Biden’s long-term care agenda faces headwinds

Two separate but interconnected proposals would require minimum staffing requirements in nursing homes and require that 80% of Medicaid payments for home and community-based services go toward compensating direct care workers.

But the problem with those proposals, some lawmakers, state officials and those in the industry say, is that they’re not realistic as long as workforce shortages continue and low Medicaid reimbursement rates remain in place.

Meanwhile, advocates for the people who use those services say the money is available, but staffing is kept low and workers are underpaid to boost profits.

The truth, said David Grabowski, a long-term care expert and health care policy professor at Harvard Medical School, is probably somewhere in between.

“Both sides are right,” he said. “There is a shortfall in Medicaid, and providers play a lot of games.”

Research has consistently demonstrated that low staffing levels lead to worse outcomes for patients, and workforce shortages in both home and community-based settings are leading to delays in care, with people being turned away from badly needed services.

“These are the frontline workers who we call heroes. Until we address those inadequacies in benefits and pay and treatment, we’re going to continue to have understaffing,” said Sam Brooks, director of public policy for The National Consumer Voice for Quality Long-Term Care.

Nursing homes

The Centers for Medicare and Medicaid Services is expected to soon release its long-awaited proposed rule setting minimum staffing levels in the nation’s 15,500 nursing homes after Biden previewed the regulations in last year’s State of the Union address.

The proposed rule is currently being reviewed by the Office of Management and Budget and is expected to be released this summer. The agency is meeting this week with the American Hospital Association and National Rural Health Association.

The nursing home industry, led by the American Health Care Association, is lobbying extensively against a minimum standard, calling it an unfunded mandate and noting low Medicaid rates, a historic departure of workers during the COVID-19 pandemic who left for higher-paying jobs in other industries and nursing home closures.

“A staffing mandate will not create applicants. And when nursing homes cannot meet this impossible standard, they will have to reduce the number of residents they serve or close entirely, exacerbating the current access-to-care crisis we’re already seeing unfold,” an AHCA spokesperson said.

A minimum staffing standard has long been recommended by experts including the National Academies of Sciences, Engineering and Medicine, which found in its 2022 report that low pay and poor benefits have “made the nursing home a highly undesirable place of employment.”

The report recognized current staffing shortages but argued that enhanced staffing and training opportunities would make nursing homes more desirable workplaces, attracting more workers.

“This is a decades-old problem, and it’s not just about post-pandemic nursing home care,” said Lee Goldberg, health policy specialist for the AFL-CIO. “These are really difficult jobs, and they don’t pay well. The problem is not nursing homes not being able to hire people, but they can’t retain people. People shouldn’t get bad care or bad working conditions because nursing homes can’t hold on to workers.”

Home and community-based services

The Biden administration also recently proposed a rule that would require that 80% of Medicaid payments for homemaker, personal care services and home health aide services go toward paying direct care workers, aiming to improve wages and attract more people to the field.

Those efforts come after Congress rejected Biden’s request for $400 billion in additional funding for home and community-based services — services that help older adults and people with disabilities stay in their homes — in his domestic policy package that passed last year.

Now that Democrats no longer have control of Congress and Republicans are calling for budget cuts, it’s even less likely that Congress will increase funding for such programs. That leaves Biden to pursue regulation, which doesn’t typically come with new money.

The goal, the administration said, is to address the “inextricable link between sufficient payments being received by the direct care workforce and access to and, ultimately, the quality of” home and community-based services.

Nationally, home health workers, including workers who do clinical work, make about $14.87 an hour, according to the Bureau of Labor Statistics.

The average reimbursement for personal care services is $23.09 per hour in the 22 states that report that data, and $119 per hour for home health agency services in the 20 states that report that data, according to KFF.

Supporters of the rule said 80% should be doable for providers since the vast majority of the service they provide is through direct care workers.

But providers say Medicaid rates don’t support higher wages. Requiring 80% of funding to go to direct care worker compensation would mean cuts in other areas like worker training, clinical supervisors, transportation and other services for patients, said Shannon McCracken, vice president for government relations for ANCOR, which represents providers caring for people with disabilities.