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Biden’s National Caregiving Plan is Strong—But Could Be Even Stronger

By Kezia Scales, PhD (she/her) | August 11, 2020

In mid-July, presidential candidate Joe Biden released a national plan for building a “robust 21st century caregiving and education workforce.”

This 10-year, $775 billion plan—which would be financed through taxes on wealthy earners and investors—brings direct care workers (and other paid caregivers) into the election spotlight at a time when they are most needed and under more pressure than ever. The plan recognizes that our country is experiencing a “caregiving crisis,” with individuals and families struggling to access the care they need while paid care workers remain persistently “underpaid, unseen, and undervalued.” To remedy these problems, the plan proposes a slate of systemic solutions.

PHI took a close look at the main elements of Biden’s caregiving plan that pertain to long-term services and supports (LTSS) and the direct care workforce—and identified how each element could be enhanced to achieve meaningful and lasting improvements in this sector.

Strong: Expand access to home and community-based services

Stronger: Reimagine our LTSS financing and delivery system

Biden’s “caregiving economy” proposal aims to ensure that more older adults and people with disabilities receive the care they need in their homes and communities—which will, the plan promises, “reduce health expenditures, help more Americans avoid unnecessary and expensive hospitalizations, and result in an expansion of the caregiving and community health workforce by roughly 1.5 million jobs.” As a starting point, the plan would eliminate the current waiting lists for Medicaid-funded home and community-based waiver services, then offer an enhanced federal match for states that offer these services through their Medicaid state plans going forward.

These and other strategies described in Biden’s plan would make a meaningful difference in the lives of many individuals and their families, not least the 800,000 people currently on waiting lists. But by focusing exclusively on Medicaid, the plan fails to engage with the overall inadequacy of our country’s approach to LTSS financing. More funding for existing Medicaid services will not help the countless individuals who exceed strict Medicaid eligibility criteria but cannot afford the prohibitive out-of-pocket costs of LTSS, nor those who will join their ranks as our population grows older and long-term care needs skyrocket.

Fixing holes in the current system is critically important, but we must also envision a more affordable, accessible, and equitable approach to LTSS financing and service delivery. This discussion is well-underway—several presidential hopefuls put forward plans to reform the U.S. long-term care system last year and a handful of states are already considering state-based LTSS social insurance programs. Last year, Washington State became the first state to launch such a program, guaranteeing a universal, if modest, LTSS benefit for all state residents from 2025 onward. Moving from a means-tested to a universal approach to LTSS financing will help ensure that all individuals can afford the services they need—and could help finance the workforce investments that are required to guarantee the availability and quality of those services.

Strong: Establish an LTSS innovation fund

Stronger: Prioritize direct care workforce innovations

Among other strategies to expand access to home and community-based services, the Biden caregiving plan would establish an “innovation fund” to support states in overcoming the institutional bias that continues to pervade our LTSS system.

Like the innovation fund model proposed by PHI, this strategy aims to promote creative new solutions to long-standing challenges in long-term care—and to identify successful, cost-effective approaches that could be scaled-up at the state or national level. However, given that the availability and quality of LTSS depends on a strong and stable direct care workforce, a significant portion of these funds should be explicitly earmarked for workforce innovations, including efforts to build workforce pipelines, enhance job quality, and improve workforce outcomes. These innovations should also be rigorously evaluated, since robust evidence of their impact would help strengthen the case for the ongoing investments that are needed to “maintain and grow a diverse, talented care and education workforce,” as described in the plan.

If passed, the federal Direct CARE Opportunity Act—which aims to strengthen the direct care workforce by funding innovative recruitment, retention, and advancement efforts—would align with this element of Biden’s caregiving plan.

Strong: Improve job quality for direct care workers

Stronger: Launch a national direct care workforce strategy

Biden’s caregiving plan proposes a range of initiatives to elevate and improve direct care jobs—explicitly recognizing that a stronger long-term care system relies on high-quality jobs in direct care.

One key priority is to increase wages for direct care workers. The plan also calls for: enhanced employment benefits for these workers, including affordable health insurance, paid family and medical leave, paid sick leave, and affordable childcare (essential for the 27 percent of this workforce who have children at home); stronger legal protections and the option to join a union and collectively bargain; and access to quality training and meaningful career ladders.

These are all critical steps toward improving direct care jobs. Tying them all together, however, will require an ambitious, multi-pronged national strategy to recruit, retain, and empower direct care workers—just as Biden’s plan recommends for nursing professionals. (The plan promises “additional funding to ensure we are building up the training, clinical and educational capacity to welcome—not turn away—the qualified individuals interested in nursing education and training, bolstering the nursing profession for years to come.” The same should be promised for the direct care workforce.) As well as addressing the job quality challenges named above, the national strategy could also tackle other issues related to worker burnout and turnover; ensure that workforce policies address diversity and disparities in the workforce in culturally competent and race-explicit ways; and inform immigration and other policies that undermine rather than strengthen recruitment efforts in this sector. This strategy could be spearheaded by a national direct care workforce advisory panel, as proposed but never implemented under the 2010 Community Living Assistance Services and Supports Act (which was established by the Affordable Care Act).

It’s heartening to see direct care workers—and the broader long-term care sector—featuring prominently in this election, given the value of these workers and the profound caregiving challenges affecting so many Americans. PHI will continue to monitor and analyze the ideas related to direct care workers that emerge across the political spectrum during this election season.

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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