Democrats say the measure is needed because the healthcare system is unprepared for the unprecedented growth in the senior population and the bill would boost incomes for the many women and people in minority groups who provide the services.
Republicans contend the plan is too costly and doesn’t meet the definition of infrastructure. Opponents also argue that any boost in wages or the unionization of home healthcare workers would ultimately funnel money—by way of dues—to Democratic-friendly labor unions.
The Biden administration doesn’t have any specific labor provisions in the plan, but changes that make it easier for home health workers to unionize could be part of a proposal from congressional Democrats. States led by Democrats—such as Oregon—have allowed independent home health workers paid by government programs like Medicaid to collectively bargain as public employees.
The diverging perspectives set the stage for a politically fraught battle over a proposal championed by Mr. Biden, who campaigned last year on ending waiting lists of seniors on Medicaid for home healthcare services.
According to the Centers for Medicare and Medicaid Services, the aging population is expected to soon strain the U.S. medical system, with total national health expenditures projected to reach $6.2 trillion by 2028 compared with $3.8 trillion in 2019.
By 2030, all baby boomers will be at the retirement age of 65 years old or older, and this will expand the size of the senior population so that one in every five residents will be at retirement age, according to the U.S. Census Bureau. In 2034, older people are projected to outnumber children for the first time in U.S. history.
Seniors get their health coverage through Medicare, which doesn’t pay for daily care at home for those who need help bathing or dressing. It also generally doesn’t cover long-term stays in nursing homes, so many of the 63 million
Seniors who can’t afford the costs may also enroll in Medicaid, a program for low-income and disabled people, which does cover nursing-home care for individuals. More than 12 million people on Medicare are also enrolled in Medicaid, but they must meet strict eligibility guidelines, and typically don’t qualify until they have only $2,000 or less in total assets, according to the American Council on Aging.
Under Medicaid programs, states can provide healthcare at home or in the community to seniors or people with disabilities, but many limit enrollment and have waiting lists for the home-based medical services. Among seniors and people who are disabled, Florida had almost 50,000 people on its waiting list for home care in 2018, and Louisiana had nearly 37,000.
The current system steers seniors into nursing homes and forces them to exhaust their financial resources, advocates of the Biden proposal say. Home and community care, they say, would be less expensive than nursing-home care.
“People don’t understand how broken our long-term care situation is until they’re a caregiver or a patient,” said Rep. Debbie Dingell (D., Mich.). “Medicaid is the largest payer of long-term care, but you have to be destitute to even qualify.”
Republicans say the proposal doesn’t belong in a legislative package on infrastructure, which they say should focus on repairing bridges and roads and improving broadband internet access.
“This is about Democrats’ goal of increasing government-controlled healthcare,” said Rep. Jason Smith (R., Mo.), adding that the proposal would benefit unions. “It doesn’t belong in an infrastructure bill. This takeover of government healthcare, they’re just trying to slip it through. They’re rewarding friends, donors and allies.”
There are more than 790,000 home healthcare aides who could see their wages rise, a provision that was advocated by the Service Employees International Union, which represents home health workers, and other groups. The mechanism for raising wages still has to be determined by Congress, although some ideas include increasing Medicaid reimbursement or enhanced state funding to pay home health workers.
Overall employment of home health and personal-care aides is projected to grow 34% from 2019 to 2029, much faster than the average for all occupations. The mean hourly wage is about $12.18, or $25,000 a year, according to the Bureau of Labor Statistics.
SEIU President Mary Kay Henry said the proposal would benefit an industry composed of women of color. “President Biden has clearly heard the demand of these women—and millions of other essential workers—to be respected, protected and paid,” she said.
Republicans such as Mr. Smith say the $400 billion would be a gift to unions. There are no specific union provisions in the president’s plan, which is still being worked on by Democrats.
Opposing the proposal carries political risks for Republicans because Democrats have already portrayed them as being unsympathetic to the healthcare plight of seniors, who historically have backed the GOP.
When Sen. Marsha Blackburn (R., Tenn.) tweeted on April 7 that “President Biden’s proposal is about anything but infrastructure,” the Democratic National Committee fired back in a tweet, saying, “Republicans in Congress are now opposed to elder care.”
Proponents say the pandemic also has left more seniors wanting to age in place because Covid-19 caused many deaths in nursing homes, which also have had to limit or ban visits. The pandemic has killed more than 174,000 residents and staff of nursing homes and other long-term-care facilities, according to AARP, which focuses on issues affecting those over the age of 50.
“Once upon a time, home was the center of healthcare,” said Thomas Threlkeld, a spokesman for National Association for Home Care and Hospice, which represents the nation’s 33,000 home care and hospice organizations. “And typically, in other countries, the care is paid for by the public purse so they can have the dignity and independence they deserve.”
The American Health Care Association and National Center for Assisted Living, which represents nursing homes, say they need financial help, too, to cope with the fallout of the pandemic and the coming surge in aging seniors.
The organization says the average age of a nursing-home resident is 85, and most have multiple underlying health conditions that require a high level of specialized care that in-home care is often unable to provide. They are lobbying for an overall increase in Medicaid reimbursement rates because they say more than 1,600 nursing homes could close this year as a result of mounting financial challenges.
“Without a commitment from lawmakers to increase Medicaid reimbursement rates, most nursing homes will be unable to afford the substantive reforms required to continue improving quality of care,” the groups said in a statement.