Let's Make It Easier to Age in Our Homes

Ask people where they want to live as they get older, and you almost always get the same answer: They want to stay in the comfort of their homes. But ask if they expect to get their wish, and you may hear many doubts.   

It should not be so hard to achieve this priority.  

One way to help these folks is by having a greater national commitment to home and community-based services. I’m talking about a range of services and supports that help people live independently when challenges emerge. 

Personal care (including help with meals and bathing), food delivery, home repairs and safety modifications, transportation, and other resources can ease the heavy responsibilities of family members helping to care for their loved ones. HCBS (Home- and Community-Based Services) can also include home health and nursing care, along with training and other assistance for these family caregivers. 

The pandemic has drawn a painful contrast between the experience of Americans staying at home versus in living in an institutional care setting. More than 186,000 residents and staff of nursing homes and other long-term care facilities have died from the coronavirus. 

Yet, the reasons for a more significant commitment to HCBS go much deeper than the pandemic.  

As our society ages, and our lifespans get longer, millions more will be living with chronic conditions that make it harder to stay independent. Increasingly, they will need services to help them – services they can find and afford.  

In today’s fractured and outdated system, that’s not always possible. HCBS are generally not guaranteed through Medicaid, and benefits can vary significantly from state to state. Meanwhile, middle-class retirees often have to pay out of their own pockets or take on debt to cover services such as home care aides, which can cost thousands of dollars a month, even for part-time care.   

It’s important to understand that basic Medicare mostly stays out of this area. If Medicare reimbursement for HCBS is available, it is usually limited and temporary. Most people do not have private insurance to cover long-term care needs.  

In recent years, however, the balance of spending has been shifting toward HCBS, reflecting not only people’s preferences but economic reality. Many studies have found that community services are more cost-effective than nursing homes, yet there are often waiting lists for HCBS.  

At the same time, not even a quarter of states devote the amount of Medicaid and state long-term services (LTSS) funding to HCBS that they comparatively do for nursing homes and other facilities for older people and adults with physical disabilities. In fact, Medicaid has long favored spending on nursing homes, reducing the available resources that could instead develop local services that promote independence. 

With state commitments varying widely, where you live can affect whether you get the services you need. To give just one example, New Mexico devotes 73.5 percent of its Medicaid and state-funded LTSS spending on HCBS programs for older people and adults with disabilities rather than nursing homes and other institutions. The figure for Kentucky is 13.5 percent.  

Culture and socioeconomic realities also come into play. Hispanic/Latino families are more likely to choose home over other care settings. Older African Americans often lack both affordable high-quality nursing home options and available HCBS in their communities. A more extensive, better-financed infrastructure of HCBS would ease inequalities that disproportionately affect underserved racial and ethnic groups. 

Enhancing the paid HCBS workforce is another crucial step in addressing economic disparities. The labor force of 3.2 million home health and personal care aides performs vital tasks for little pay or opportunity to climb a career ladder. Average pay in one recent estimate is $13 an hour, falling more than 20 percent short of what is considered a “living wage” that meets basic needs like housing and food security. Women of color also occupy many of these jobs and have been hurt economically by the pandemic. Americans will benefit by supporting these workers who greatly impact a person’s quality of life.  

Fortunately, the political support for HCBS is starting to grow. 

Earlier this year, Sens. Bob Casey (D-Pa), Cory Booker (D-NJ), and more than a dozen of their colleagues made a strong pitch for HCBS funding in a letter to President Biden. “At the outset of your Administration, we have the opportunity to rescue a teetering caregiving system and recreate it to transform the lives of millions of workers and to serve as an economic workhorse,” they wrote. 

The president later included $400 billion to strengthen HCBS as part of his infrastructure proposal. The measure would make new funds available to enhance workers’ pay and training. Separately, the American Rescue Plan Act, which became law in March, offers a one-year bump of 10 percent in federal matching funds for specific state Medicaid HCBS efforts. The Better Care Better Jobs Act, introduced in the Senate and in the House by Rep. Debbie Dingell (D-MI) in late June, would make the federal match funding hike permanent for states that take certain steps, such as broadening eligibility for HCBS and providing support for family caregivers.   

These are encouraging developments, but we need to think even bigger. Hard-pressed middle-class families who do not qualify for Medicaid need greater access to a more robust system of HCBS. Investment in HCBS supports families across the United States and leads to continuing innovations in the delivery of long-term care and job creation for the middle class. The nation will benefit from services that help people age where they prefer.