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Why Long-Term Care Needs Infrastructure Financing

Some may argue over semantics, but the need is urgent and great

By Bob Blancato

Which headline are we more likely to see later this year or early next year: "Congress Passes Historic Legislation Creating a Long-Term and Home and Community-Based Care Infrastructure" or "Congress Again Punts on Long-Term Care?"

A long-term care worker brushing the hair of a patient.
Credit: Getty

We are once again at a crossroads in the long and sometimes tortuous history of addressing the issue of long-term care and long-term services and supports in America. The need is as great as it ever has been, perhaps greater, and we now have some excellent proposals and related legislation offering solutions.

We are in the middle of a significant demographic shift that will exacerbate the gaps in our long-term care supports and services.

In March, President Joe Biden proposed the American Jobs Plan which included a landmark $400 billion proposal for long-term care home and community-based services under Medicaid.

Among other things, it would make permanent a program known as Money Follows the Person, which moves people out of nursing homes and back into their homes or homes of loved ones. Biden would also offer caregiver workers a raise and stronger benefits. His plan would lower the waiting list for home care and community-based services under Medicaid.

Long-Term Care Missing From Bipartisan Plan

But the $400 billion plan was scuttled when a bipartisan group of Senators came to an infrastructure legislative compromise focusing on traditional infrastructure (money for things like highways and bridges) and not human infrastructure like long-term care.

Meantime, momentum for expanding access to home care and community supports grew when Sen. Bob Casey (D-Pa.), the chairman of the Senate Special Committee on Aging, introduced the Better Care Better Jobs Act alongside 40 co-sponsors.

Both Biden's and Casey's proposals recognized the vital importance of supporting the home health care workforce required to meet the needs of many older adults who are now forced to "spend down" their life savings to next to nothing just to qualify to get waitlisted for a Medicaid nursing home bed.

Recently, Rep. Tom Suozzi (D-N.Y.), who sits on the important House Ways and Means Committee, produced one of the most transformative long-term care bills in years. It's aptly called the WISH Act (Well Being Insurance for Seniors to Be Home Act).

That bill would create a federal public-private partnership to provide long-term care insurance so older adults could receive the care and support necessary to remain in their homes and communities instead of having to "spend down" their assets.

A Federal Long-Term Care Insurance Plan?

Suozzi notes that this legislation has not only the potential to dramatically enhance long-term care options for older Americans and their family members, it would reduce federal and state Medicaid costs by a quarter.

My former Long-Term Care Financing Collaborative colleague Howard Gleckman wrote about the bill on Forbes, saying that for many older adults, it would shift public financing for long-term care from Medicaid "to social insurance available regardless of income. The cash benefit would give beneficiaries substantial flexibility in how they spend the assistance, in contrast to Medicaid where benefits are limited by state and federal rules."

There's another intriguing approach for long-term care infrastructure proposed in an article in The Hill by three noted thought leaders in aging: Anne Tumlinson (a Next Avenue Influencer in Aging), Prof. David Grabowski and Robert Kramer.

They called for "a centralized community-based resource" where older adults could quickly and easily access aging services through community spaces "as familiar as the post office or the bank." (I would note that this is precisely what an Area Agency on Aging or an Aging and Disability Resource Center already does. But the new idea would provide more resources for this network, including making more people aware of their important services.)


So, in some respects, the table is set: We are in the middle of a significant demographic shift that will exacerbate the gaps in our long-term care supports and services and we have viable proposals from the administration and Congress that could help address the crisis.

Prospects for Long-Term Care Help From Washington

What happens from here? The headwinds of history coupled with a reality that denial delays policy make me a bit skeptical about prospects for passage.

I have contended for years that America's long-term care crisis is driven by denial. Even though it is the largest unfunded liability confronting the boomer generation, there is no great public clamoring for action.

85% of Americans agree that now is the right time to think about building a better aging services system.

While the issues of long-term care, home care and community-based care have some of the best policy minds associated with them, they lack strong political minds to make this what it should be — a "kitchen table" issue. 

Perhaps things are changing. LeadingAge, a group of nonprofit providers of aging services, just released a poll which found that 85% of Americans agree that now is the right time to think about building a better aging services system. And 86% say the government must make a bigger investment in services and care for older Americans.

Despite the broad-based support for building a better aging services system, the sad reality is that this is not a new issue.

"In a nation of insurance abundance, the dearth of public or private insurance to cover the costs of long-term care is like wearing a bulletproof vest with a hole over the heart," stated former Sen. John Heinz (R-Pa.) in a 1986 article on the nation's lack of a long-term care system.

So, the issue is not new, but the urgency is.

We have the opportunity — mostly through a budget reconciliation bill in Congress — to get some of these proposals passed. The missing ingredients? Political action and political will.

Perhaps one more finding in the LeadingAge poll delivers the message: 83% of Americans say that elected officials have failed older adults and the people who care for them by ignoring and underfunding America's aging services for decades.

Supporting government long-term care infrastructure funding always made good policy sense.  If you add great political sense to the mix, it just might change that picture.

I would much prefer the headline "Congress Passes Historic Legislation Creating a Long-Term and Home and Community-Based Care Infrastructure."

And I would even more prefer to see it in my lifetime.

Bob Blancato is national coordinator of the Elder Justice Coalition, a national advocacy voice supporting elder justice in America, and president of Matz Blancato and Associates. He is a 2016 Next Avenue Influencer in Aging and the 2023 winner of the Generations United Jack Ossofsky Award for Lifetime Achievement in Support of Children, Youth and Older Adults. Read More
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