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Better Care Better Jobs Act Could Transform Direct Care Jobs

By Kezia Scales, PhD (she/her) | July 13, 2021

When President Biden released his American Jobs Plan this spring, he made a bold promise to “solidify the infrastructure of our care economy” alongside efforts to improve roads, bridges, the power grid, broadband, and more.

Building on the spirit and promise of Biden’s proposal, legislators recently introduced the Better Care Better Jobs Act, which would allocate hundreds of billions of dollars toward strengthening home and community-based services (HCBS), addressing disparities in access to these essential services, and elevating the quality of jobs for the direct care workers who provide them.

This legislation is urgently needed. Our country’s existing HCBS infrastructure is fragmented, underfunded, and inadequate—with devastating consequences during the COVID-19 pandemic. For years, HCBS providers have been unable to recruit enough workers to meet demand—and now more than ever given the increased competition for workers across sectors. Consumers struggle to access and/or pay for the services they desperately want and need—with older adults of color disproportionately underserved. And despite their invaluable role, direct care workers still face persistently low wages and inadequate benefits, few training and advancement opportunities, and limited support and recognition.

Here are six ways that the Better Care Better Jobs Act—if passed and effectively implemented—could transform the HCBS landscape and the lives of those who receive and provide services.


The Better Care Better Jobs Act designates more than $100 million to states to develop “HCBS infrastructure improvement plans.” This funding would enable states to assess their existing Medicaid-funded HCBS systems, identify gaps and disparities, diagnose workforce challenges, and design appropriate, equitable, and sustainable services—all with input from a range of stakeholders, including consumers, family members, direct care workers, providers, health plans, and others. During the planning period, states would be eligible to continue receiving the enhanced HCBS funding provided by the American Rescue Plan Act.


A cornerstone of the Better Care Better Jobs Act is a permanent 10 percentage-point increase in the federal matching rate to states for delivering HCBS, plus an 80 percent match for related administrative costs. To receive this funding, states would be required to strengthen and expand HCBS in a range of ways—including by broadening eligibility, requiring coverage for personal care services, adopting consumer and family caregiver supports, improving coordination between HCBS and other programs (such as housing, transportation, and employment), and more.

Importantly, states would also be obligated to implement strategies to strengthen and stabilize the direct care workforce that provides HCBS. Among other requirements, states would have to assess and regularly update their HCBS reimbursement rates (with meaningful input from stakeholders) to cover workforce recruitment and retention costs; ensure that rate increases are passed through to workers’ wages; and update training and credentialing standards and opportunities for both workers and family caregivers.


Under this proposed legislation, states would also be eligible to receive an additional 2 percentage-point increase for HCBS to establish or strengthen self-directed service programs, which enable older adults and people with disabilities to directly employ and manage their own workers (who are known as “independent providers”). This funding would support states to develop matching service registries or other mechanisms to connect consumers and workers, recruit and train new independent providers, and support consumers in their role as employers. States would also be required to allow cooperation between self-directed programs and labor organizations where relevant.


The Better Care Better Jobs Act would also create an unprecedented role for the federal government in helping to share knowledge and improve consistency and coordination across state HCBS programs. As one example, the U.S. Secretary of the Department of Health and Human Services (HHS) would be tasked with submitting an initial report to Congress summarizing the challenges facing HCBS and its workforce nationally, plus subsequent reports documenting HCBS infrastructure development and outcomes. The Secretary would also be required to coordinate with the U.S. Department of Labor and the Centers for Medicare & Medicaid Services to issue stakeholder-informed federal and state-level recommendations for achieving competitive direct care wages and other job quality improvements.


Quality measurement has been a long-standing challenge in HCBS, given the lack of consensus about metrics and measures. To address this gap, the Better Care Better Jobs legislation directs HHS to develop, publish, and regularly update—in consultation with a range of federal departments and agencies and other stakeholders—a set of core and supplemental HCBS quality measures, including workforce measures. As well as adopting these quality measures, states would be required to issue regular reports on the implementation of their HCBS infrastructure improvement plans and, after several years, would need to demonstrate that they had successfully increased the availability of HCBS, reduced disparities among consumers, and reached competitive wage and benefit levels for the majority of direct care workers, among other accomplishments.


The bill also mandates a federal study of the changes made to HCBS service delivery during the COVID-19 pandemic. The goals of this study would be to: describe the types of changes that were implemented; evaluate the efficiency, value, and success or failure of those changes; and promote legislative and administrative actions that would allow successful innovations to be sustained beyond the pandemic. Among other findings, this study could document the impact of short-term workforce investments (such as hazard pay measures) that could translate into permanent improvements.

The Better Care Better Jobs Act is led by Senators Bob Casey Jr. (D-PA), Ron Wyden (D-OR), Chuck Schumer (D-NY), Patty Murray (D-WA), Tammy Duckworth (D-IL), Maggie Hassan (D-NH), and Sherrod Brown (D-OH), and by Representatives Debbie Dingell (D-MI), Frank Pallone (D-NJ), Jan Schakowsky (D-IL), and Doris Matsui (D-CA).

Read the full text of the bill here and a section-by-section summary here.

Kezia Scales, PhD (she/her)
About The Author

Kezia Scales, PhD (she/her)

Vice President of Research & Evaluation
Kezia Scales leads PHI’s strategy for building the evidence base on state and national policies and workforce interventions that improve direct care jobs, elevate this essential workforce, and strengthen care processes and outcomes.

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