President Joe Biden is trying to make good on one of his main campaign promises.
The Biden administration on Wednesday unveiled a new $2 trillion infrastructure proposal to create jobs, build roads, fix bridges and more. On top of that, the proposal — officially dubbed the American Jobs Plan — would substantially increase funding for home- and community-based services (HCBS).
“President Biden believes more people should have the opportunity to receive care at home, in a supportive community or from a loved one,” a White House fact sheet on the proposal states.
In order to expand access to HCBS under Medicaid, Biden is specifically calling on Congress to redirect $400 billion toward home-based care. In theory, much of that funding would be used to improve low-wage caregiving jobs, which are often held by women and people of color.
“The HCBS expansion under Medicaid can support well-paying caregiving jobs that include benefits and the ability to collectively bargain, building state infrastructure to improve the quality of services and to support workers,” the fact sheet reads. “This will improve wages and quality of life for essential home health workers and yield significant economic benefits for low-income communities and communities of color.”
Additionally, the American Jobs Plan pushes for the expansion of the popular Money Follows the Person (MFP) program, which allows certain Medicaid users to more seamlessly transition from a nursing home back into the home. MFP was most recently given a $165 million bump in September under the Trump administration.
While campaigning for president, Biden pitched a $775 billion overhaul of the nation’s caregiving infrastructure. At that time, the president described current compensation for most in-home care workers as “unacceptable.”
Apart from $400 billion for HCBS, Biden’s proposal includes $621 billion for transportation, $300 billion for manufacturing and $213 billion for housing, plus $180 billion for research and development. It also includes funding for schools, digital infrastructure and the U.S. water infrastructure, among other areas.
To pay for the American Jobs Plan’s $2 trillion price tag, the White House is proposing to increase the corporate rate to 28%.
A ‘monumental advance’
It’s important that in-home care providers view the American Jobs Plan for what it is — a proposal. The plan is likely to face unified Republican opposition, meaning Democrats will likely have to attempt passage through the use of a fast-track budget mechanism known as reconciliation.
Still, a sitting U.S. president actively supporting in-home care to the tune of $400 billion is a major victory.
The Biden administration’s support for home-based care is a “monumental advance” in the decades-long effort to provide full access to health care outside of an institution, William A. Dombi, president of the National Association for Home Care & Hospice (NAHC), told Home Health Care News.
“This effort deserves the complete support of the Congress and the American public,” Dombi said in an email. “It is time we honor our parents and grandparents with the opportunity to age in place and to provide full access to the least restrictive health care environment for persons with disabilities. The benefits of home care are long-established.”
Similarly, LeadingAge — another Washington, D.C.-based trade group with a large cohort of home health and home care members — called the proposal a step in the right direction.
“The Biden infrastructure plan’s caregiving elements are a promising start for the much-needed rebuilding of our failing aging services infrastructure, including an important focus on supporting home-based health care workers,” a spokesperson for the organization told HHCN in an email. “Much work needs to be done to make America a better place to grow old.”
There are a number of factors the Biden administration likely took into account when putting forth this plan. One is likely the nation’s persistent underinvestment in home-based care compared to other countries.
Only 15% of U.S. seniors 80 or older receive care at home. In Switzerland, Denmark, Mexico and Sweden, that figure is above 30%, with numbers even higher in Israel and Lithuania.
Medicaid has slowly evolved over the years, placing a greater emphasis on home- and community-based services. But the ground gained has been relatively minor compared to investments in other settings.
In 1995, Medicaid spent about 18 cents out of every long-term care dollar on HCBS services. Today, that number has reached 57 cents per dollar.
“When Medicaid was created, it covered nursing home and institutional services — and that was it,” Matt Salo, executive director of the National Association of Medicaid Directors (NAMD), told HHCN. “Since the early 1980s, when the first HCBS waivers started getting approved, we’ve been on this undeniable and unstoppable move toward rebalancing and focusing more on the home and community.”
NAMD is a bipartisan, nonprofit professional organization that represents leaders of state Medicaid agencies across the U.S.
Another factor that the Biden administration likely had to weigh was the considerable toll the COVID-19 emergency has taken on nursing homes and other long-term care facilities.
Although numbers have sharply declined since the vaccine rollouts started, more than 174,000 nursing home residents have died as a result of the COVID-19 virus, according to AARP. This includes nursing homes and other facility-based long-term care settings.
Funding for caregivers
For home-based care providers, an injection of funds could boost the caregiver workforce at a time when the demand for care continues to increase.
“This workforce crisis has been ongoing for far too long — and the lack of investment has been going on for far too long,” Esmé Grewal, a board member of the Partnership for Medicaid Home-Based Care (PMHC), told HHCN. “We are at this important stage in our history, where we are soon going to have more folks in the aging population than in the younger population.”
In addition to Grewal’s role at PMHC, she also serves as the vice president of government relations at BrightSpring Health Services.
Dombi similarly noted the importance of removing barriers to home-based care, including insufficient caregiver compensation.
“The caregivers should be given the high respect they deserve, along with fair compensation for the essential services they provide,” he said. “We look forward to working with the president and Congress to bring to reality the full value of home care.”
While acknowledging the favorable aspects of the proposal, Salo pointed to the fact that there are still questions surrounding another relief measure, the American Rescue Plan, which increases the federal matching rate for spending on Medicaid home- and community-based services.
Specifically, the plan raises the federal matching rate by 10% from April 1, 2021, through March 31, 2022.
“As of now, we have absolutely no guidance whatsoever from the feds on a laundry list of issues, in terms of, ‘What does this really mean?’” Salo said. “How can you make meaningful investments in a system if it can only be new spending, and it’s only going to last a year? We are laser-focused on trying to figure that out. And we need to do that before we start thinking about $400 billion more. We are focused on what is in law now.”
Looking ahead, it’s difficult to predict what will happen with Biden’s proposal, but Grewal points to the history of bipartisan support when it comes to home-based care.
“It’s hard to say how the proposal will play out in Congress,” she said. “However, we’re really fortunate to have a great history of bipartisanship when it comes to home- and community-based services. We have wonderful members in Congress, on both sides of the aisle, who recognize the value of investing in these services. Our hope is that this will continue.”