In an important symbolic step, 17 Senate Democrats announced they will work together to develop a plan to improve long-term services and supports in the US.
The effort is led by the Senate Finance Committee’s top Democrat, Ron Wyden of Oregon, a long-time supporter of services for older adults and younger people with disabilities. Many of its participants are members of the Finance and health committees, the panels that would write such legislation.
For now, the 17 Democrats represent a minority of the minority party in the Senate. And they have no more than a framework that builds around three key ideas: A robust home-based care system, more support for family caregivers and paid care workers, and higher-quality nursing homes.
Long-term Care And Affordability
Their long-term care initiative is a tied to a broader Wyden project to build a Democratic “affordability” agenda that also includes lowering drug costs and reforming health insurance.
The long-term services and supports piece may borrow from plans proposed by then-President Biden and Vice-president Kamala Harris. But those went nowhere, even when Democrats controlled Congress.
Still, the combined support of key Senate Democrats could jump start a moribund congressional debate over long-term care. Perhaps their most ambitious idea: “Finance Committee staff will develop policies to invest in Medicaid home- and community-based services and establish a home care guarantee for people with Medicare.”
That last element would be a huge step since Medicare generally does not pay for long-term care.
No Public LTC Insurance
One idea not on the senators’ agenda: A public long-term care insurance program. That concept, which is being developed in the House by Representative Tom Suozzi (D-NY) has gotten little traction among these Democratic senators. Nor has Washington State’s WA Cares public insurance program that will begin to pay modest benefits starting in July.
Senate aides say the group is cool to public insurance for three reasons. The senators dislike any model that mimics private insurance, they don’t want to create an entirely new federal program, and as currently designed Suozzi’s bill would cover older adults only and not younger people with disabilities.
It also may be because Suozzi is looking for a bipartisan financing solution while these senators are being explicitly partisan. In the runup to the November elections, they want Democratic ideas that contrast sharply with Republican efforts to cut Medicaid long-term care benefits.
Medicare Or Medicaid?
Expanding the home care benefit in Medicaid while trying to create a similar Medicare benefit can help make sure people don’t fall through the benefit cracks won’t be easy. For example, how would the two programs work together for people eligible for both?
It is hard to imagine two parallel long-term care systems, which would be complex to navigate and needlessly expensive to administer. Eventually, either Medicare or Medicaid would have to become the primary system for delivering long-term services and supports. One option could be to enhance Medicaid for now, then transition home care to Medicare in the future.
The lawmakers are trying to balance the very different views of long-term care advocacy groups. Some want to protect Medicaid as the primary source of government funding, especially to cover people with disabilities. They believe that by endorsing any shift to Medicare, these Democrats would implicitly be turning away from Medicaid, giving Republicans more opportunity to cut the program further.
However, other advocates believe Medicare home-based care makes more sense. It would be available to anyone who needs a high level of care, not just those with very low incomes and few financial assets. It would make it easier to coordinate supports and services with health care. And, as part of Medicare, it may be more politically stable than Medicaid, which is enduring substantial cuts under the Trump Administration.
Two recently released ideas may provide some hints about where these Democrats are headed.
One is a major expansion of Medicaid home-based care introduced by Representatives Debbie Dingell (D-MI) and Jan Schakowsky (D-Il).
The other is a plan designed by a group of Brookings Institution experts that would create a Medicare home care model while retaining Medicaid for some home-based services as well as nursing home care.
How Will They Pay For It?
The senators’ biggest challenge may be paying for what inevitably will be costly new benefits.
Senate staffers won’t estimate the cost. However, Biden’s enhanced home care plan would have cost about $400 billion over 10 years—a price tag that was unacceptable even to a Democratic Congress. The Brookings plan contemplates about a 5% income-tax surcharge for people over age 55.
Any cost likely be pushed higher by the final leg of their three-legged stool—increasing opportunities for direct care workers. The’d pay the workers more and toughen staffing requirements for nursing homes—rules proposed by Biden but scrapped by Trump.
There are good reasons to boost low pay for direct car workers, where there currently is a significant labor shortage. And, politically, such a step is important to powerful unions.
But more care workers making higher pay inevitably will add to the overall costs of whatever program the lawmakers design. And, at least for now, the senators are far from consensus on how they’d foot the bill.
Starting A Debate
At this stage, the senators are talking about what would likely be more of a message bill than passable legislation.
They’ll eventually need to find a way to thread the needle between the Medicare LTSS advocates and the Medicaid LTSS supporters. Without full control of the House, Senate, and White House, legislation this partisan and ambitious has no chance of becoming law.
And a lesson Democrats should have learned from the 2010 Affordable Care Act is that while Congress may be able to pass big bills with only one-party support, those laws have little staying power.
Despite all those obstacles, the positive message is that a mid-sized cadre of Senate Democrats believes long-term care reform is important enough to highlight as part of their affordability agenda in this year’s campaign, and perhaps in 2028 as well. And given the past unwillingness of most lawmakers of either party to confront this massive need, that counts as progress.
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