President Biden’s $ 400 billion proposal to improve long-term care for older adults and people with disabilities was received either as a long overdue addition to the social security net or as an example of a misguided government transgression.
Republicans ridiculed the inclusion of elderly care in an infrastructure program. Others ridiculed it as a gift to the Service Employees International Union, which aims to organize caregivers. It was also blamed for omitting childcare.
For Ai-jen Poo, co-director of Caring Across Generations, a coalition of stakeholders working to strengthen the long-term care system, this was an answer to years of hard work.
“Although I’ve been fighting for it for years,” she said, “if you’d told me 10 years ago that the President of the United States would give a speech in which $ 400 billion would be allocated to improve access to these services and to strengthen this work. ” Kraft, I didn’t think it would happen. “
What has failed the debate on the President’s proposal is that, despite the large number, its ambitions remain uniquely narrow compared to the enormous and growing demands of an aging population.
Mr Biden’s proposal, which is part of his US $ 2 trillion employment plan, is only aimed at empowering Medicaid, which pays just over half the cost of long-term care in the country. And it is aimed only at home care and outpatient care in facilities such as day care centers for adults – not at nursing homes, which make up just over 40 percent of the Medicaid care budget.
Even so, the money would be used up very quickly.
Consider an important goal: increasing caregiver wages. In 2019, the typical wage for the 3.5 million household and personal care workers was $ 12.15 an hour. They earn less as janitors and telemarketers, less as workers in food processing plants or on farms. Many – usually women of color, often immigrants – live in poverty.
The helpers are employed by care facilities that bill Medicaid for their hours worked in the beneficiaries’ homes. The agencies regularly report labor shortages, which may not be surprising given the low pay.
Increasing wages can be essential to meet booming demand. The Department of Labor estimates that these occupations will require 1.6 million additional workers over 10 years.
It won’t be cheap, however. An increase in the hourly wages of the aides to $ 20 – still below the average wage in the country – would more than consume the eight-year effort of $ 400 billion. That would leave little money for other priorities, such as meeting the demand for care – 820,000 people were on the states’ waiting lists in 2018 with an average waiting time of more than three years – or the provision of more comprehensive services.
The battle for resources is likely to strain the coalition of unions and groups that advance the interests of elderly and disabled Americans who have worked together to advocate Mr. Biden’s plan. Even before nursing homes complain that they are being left out.
The president “needs to strike the right balance between reducing the waiting list and increasing wages,” said Paul Osterman, professor at the Massachusetts Institute of Technology’s Sloan School of Management who has written about the country’s care structures. “There is tension.”
Care for the elderly has long been at the center of political struggles over social security. President Lyndon B. Johnson considered bringing the benefits of establishing Medicare in the 1960s, said Howard Gleckman, an expert in long-term care at the Urban Institute. However, House Ways and Means Committee chair Wilbur Mills cautioned how expensive this approach would be when baby boomers retired. Better, he argued, make it part of Medicaid and let states shoulder a lot of the burden.
That compromise resulted in a patchwork of services that has abandoned millions of seniors and their families and yet consumes around a third of Medicaid spending – about $ 197 billion in 2018, according to the Kaiser Family Foundation. According to Kaiser’s calculations, Medicaid pays about half of the long-term care services. Payouts and private insurance together make up just over a quarter of the tab. (Other sources, like veteran programs, cover the rest.)
Unlike institutional care, which requires government Medicaid programs, home and community care services are optional. That explains the waiting lists. This also means that the quality of the services and the rules for using the services are very different.
Although the federal government pays at least half of the state’s Medicaid budgets, the states have plenty of leeway in how the program runs. In Pennsylvania, Medicaid pays an average of $ 50,300 per year per recipient of home or outpatient care. In New York it pays $ 65,600. In contrast, Medicaid pays $ 15,500 per recipient in Mississippi and $ 21,300 in Iowa.
This regulation has also left the middle class in the lurch. The private insurance market is shrinking and can no longer handle the high cost of end-of-life care: it’s too expensive for most Americans and too risky for most insurers.
As a result, middle-class Americans in need of long-term care either resort to relatives – usually daughters who throw millions of women out of work – or use up their resources until they qualify for Medicaid.
Regardless of the boundaries of the Biden proposal, proponents of its main constituencies – those in need of care and those who provide it – stand firm behind it. After all, this would be the largest expansion in long-term care support since the 1960s.
“The two big issues of waiting lists and labor are related,” said Nicole Jorwic, senior director of public policy at Arc, which promotes the interests of people with disabilities. “We are confident that we can do this in such a way that we can overcome the conflicts that have stopped progress in the past.”
And yet the dispute over resources could reopen the conflicts of the past. For example, when President Barack Obama proposed extending the Fair Labor Standards Act of 1938 to include domestic carers, who would cover them with minimum wage and overtime rules, attorneys for beneficiaries and their families opposed fearing that states with budgetary pressure would cut off -Service around 40 hours a week.
“We have a long way to go to get this into law and get it done,” said Haeyoung Yoon, senior policy director of the National Domestic Workers Alliance, of the Biden proposal. On the way, she said, the supporters have to stick together.
Given the scale of the need, some wonder if there could be a better approach to supporting long-term care than spending more money on Medicaid. The program is constantly being asked for resources that are forced to compete with education and other priorities in state budgets. And Republicans have repeatedly tried to narrow their scope.
“It’s hard to imagine that Medicaid is the right funding tool,” said Robert Espinoza, vice president of policy at PHI, a nonprofit research group that monitors the home care sector.
Some experts have instead proposed the creation of a new line of social insurance, possibly financed by payroll taxes, to provide a minimum of services to all.
A few years ago, the Long-Term Care Financing Collaborative, a group that was formed to ponder how to pay for long-term care for the elderly, reported that half of adults typically have “high levels of personal support at some point “Would need for two years at an average cost of $ 140,000. Today around six million people require these types of services, a number the group expects to grow to 16 million in less than 50 years.
In 2019, the National Social Insurance Academy published a report proposing nationwide insurance programs paid by a special tax to cover a bundle of services from early childhood care to family vacations to long-term care and support for older adults and the disabled.
This can be structured in a number of ways. An option for seniors, a disaster insurance plan that covers expenses up to $ 110 per day (in 2014, after a waiting period determined by the beneficiary’s income) could be funded by a one percentage point increase in Medicare tax.
Mr. Biden’s plan is not very detailed. Mr Gleckman of the Urban Institute notes that it has become vague since Mr Biden suggested it on the campaign – perhaps because he realized the tensions that would arise from it. In either case, a major overhaul of the system may be required.
“This is a significant historic investment,” said Espinoza. “But when you consider the extent of the crisis ahead of us, it is clear that this is only a first step.”