Yuri Gripas/Abaca/Sipa USA via AP Images
President Joe Biden greets participants during an event for the signing of an executive order on increasing access to high-quality care, in the Rose Garden at the White House, April 18, 2023.
Last week, the Biden administration announced what the White House press office called the “Most Sweeping Set of Executive Actions to Improve Care in History.” If only.
The actions are a series of directives to government agencies “to expand access to affordable, high-quality care, and provide support for care workers and family caregivers.” The problem, of course, is that better care costs money.
It costs money to build more facilities, money to subsidize the ongoing expenses of child care and home care, money to increase the pay of care workers, whether in Medicaid-funded nursing homes, or in day care programs for kids. And while Biden’s latest order tweaks what agencies are directed to do, in the absence of more congressional funding the White House cannot cause more money to flow.
Indeed, in the context of House Republicans holding the debt ceiling hostage for deep cuts in social outlays, such spending is already on the defensive. House Speaker Kevin McCarthy even wants to add work requirements to Medicaid. Since the largest single category of Medicaid outlays is nursing home care, one can only imagine how work requirements would be applied to residents who are physically incapacitated or in memory care units.
Biden’s heart is in the right place; and it is tragic that the White House is reduced to the sort of tokenism in the latest executive orders. When the administration last August finally succeeded in persuading Manchin, Sinema et al. to enact much of what began as Biden’s Build Back Better program via budget reconciliation, rebranded as the Inflation Reduction Act, what remained on the cutting-room floor was over a trillion dollars of outlays to expand support for the entire range of caregiving. The earlier American Rescue Plan Act of 2021 did provide over $60 billion for expanded child care and Medicaid home care.
Biden’s FY2024 budget includes the scale of outlay for the care economy that could begin to make a difference: $600 billion over ten years for affordable child care and free universal pre-K; as well as $150 billion for better home care under Medicaid. But Congress will approve outlays like these only if Democrats take back the House and gain a couple of seats in the Senate.
Thus Biden’s dilemma. It’s important to keep the spotlight on the need for more and better caring services. I’m not sure it’s smart politics to make exaggerated claims for executive actions that will make only a marginal difference.
One thing that Biden could do by executive action is not in last week’s set of directives: He could direct Medicaid to crack down on for-profit nursing home chains, especially those owned by private equity companies.
Medicaid reimbursements to nursing homes are insufficient to provide both decent earnings for caregivers and high-quality care for residents. When profits are added to the mix, both care and worker earnings suffer.
Studies have thoroughly documented that resident outcomes are worse in for-profit homes. These homes should be subject to stringent audits for quality of care, to the point where they cease to be profitable, and private chain operators would leave the field to ethical not-for-profits. That at least would be an executive order worth bragging about.
