Likely Democratic presidential nominee Joe Biden is, very slowly and cautiously, acknowledging the need to reform the way we support frail older adults and younger people with disabilities. In recent days, a task force created by his campaign made several proposals to expand home and community based care under Medicaid and support both family and paid caregivers.
Since covid-19 has killed more than 112,000 people over 65 in the past four months—80 percent of all pandemic deaths in the US-– it is hard to miss the need. And the crisis may have attracted the attention of the former vice-president, whose proposals for supporting frail older adults and their caregivers were among the modest of the Democratic primary candidates last spring.
Biden’s developing agenda remains extremely cautious. His task force would not, for example, end Medicaid’s bias that drives people to receive long-term care in nursing homes. Nor does it propose new ways to publicly finance services and supports outside of the hard-pressed Medicaid system. And it is not even clear whether Biden will fully embrace any of these recommendations. They are included in a much bigger package of ideas developed by supporters of both Biden and his former rival for the Democratic presidential nomination, Sen. Bernie Sanders (I-VT).
Still, Biden is edging toward reform. For example, the task force would:
Enhance Medicaid’s long-term services and supports (LTSS). The group would eliminate state waiting lists for home and community-based care. Because of funding shortages, some states require people to wait for years before they can access home-based care. But the group is silent on where the billions of dollars would come from to do that.
It also dodges the real flaw in Medicaid LTSS. It says only that Democrats would “work to develop a broader approach to eliminate the institutional bias within Medicaid.” Currently, very poor older adults and people with disabilities are guaranteed Medicaid LTSS only in nursing homes. In addition, nursing homes are the only setting where Medicaid pays for room and board.
The federal government does allow states to offer long-term care in other settings, such as people’s homes. But they only can do so after getting special waivers, a time-consuming and cumbersome process. And because there are many different exceptions, it is difficult for either states or families to understand them.
The best solution would be to scrap the program’s institutional bias, an idea widely favored by advocates for older adults and adults with disabilities. It seems especially appropriate now, after more than 50,000 long-term care residents and staff have been killed by covid-19. But the idea is opposed by many in the nursing home industry and some governors. Biden’s group missed an opportunity.
Support for paid aides. The group backs a $15 national minimum wage, in many places a significant boost for home care aides, who earn an average of about $11 per hour today, or nursing home aides, who earn about $13. It also supports improving nursing home staffing and standards and requiring paid sick leave. The pandemic amplified both problems.
Support for family caregivers. The group has several ideas, including paid family leave for those caring for ill relatives as well as infants. It also would allow family members to accrue Social Security benefits and contribute to retirement plans while they are acting as caregivers for relatives.
What the group did not propose. Aides do need higher wages and better working conditions. But where will the money come from to pay them? More federal funding could boost Medicaid. But what about those families whose loved ones are not eligible for the program? Long-term care already is unaffordable for most of them. How will they pay those added costs?
Other Democrats, including Biden’s former rival Pete Buttigieg and House Energy & Commerce Committee Chair Frank Pallone (D-NJ) have proposed a public catastrophic long-term care insurance program. Washington State has enacted a different form of public insurance, and several other states are considering their own versions.
Yet, Biden’s task force was not yet prepared to address financing. Unless the former vice president does, few of his other proposals will happen.
For all of its caution, Biden’s long-term care agenda is much more ambitious that President Trump’s. The White House has proposed an off-and-on family leave plan that seems mostly focused on parents of babies. A Treasury Dept. task force has been studying federal incentives to boost the private long-term insurance, but has not yet issued recommendations.
In the wake of the pandemic, the Administration has proposed cutting nursing home regulations and promised, but rarely delivered, testing and personal protective equipment to these facilities. Trump has proposed cutting, not enhancing, Medicaid.
Biden will make many promises over the next four months. But if he is elected president, his first few years in office likely will be focused on only one domestic issue—covid-19 and its economic and social fallout. It would be an ideal time for him to reform a failed long-term care system that has been so ravaged by the pandemic. And it would be a tragedy if he misses it.
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