communities. 

Republicans, some of whom are separately trying to reach a narrower bipartisan deal focused on roads, bridges, and other physical repairs, have resisted the arguments from Democrats and worker advocates that home care investments belong in an infrastructure bill. That’s an obstacle shaping Democrats’ preference for the go-it-alone strategy in a budget reconciliation measure.

“We’re working with reconciliation, and we have got a broad but somewhat unique coalition in the disability community. We have AARP, SEIU,” Casey said in a June 10 interview. “It’s a pretty broad coalition that hasn’t always been on the same page.”