Graeme Sloan/Sipa USA via AP Images
Sens. Mark Warner (D-VA), Susan Collins (R-ME), and Joe Manchin (D-WV) huddle after leaving a bipartisan meeting on infrastructure legislation, June 23, 2021, at the Capitol in Washington.
Senate Democrats introduced a bill yesterday intended to enact President Biden’s promised $400 billion for in-home disability and elder care, known as the Better Care Better Jobs Act. Democratic Senate staff and advocates spent weeks attempting to gain support for the bill, both from Republicans and from their own party. However, they were blindsided by the same-day announcement of a bipartisan infrastructure plan from the White House, one that leaves out home care altogether.
The bipartisan bill will focus on traditional infrastructure like roads and bridges, as well as newer innovations like broadband, according to Jeff Stein of The Washington Post. The text has not yet been released, but it is clear that much-needed care for disabled people and seniors didn’t make the cut.
But there is a blueprint for one key aspect of a human-focused infrastructure plan. The Better Care Better Jobs Act would incentivize states to expand home care and improve worker pay through grants. The federal government would foot 90 percent of the costs necessary to implement those plans. There is flexibility in the plan, and states can design programs any way they like. There are some drawbacks, though. According to the bill, states must meet benchmarks around home care availability, raises for workers, and recruitment and retention, all issues that challenge the industry. An estimated 43.8 percent of home care workers quit within a year of starting the job. During the pandemic, that number likely worsened, as workers quit to care for their own children, and in fear of their own health.
Senate Democrats had been fruitlessly attempting to entice Republican support for weeks, according to two sources on the Hill. But consensus is unlikely, and the text of the Better Care Better Jobs Act was written with reconciliation in mind, a way to avoid dependence on the votes of Senate Republicans. Sources close to the issue seemed relatively confident that there would not be a bipartisan bill. “You can argue about whether or not [home care is] infrastructure, but the bottom line is you need it. We need it. The country needs it, and we’re going to move forward with it,” they said.
Senate Republicans (and ten Democrats) don’t support funding the programs, yet have repeatedly made public statements stressing the importance of home care for their own loved ones and their constituents. Republicans, in particular, object to the term “infrastructure” being used, as it is not in the bipartisan bill the White House has put forward. “I don’t think [home care] belongs in an infrastructure bill,” said Sen. Susan Collins (R-ME) at a recent summit on caregiving hosted by the nonprofit news organization The 19th News. “I have been a strong proponent and leader on home health care issues,” added Collins. So if it were proposed as a stand-alone program from the infrastructure bill, would Collins support it? She has not signed on to the Better Care Better Jobs Act, and she could not be reached for comment as to why.
Overall, the proposed spending is extremely popular. Data for Progress found that 72 percent of Americans support spending over $400 billion to end waiting lists to access home care through Medicaid, as well as to expand and improve existing programs.
Republicans want to connect with voters’ concerns about home care while avoiding the visionary aspects of this legislation. Noting that his mother worked as a nursing assistant, Sen. Tim Scott (R-SC) praised home care in a recent Special Committee on Aging hearing on caregiving. However, a report released from Scott’s office describes the promise of $400 billion for home care as “rewarding union loyalty over outcomes.” Bizarrely, he holds up self-directed care as a solution that would work better. Self-directed care is a model of home care in which a disabled person chooses their own aide, rather than going through an agency that assigns one. The advantage of self-directed care is that friends and family can get paid for the care work they do. But self-directed care, like all home care, is reimbursed by Medicaid, the same underfunded system Scott objects to putting money into.
The Better Care Better Jobs Act incentivizes self-directed care by increasing the amount of federal funding states with such programs receive, by offering an extra 2 percent in federal Medicaid funding. The bill does mention unions, but only insofar as it directs states to be cooperative with home care worker unions. States would need to bargain with existing unions and remain neutral during home care worker union organizing drives. Sen. Scott has not signed on to the Better Care Better Jobs Act, and he could not be reached for comment.
One problem with the Better Care Better Jobs Act is that the program is optional. Twelve states opted out of Medicaid expansion, despite evidence that it has many clear benefits, including a significant increase in early-stage cancer diagnoses and a decrease in premature deaths. Under the Affordable Care Act, the federal government pays 90 percent of the cost of Medicaid expansion. In the long term, Medicaid coverage leads to savings in uncompensated medical care.
The bigger risk is that President Biden will move on to the next issue, leaving the home care system in its current underfunded disrepair. Advocates hope that will not be the case. Nicole Jorwic, senior policy director for the advocacy group The Arc of the United States has hope: “I believe it is true, without a doubt, that [the Biden administration is] committed to making sure that this $400 billion piece [of funding for home care] will get included in a broader reconciliation package.”
