As the long process of emergence from the COVID-19 pandemic continues, now more than ever, we must invest in sustainable long-term care. Older adults and people with disabilities who rely on long-term services and supports (LTSS), in particular, home and community-based services (HCBS), were some of those most impacted by the pandemic. Our long-term care system was already unsustainable well before the pandemic, and improvements to that system are now a critical component of building a more stable American infrastructure. 

As part of this rebuilding effort, President Biden recently unveiled the American Jobs Plan, his $2 trillion plan to address the nation’s infrastructure needs. Within the plan is $400 billion to improve HCBS and extend Medicaid’s Money Follows the Person program that allows people with disabilities to live independently and older adults to age in place, options that an overwhelming majority of those cohorts prefer. It also proposes better wages and benefits for direct care workers, the majority of whom are women and people of color.   

Many people with disabilities and older adults are eligible for Medicaid HCBS services but don’t receive them because they are an optional, rather than mandatory, Medicaid benefit. Therefore, states are not required to make the benefit available to every person who is eligible to receive it. This results in barriers to care, such as waiting lists that are often years long. As a result, many race and population-based inequities exist and prevent those who are eligible and may have the greatest level of need from receiving care. Additionally, the typically low wages of the direct care worker industry create labor shortages which threaten the availability of home-based care in many regions. It is estimated that one million more care workers will be needed in the next decade to provide care for older adults and people with disabilities, a target that will be difficult to reach without a meaningful improvement in pay and working conditions. An increase in pay for care workers would improve well-being for both caregivers and care recipients by reducing staffing shortages, creating quality jobs for care workers, and infusing economic growth into local communities.   

The new investments in the Biden plan represent the administration’s emphasis on improving caregiving not only as a health policy issue but also as an issue of both infrastructure adequacy and racial justice. Home and community-based services are indeed vital infrastructure for our nation, as they support activities of daily living, protect people with disabilities from institutionalization, and equip families with the necessary supports for their loved ones. Additionally, inclusion of home health workers in the infrastructure bill could signal a recognition of the gender imbalances underlying caregiving work, an imbalance shouldered by the women of color who do the majority of caregiving.  

Although it is confirmed that the $400 billion in funding will be dedicated to LTSS, it remains to be seen how this amount will be allocated to various priorities. While the Biden administration has signaled its support for the caregiving workforce, it does not include specific wage stipulations nor a path to unionization for care workers. The White House has also supported state infrastructure for care workers, but the details of that infrastructure remain to be seen. There are existing proposals for how states can best support care workers, but a lasting plan to improve HCBS must include an administrative and legislative commitment to specific supports. 

With the implementation of the American Jobs Plan, more people who are eligible for and rely on home and community-based services should be able to receive the full benefits they are entitled to. There are also exciting developments in Congress to advance legislation to make HCBS a mandatory Medicaid benefit, which would then make these critical services available to all who are eligible. If these promising proposals to fund and expand HCBS become law, advocates must hold states accountable to ensuring all who qualify for Medicaid HCBS have barrier-free access to care. This new investment in care infrastructure will ensure more older adults and people with disabilities are able to remain in the community and live independently.