Congress must fully fund home and community-based services

As part of a revised framework for the Build Back Better Act now under intense negotiations in Congress, President Joe Biden proposed $150 billion in federal funding for the nation’s home- and community-based services (HCBS) infrastructure, a far cry from the $400 billion the President first proposed back in the spring.

While the dollars remain significant, this reduced level of funding does not meet the need or the moment amidst an ongoing pandemic, a national shortage of homecare workers, a fragile economy, and the aging of America. By 2030, one in four Americans will be 65 or older, up from 15 percent of the population today.

Today, nearly 820,000 people find themselves on waiting lists for badly needed services including home-based care, food and medical assistance, support for family caregivers, transportation, and skilled nursing. With an average wait time of over three years, many have become sicker and frailer, and others have even died. These people are being denied the ability to receive care and support in their own homes rather than in nursing homes, a stated desire of the overwhelming majority of adults in America. 

Beyond waiting lists, robust funding for HCBS would create thousands of new and better paying jobs for caregivers — the majority of whom are women of color — and mark a historic investment in an area of care that has been neglected and underfunded for decades.

The Medicaid HCBS provision in the proposed Build Back Better agenda is a giant step in the right direction to addressing longstanding deficiencies in care for older adults and those with disabilities. It would be the most meaningful investment in long-term care by any president since Lyndon Johnson signed legislation to establish the Medicare and Medicaid programs in 1965.

But without significant investment in HCBS right now, and considerably higher than what is currently on the table, the human and economic toll will only grow larger and become more difficult, if not impossible, to manage. Experts estimate it would take at least $250 billion to clear the waiting lists for care and services alone.

Congress must tread carefully as it considers the final price tag for HCBS. Every cut from the originally proposed $400 billion has immediate, mid- and long-term consequences to individuals and their families and the economy.

Not only does expanded HCBS have the potential to reduce ER visits, keep more people healthy and independent, and cut nursing home and hospital admissions, a recent report from Moody’s Analytics finds seniors and people with disabilities would “receive higher-quality care from better trained and more highly paid direct care workers.”
Additionally, more of the 40 million unpaid informal caregivers will be able to take other jobs, and “the economy will receive an immediate boost from this increased government spending along with a lift in long-term growth from higher labor force participation.”

The pandemic’s impact, particularly on seniors, has added urgency to fix a system that keeps essential care out of reach for far too many people. While emergency relief bills have helped, these funding increases are only temporary, pale in comparison to the outsized need.

Deaths among residents and staff of long-term care homes now represent one-third of all COVID-19 deaths in the country, despite only accounting for 1 percent of the total population. These grim outcomes have triggered a national awakening to the need for more care options in the home. Simultaneously, the national shortage of home health care workers is teaching us the harsh lesson that without an adequate and well-resourced workforce our entire long-term care system can collapse.

The overwhelming demand for services will only rise over the coming years as America’s population ages, and without government action, we will face an even greater crisis of care than we do today. Insufficient funding will only serve as a Band-Aid on the gaping wound within our HCBS infrastructure.

Shelley Lyford is the president and CEO of West Health, a family of nonprofit, nonpartisan organizations dedicated to lowering the cost of health care and improving aging in America.