Scaled-back social services bill still vital to Michigan home care workers

Like just about everything else in President Joe Biden's sweeping plan to remake social services, his proposal to spend $400 billion improving home- and community-based long-term care for older and disabled Americans has been scaled back dramatically.

But there are still provisions that could significantly expand home care in Michigan and across the U.S. and help raise wages for the people who provide it.

"Is this going to make a difference? Undoubtedly, yes," said MaryBeth Musumeci, associate director at the Kaiser Family Foundation's Program on Medicaid and the Uninsured, based in Washington. "This is an important investment in an area that hasn't seen a significant infusion of money since the (Affordable Care Act, passed in 2010)."

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In the version of the so-called Build Back Better act passed last month by the U.S. House, some $150 billion is dedicated to improving access to long-term home care and care provided in settings such as assisted care facilities and trying to ensure workers see their wages increase. Most of that amount involves a program — if it survives scrutiny in the Senate — that could raise the share the federal government offers to reimburse states for home- and community-based care provided through Medicaid, the health insurance program for lower-income Americans and disabled people.

That share was increased by 10 percentage points for one year under the COVID-19 response plan proposed by Biden and passed by Congress this year. The new proposal drops that increase to 6 percent— but maintains it in perpetuity.

That means that if the legislation passes as is, states will have an incentive to expand home care programs. If Michigan, for instance, develops a new plan to expand access by increasing enrollment or lifting income requirements, and puts in place programs to retain and provide better pay to workers, it could get more from the federal government to pay for it.

Each state already has a basic federal reimbursement rate for Medicaid services of at least 50 percent based on per capita income in that state compared with the national average; in Michigan, rather than receiving the 72 percent federal reimbursement it would get for most other Medicaid expenditures, it could be reimbursed at 78 percent for an expanded home health care program.

If those programs were "self-directed" — meaning the recipients or their representatives have greater authority in deciding who gets hired to provide the service, meaning less bureaucratic involvement and cost — it could mean an 80 percent reimbursement for the first year and a half of the program.

And unless some future Congress and president moved to strip it away, the funding wouldn't disappear at some set date  — a key component in any state's decision as to whether it wants to enact such a program in the first place.

Wait lists for home care have grown

In recent years, more states have moved to provide home- and community-based personal care services through Medicaid, knowing they can allow more older Americans and disabled people to stay at home, sometimes at a fraction of the cost of institutional or nursing home care while also providing assistance with meals, chores and cleanliness. But those plans vary greatly from state to state and can have enrollment caps and other limits as to who can join or whether family members can be paid. 

While every state is required to offer certain benefits, including institutional care, to lower-income and disabled people who qualify for typical Medicaid — for a single person in Michigan, that means income of no more than about $17,000 a year — home- and community-based options and eligibility can differ greatly, as states have asked the federal government for permission to try out programs targeted at specific populations with varying circumstances and income levels. 

For instance, in Michigan an individual could earn up to about $2,349 a month — about $28,000 a year — and still qualify for home care under some of its programs. 

As a result, states across the nation have seen the number of people waiting to join such programs grow significantly. In 2018, some 820,000 people were waiting to be admitted to a home- or community-based program; in Michigan, where about 90,000 people received care either under traditional Medicaid or other programs, the wait list included more than 3,000 seniors and disabled persons.

"We know there is a crisis going on," said Barry Cargill, president and CEO of the Michigan Home Care and Hospice Association, a group of some 250 providers. "It's extremely difficult to hire enough workers. What we're able to pay ... is fairly low because of what reimbursements are. This will be an important shot in the arm for state Medicaid programs."

The situation, he said, has only been exacerbated by the COVID-19 pandemic, with care providers having an even harder time hiring people.

The added funding for expanded home care programs isn't the only benefit provided in the Build Back Better plan as it passed the U.S. House. It also includes $1 billion for grants that could be used on programs to retain workers and provide better pay. Biden has left no doubts either that he wants home care workers to be left alone to join unions if they wish — state officials accepting the increased federal share have to ensure that their programs do not "promote or deter the ability of workers to form a labor organization or discriminate against workers who may join or decline to join such an organization.”

Home care workers in states where they have been allowed to organize say they have seen increased wages in a field where the average worker made less than $13 an hour in 2020.

The legislation also includes some other pieces, such as making spousal impoverishment rules — which ensure that a spouse won't see his or her assets swallowed up in order to qualify first for coverage — permanent. There are also other measures being considered independent of the Build Back Better plan, such as a bipartisan bill that would provide a tax credit of up to $5,000 for people taking care of family members for expenses they incur over a certain threshold.

Mike Wittke, vice president for research and advocacy at the Washington, D.C.-based National Alliance for Caregiving, a nonprofit organization of corporate, academic and other groups involved in caregiving, said the measures aren't as transformational as they might have been: 12 weeks of paid family medical leave, which was initially proposed, has been scaled down to four and could be dropped altogether; that tax credit for caregivers that is being considered wouldn't be refundable, meaning it could only cut a provider's taxes down to zero, not be paid back to them in the form of a refund.

But he said there is clearly a move in the right direction. 

"What is really more transformational is that we're recognizing how important this issue is," he said, adding that a lot of families are not only trying to care for an aging parent but also save for college costs at the same time. "That is just an extremely crippling situation that millions of families are going through.”

What comes out of an evenly split Senate is anyone's guess for now. While there haven't been any specific mentions of caregiver provisions being stripped out, there also isn't any question that some key senators have been looking to cut the Build Back Better bill's overall cost, which the White House has put at $1.75 trillion and some watchdog groups say could be more than that. 

Advocates, meanwhile, keep pressing to keep the support as robust as they can.

“The Senate’s job is clear: to adopt these investments without shaving off one dollar, and indeed to increase them,” said Katie Smith Sloan, president and CEO of LeadingAge, which represents service providers for older Americans. "What happens in the next few weeks will determine whether millions of Americans can access the care they need as they grow older."