‘Better Care Better Jobs Act’ Seeks Permanent FMAP Bump, Higher Wages for HCBS Workers

A bicameral group of U.S. lawmakers unveiled new legislation Thursday designed to pump hundreds of billions of dollars into home-based care over the next several years.

The legislation — officially titled the “Better Care Better Jobs Act” — is sponsored by U.S. Sens. Bob Casey of Pennsylvania and Ron Wyden of Oregon, in addition to U.S. Rep. Debbie Dingell of Michigan. The three Democrats have been vocal supporters of home- and community-based services (HCBS), especially Casey in recent months.

“We know that home- and community-based services are very, very popular,” the Pennsylvania senator said during a conference call to announce the new bill.

Advertisement

The Better Care Better Jobs Act comes as lawmakers continue to debate the role that “caregiving” plays in the nation’s current and future infrastructure. President Joe Biden originally called for a $400 billion boost to HCBS as part of his American Jobs Plan proposal, but that inclusion was immediately met with resistance from Republican leaders, who argued that “infrastructure” only applies to things like roads, bridges and railways.

Just hours after the HCBS legislation came out, news broke that the White House had reached a new $579 billion infrastructure deal with congressional leaders from both major political parties.

That compromise reportedly does not include any investments for home-based care.

Advertisement

“We have a deal,” Biden said Thursday, speaking outside the White House. “I think it’s really important we’ve all agreed that none of us got all that we wanted.”

The president’s endorsement signals a turning point in efforts to pass a comprehensive infrastructure plan, but it is far from a guarantee that a package will be enacted anytime soon.

Additionally, even though Thursday’s infrastructure compromise doesn’t include investments in HCBS senior or child care, that doesn’t mean the Better Care Better Jobs Act is destined for failure.

The Better Care Better Jobs Act

Broadly, the Better Care Better Jobs Act looks to strengthen the country’s HCBS landscape by giving states more money to expand their home-based care programs while also making certain popular policies permanent.

One specific part of the bill, for example, sets aside $100 million for states to develop plans to expand access to Medicaid HCBS and strengthen the home-based care workforce, which is largely made up of low-wage workers, the majority of whom are women and people of color. That funding would be distributed no later than 12 months after the enactment of the Better Care Better Jobs Act.

Also among its many provisions, the legislation seeks to make states eligible for a permanent increase to their federal Medicaid match of 10 percentage points, building upon the temporary bump built into the American Rescue Plan.

While the Partnership for Medicaid Home-Based Care (PMHC), LeadingAge and other HCBS stakeholders voiced appreciation for that initial HCBS payment boost, they repeatedly voiced concerns about a temporary, one-year increase setting up a fiscal cliff for in-home care providers down the road.

A permanent increase to the federal Medicaid match would help avoid that — and likely accelerate HCBS gains — by giving states and providers a greater sense of stability.

“The Better Care Better Jobs Act calling for increased investment in HCBS is recognition of the value of, and demand for, community-based long-term care services for older adults and individuals with disabilities,” PMHC said in a statement shared with Home Health Care News.

To be eligible for the 10-percentage-point increase, states would have to potentially expand HCBS eligibility requirements, offer further support for family caregivers and adopt programs to help individuals better navigate the long-term care system.

On top of that, states would also need to address HCBS payment rates “to promote recruitment and retention of direct care workers,” in part by “regularly updating HCBS payment rates with public input.”

Ultimately, rate increases would need to be passed through to direct care workers in the form of increased wages or more training opportunities.

“This bill would mean better pay and benefits for care professionals, when almost half of home care worker households must currently depend on some form of public assistance,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement shared with HHCN. “And it would provide some relief for more than 40 million Americans who provide some form of unpaid caregiving for an older adult — at an average of 34 unpaid hours a week in care.”

States would have to demonstrate that they’re accomplishing all of these goals through regular reporting. If passed, the Better Care Better Jobs Act would also provide more funding to the U.S. Centers for Medicare & Medicaid Services (CMS) to conduct oversight and monitoring activities.

“PMHC stands ready to assist the Congress in further refining the HCBS policy proposals within the Better Care Better Jobs Act in the coming months,” PMHC’s statement reads. “In addition to increased investment in HCBS, PMHC encourages Congress to support implementing policy proposals that elevate the essential home care workforce.”

The economic impact of stronger HCBS

In addition to the previously outlined provisions, the Better Care Better Jobs Act would make permanent both the spousal-impoverishment protections in Medicaid and the Money Follows the Person program, the latter of which is meant to help people transition out of long-term care facilities back into their homes.

The bill’s $400 billion investment in HCBS would create over 1.1 million jobs, including nearly 800,000 direct care jobs each year over the next 10, the National Domestic Workers Alliance estimates. That investment would create an additional $40 billion in estimated new income for American workers and their families.

By 2030, caregiving jobs are predicted to represent the fastest-growing workforce in the American economy. At the same time, many in-home care workers are leaving the profession due to low wages and a general lack of appreciation.

“The Better Care Better Jobs Act ensures that more of us will have access to home- and community-based care and services,” Ai-jen Poo, executive director of the National Domestic Workers Alliance, said during Thursday’s conference call. “And it will strengthen our caregiving workforce in ways that are so long overdue.”

In 1995, Medicaid spent 18 cents out of every long-term care dollar on HCBS. 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.

Nationwide, home care workers earn a median wage of $12 per hour, according to research from direct care worker advocacy group PHI. Roughly 18% of workers live in poverty.

Those statistics are “not consistent with American values,” Casey argued.

“We claim that we’re the greatest country in the world,” he said. “We also claim that we really care about our seniors, our loved ones, that we care about people with disabilities, that we care about our children. How can we say that? How can we say that, with any credibility, if the people providing that care are paid $12 an hour, on average, and, in most cases, have no benefits?”

What comes next

In all likelihood, the Better Care Better Jobs Act will not make it into a bipartisan infrastructure package. That’s especially true after the White House endorsement.

Moving forward, the HCBS bill would have to pass as a standalone bill that goes through the traditional legislation process. That route is similarly doubtful, however, with Democrats and Republicans effectively lodged in a stalemate for sway in the Senate.

Another avenue could be reconciliation, with Democrats actively working on a plan to unilaterally push through important chunks of an immediate infrastructure package that got scrapped.

Working in the bill’s favor is the constant attention that home-based care has been receiving since the COVID-19 pandemic began, plus the clear and growing demand for in-home care.

Today, there are over 3.5 million older adults and people with disabilities receiving HCBS.

Though all states provide coverage for some HCBS services, eligibility and benefit standards vary, leading to significant variation and gaps in coverage. Some states cap the number of individuals who may receive services, which has left almost 820,000 Americans on wait lists.

Without action, that wait-list number could soon swell into the millions, Casey predicted.

“The goal here is to have the best home- and community-based services in the world,” he said on the call. “We don’t want America to be in second place, third place or 10th place. We want to be No. 1 in the world in caregiving.”

Companies featured in this article:

, ,