Biden’s “Infrastructure” Plan Misses the Mark on Care for Individuals with Disabilities
President Joe Biden last week proposed $400 billion in new federal spending on home- and community-based services for seniors and individuals with disabilities as part of a $2 trillion infrastructure package. While these provisions might at first glance seem out of place with a topic normally associated with roads and bridges, the proposal fits with the broader themes of Biden’s plan. As with the overall package, Biden’s home-based care proposal begins with a good idea but points it in the wrong policy direction, using it as an excuse to expand government rather than tackling important structural reforms.
The proposal stems from a longstanding disparity within the state-federal Medicaid program. While states must cover nursing home care for all eligible Medicaid beneficiaries, home- and community-based care remain only optional services for states to cover. As a result, states can, and do, institute waiting lists to access home- and community-based care. Beneficiaries on these lists receive full medical benefits, but have to wait—years, in some cases—to qualify for services like visits from a home aide to help with activities of daily living.
Waiting lists for home-based care preceded Obamacare, but that law arguably worsened the problem. Whereas states received an enhanced match that started at 100 percent, now 90 percent, for expanding Medicaid coverage to able-bodied adults, states wishing to reduce or eliminate their waiting lists for home-based care receive only their regular federal match, which this year varies from 56 percent to 84 percent.
By paying states more to cover able-bodied adults than to reduce their waiting lists, Obamacare effectively discriminated against some of the most vulnerable in our society: individuals with disabilities. Perhaps unsurprisingly, then, the number of beneficiaries on waiting lists grew from 511,000 in 2010—the year of Obamacare’s enactment—to nearly 820,000 by 2018. At least 21,904 individuals with disabilities in states that expanded Medicaid died while on waiting lists for home-based care—the result of states prioritizing able-bodied adults over the most vulnerable.
Judging by its proposals, the Biden administration wants to solve this discrimination with hundreds of billions of dollars in new taxpayer funds. The “stimulus” bill Biden signed into law in March included a 10 percent increase in the federal match for Medicaid coverage of home-based services, through March 2022. The proposal he released last week would take that further. It pledges $400 billion to “expand access to home and community-based services.”
While the Biden proposal did not include many details beyond the $400 billion figure, expanding access to home-based services with new federal dollars will not solve existing problems. For starters, Medicaid currently has a bias towards institutional care in nursing homes, which adding new money to the system might not eliminate.
When one of us (Jacobs) served on the congressional Commission on Long-Term Care in 2013, he heard about proposed reforms to create a new bias in favor of home-based care by capping and limiting nursing home slots, or by requiring beneficiaries to try home-based care before moving into a nursing home. Eight years later, the way COVID-19 spread like wildfire in nursing homes—in part due to the disastrous decisions of governors like Andrew Cuomo to require homes to admit COVID-positive patients—makes a re-examination of nursing home care more urgent. Adding more federal money to support home-based care, rather than funding it by shifting existing dollars away from nursing homes, avoids the underlying problem rather than solving it.
As the old saying goes, to govern is to choose—but the Biden proposal attempts to avoid hard choices. Rather than tackle the flawed nursing home system, or fix the inequities created by Obamacare, the administration hopes that a flood of new federal dollars will solve every problem. At a time when our nation faces $28 trillion of debt, future generations deserve better than this ill-targeted approach.
This post was originally published at Newsweek.