Senators, Advocates Tout ‘Once-in-a-Generation Opportunity’ for Funding HCBS

“Care cannot wait — and neither should Congress.” That was the message delivered Thursday by Brittany Williams, a professional home care worker and third-generation caregiver from Washington state, during a U.S. Senate Special Committee on Aging hearing.

“Even as a child, I could see that care is essential,” Williams told the committee. “It is life-giving work that I am blessed and proud to do. But this job is hard. I always say that home care workers are the maintainers of life, but we can barely survive ourselves.”

The home care worker’s remarks come as members of Congress debate what should be included in a major infrastructure package, with Republicans and some Democrats at odds over possible funding for home- and community-based services (HCBS).


Several members of Congress this week endorsed a roughly $1 trillion bipartisan plan that would revamp transportation and waterway systems, but leave out HCBS. If the two political parties can’t agree on terms, however, some reports say Democrats are willing to spend upwards of $6 trillion in an infrastructure package that they push through on their own.

That would likely include funding for HCBS, considering President Joe Biden included $400 billion for the U.S. caregiving system in his original American Jobs Plan proposal.

“Medicaid home- and community-based services enable more than 3.5 million people to remain in their homes, to stay active in their communities and to lead independent lives,” Senate Special Committee on Aging Chairman Bob Casey, a Democrat from Pennsylvania, said at the hearing. “This assistance often includes help with activities of daily living, such as eating, bathing and managing medications. But too many Americans … are not able not able to access the services, placing significant financial and emotional strains on families.”


In addition to Williams, other caregiving witnesses called to testify included Stephanie Blunt, the executive director of the Trident Area Agency on Aging in North Charleston, South Carolina, and Theo Braddy, a consultant and the former CEO of the Center for Independent Living of Central Pennsylvania.

Ai-jen Poo, executive director of the National Domestic Workers Alliance, also spoke.

“We’ve worked for over a decade to bring attention to the urgency of [investing in] Medicaid home- and community-based services,” said Poo, who also launched Caring Across Generations in 2011. “We now have a once-in-a-generation opportunity to invest and build the 21st century care infrastructure we need.”

While nearly 90% of older adults and people with disabilities want to receive care at home, many are unable to do so because of the nation’s thin home care workforce. From 2018 to 2028, the U.S. will need to fill over 4.4 million home care job openings, according to PHI data.

Additionally, even in areas where there are sufficient home care resources, many Americans are forced to instead turn to long-term care facilities due to antiquated Medicaid rules. Nationally, there are more than 800,000 older adults and people with disabilities on waiting lists for Medicaid HCBS.

“People wait years, sometimes decades, for access to services,” Poo continued. “There are home care deserts across the country, especially in rural communities. And we are facing an ‘elder boom.’ By the year 2050, the population of people 65 and older will nearly double.”

For the most part, there’s strong bipartisan support for HCBS and anything that enables aging in place.

Republicans and Democrats just disagree on whether caregiving is infrastructure — and whether the government needs to spend more money on home-based care.

“My concern with the president’s approach to [HCBS] is just throwing money at the issue won’t solve the problem of quality control,” Sen. Tim Scott (R-S.C.), ranking member of the Special Committee on Aging, said at the hearing. “That won’t solve the problem of family members being able to take care of their family members. We can’t use a one-size-fits all plan.”

In 1995, Medicaid spent 18 cents out of every long-term care dollar on home- and community-based services. Today, that number has reached 57 cents per dollar, Harvard professor and researcher David Grabowski noted in a January journal article.

Globally, U.S. spending on HCBS lags behind nearly all other developed countries.

If included, at least some of the HCBS funding in any infrastructure package would go toward supporting higher-paying home care jobs. That would likely make recruiting and retention easier for providers, which generally support wage increases for their workers but struggle with razor-thin margins in many states.

“You are right, and I’m quoting you, ‘Care cannot wait — and neither should Congress,’” Sen. Richard Blumenthal (D-Conn.) said to Williams. “That’s why many of us feel … that this kind of home- and community-based service should be part of our infrastructure package. It has to be a part of what we do.”

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