American Jobs Act proposes big dollars for caregiving — here’s the bigger vision it lacks

President Biden’s American Jobs Plan includes a provision to invest $400 billion in “caregiving infrastructure,” including to create jobs and raise wages and benefits for workers who care for the elderly.

Having built a 40-year career as a care manager to older adults, my first reaction to this news was sheer jubilation. It’s about time we as a nation acknowledged the critical importance of caring for adults in their fragile years to both the economy and the fabric of our society. Once I’d come back down to earth, I began to wonder: In what other ways might a $400 billion investment be used to jumpstart the sort of fundamental change our eldercare system so desperately needs?

As everyone knows, the coronavirus hit nursing homes and other long-term care facilities the hardest. Their residents constitute less than 1 percent of the U.S. population yet accounted for at least 32 percent of all COVID-19 deaths. To date,182,000 COVID fatalities occurred in long-term care facilities, residents and staff combined. What seemed minor by comparison was the emotional blow for families unable to visit their loved ones in nursing homes.

This is just the tip of the iceberg of the nursing home dilemma, which is central to any

conversation about changing our eldercare system. Nursing homes, which are one of the most prevalent and accessible formats for care, are profit driven. Their goal is to drive profits up and costs down for stakeholders. This negatively affects the quality of care and collides with the desires of most aging adults, who do not want to be subjected to batteries of tests and life-prolonging procedures, all of which are highly profitable for those implementing them.

There is also a severe nationwide shortage of nursing home caregivers and home health care workers. Biden’s American Jobs Plan could potentially help, but the fact remains that without addressing the broader structural issues, chances are neither the quality of care nor the emotional impact on families will improve.

COVID has been the perfect storm for prompting some long-needed soul-searching about how we care for our older loved ones. Early in the crisis, families began seeking short-term alternatives to nursing home care while questioning their loved ones’ safety and the quality of their care. Now, with the Jobs Plan on the table, it’s time to ask two more essential, underlying questions:

Are nursing homes really the best way to provide care for our fragile, older parents in general?

And what better alternatives might there be?

My answer to the first question is an unequivocal “no.” After 40 years of working directly with institutions, I have seen that the absolute best place to provide and receive care for an older adult is at home or in small, not large, institutions. According to a 2018 AARP survey, 75 percent of older Americans would prefer to age in the comfort of their homes. If home is where they are happy, home is also far more likely to be the place where they will stay as healthy as possible.

Most of the myriad possible alternatives I envision begin with a redesign of how Medicaid funds are allocated for eldercare. Some steps to this redesign include:

• A chance to opt out of nursing home care, which is covered in part by Medicaid, and to receive a tax credit instead that could be applied to care in another setting. 

• Support for local initiatives such as shared housing or matching services that help identify groups of older adults facing similar health issues who can seek care in a small setting together. 

• Reinventing nursing homes into much smaller facilities where caregivers tend to be happier because their workload is sustainable and the quality of care can increase.

• Prioritizing care during the fragile years over deathbed care. Ten percent of all health care ($365 billion) is spent at the very end of life. Additionally, more funds are spent on unnecessary medical procedures attempting to prevent an inevitable death. Why not channel those funds and efforts to those who still have time ahead of them but still need some measure of care?

• Public-sector support and a new mission for hospice. Hospice is a lucrative business provided only by the private sector. Imagine reallocating these Medicare dollars to designated medical providers: geriatric physicians, internists and primary care physicians or directly to those nursing homes that already care for older adults in their last days?

• Rerouting nursing home funds to adult children caring for their aging parents at home, especially those who need to scale back on work for this purpose.

There are so many untapped opportunities to save money, improve working conditions and boost happiness among both caregivers and older adults. History shows us that a crisis can trigger rapid change. Let’s get started.

Amy Cameron O’Rourke is an advocate for senior care in the U.S. A professional care manager with more than 40 years of experience, she is director of care management at Arosa and author of “The Fragile Years.”