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April 20, 2022

ICYMI: Biden Administration Announces Sweeping EO to Support Care Workers

The Biden Administration outlined several new plans ostensibly targeted at supporting care workers and family caregivers. Continuing a framework set out early in the Biden campaign, the strategy targets caregivers and workers in childcare, aging services, and services for people with disabilities.

The fact sheet supporting the executive order outlines ambitious goals at a very high level. As the details emerge, providers will be able to gain a practical understanding of how these sweeping actions will impact care. While many of the plans announced in the document have been announced before, a number of the elements appear to be new.

Much of the executive order focuses on making childcare more accessible and affordable for families, including military families; improving access to home-based care for veterans; and boosting job quality for early educators.

On the positive side, we are pleased that:

  • The Administration continues to say it is focusing on aging services and specifically on paid and unpaid caregivers. Aging services providers are facing a staffing crisis of historic proportions.
  • The White House has heard our message that an “all of government” approach is needed.
  • The President continues to talk about his proposed $150 billion expansion of Medicaid home and community-based services.
  • The President is directing the US Department of Health and Human Services (HHS) to focus on dementia.

There are a few concepts related to, or potentially related to, long-term care worth noting, including the following:

Enhance job quality for long-term care workers. The President is committed to improving the quality of long-term care jobs in this country so that Americans can get the reliable, high-quality care they deserve—whether in their homes and communities or nursing homes. To advance the President’s long-term care priorities, the Executive Order directs HHS to consider issuing several regulations and guidance documents to improve the quality of home care jobs, including by leveraging Medicaid funding to ensure there are enough home care workers to provide care to seniors and people with disabilities enrolled in Medicaid, as well as build on the minimum staffing standards for nursing homes and condition a portion of Medicare payments on how well a nursing home retains workers.

Support family caregivers. Without adequate resources, family caregiving can affect caregivers’ physical and emotional health and well-being and contribute to financial strain. These negative consequences are felt most acutely by women, who make up nearly two-thirds of family caregivers and who drop out of the workforce at higher rates than men. To provide greater support to family caregivers, the Executive Order directs HHS to consider testing a new dementia care model that will include support for respite care (short-term help to give a primary family caregiver a break) and make it easier for family caregivers to access Medicare beneficiary information and provide more support to family caregivers during the hospital discharge planning process. Additionally, VA will consider expanding access to the Program of Comprehensive Assistance for Family Caregivers and provide more mental health support for caregivers enrolled in that program. These actions build on the 2022 National Strategy to Support Caregivers.

Advance domestic care workers’ rights. To provide greater protection for domestic care workers providing care for our loved ones, the Department of Labor will publish a sample employment agreement so domestic child care and long-term care workers and their employers can ensure both parties better understand their rights and responsibilities.

Outlining our concerns

We have several concerns about today’s announcement, as spelled out in the fact sheet. The devil will be in the details, which are not announced yet. Our top five concerns are:

The entire continuum matters. Don’t frame the debate as HCBS vs. nursing homes. It’s time to stop the finger-pointing at nursing homes. The continued framing that pits home and community-based services against nursing home care fails to recognize that the entire continuum of aging settings and services needs attention and resources. The fact sheet suggests that the Administration will “leverage Medicaid” to ensure there are sufficient HCBS workers while simultaneously committing to adding additional regulations and requirements to the staffing ratio mandates (as yet, this proposed rule is not released) and punish nursing homes (by withholding Medicare SNF reimbursement) for not being able to retain staff.

Disability policy and aging policy are not the same. The announcement underscores the Administration’s continued conflation of needs, services, and supports for primarily working-aged people with disabilities with those of older people. While there are some commonalities, the fact sheet includes and is based on several fallacious assumptions that the issues are identical for both groups of consumers. For example, the “hundreds of thousands” of people on Medicaid HCBS waiting lists are working-aged people with disabilities, not older people.

Home and community-based services include community-based services. This fact sheet and other communications from the White House seem to be based on the assumption that “HCBS” happens almost exclusively in the individual home of each beneficiary. There are not enough care workers to provide this type of care; the financing is not likely to ever cover the costs even if there ever are enough workers, and care in each person’s home is not necessarily the best care for every beneficiary. Medicaid funds are used for adult day services and assisted living. Fact sheets and other communications should recognize that while home care is a vitally important part of the continuum, there is variability under the HCBS umbrella.

It will take focused aging expertise in the White House to address the aging of the population broadly and meaningfully. Asking multiple departments to talk with stakeholders is a small and early step and an acknowledgment that our message is being heard. However, the issues go well beyond caregiving, and the goal should be to tie together the work of all government agencies.

There will never be enough people to work in aging services without comprehensive immigration reform. Simply put, there are 1.7 jobs in the economy for every job seeker. The math doesn’t work without new people coming to the U.S. Supporting caregivers, leveraging payment incentives, and increasing their ranks cannot be done without changes to our immigration system.

Today’s order outlines ambitious goals at a high level, and we will keep you updated as we uncover additional details and advocate on your behalf every step of the way. Check Advantage and LeadingAgeMN.org for ongoing updates.

Thanks to LeadingAge, our national partner, for ongoing advocacy and partnership to shape policies at the federal level that impact older adult service providers.

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