In his campaign, President-elect Joe Biden promised a wide range of policy changes aimed at supporting older adults, including paid leave and tax credits for families caring for older adults, significantly more funding for Medicaid community-based long-term services and supports, and significant reforms to Social Security The question will be how much can he get done, given other priorities and ongoing uncertainty over which party will control the Senate in 2021.
Biden made family caregiving a priority in his campaign. However, it is likely to take a back seat, at least at first, to other issues, including regulation and funding of nursing homes in the wake of the covid-19 pandemic.
Ending the pandemic will be the first item on Biden’s agenda. He’s already established a task force aimed at doing what President Trump did not—creating a national strategy to address the nation’s biggest public health crisis in 100 years.
For older adults, the new president will have to navigate a couple of important covid-19-related issues. Those with chronic conditions and their caregivers will need early access to any vaccine. And the Administration will need to provide senior living facilities access to quick, cheap, and accurate coronavirus testing and to personal protective equipment.
These remain critical gaps in preventing outbreaks of covid-19 in nursing homes and other congregant care settings. At the same time, Centers for Medicare and Medicaid Services (CMS) will need to develop a national strategy to reopen facilities to family members who have been unable to visit loved one for eight months.
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Balancing the need for strong infection control with residents’ need for social connections will be a special challenge as covid-19 cases seem to be exploding across the country.
The Biden Administration also will have to address nursing home regulation and financing. It will need to find a way to get facilities the resources they need, but also to create workable financial incentives that encourage them to improve quality in exchange for additional funding. CMS also will have to acknowledge that many facilities will fail, and not give in to the temptation to bail out every operator.
Once it implements a covid-19 strategy, the administration will have an opportunity to turn to other priorities. Control of the Senate will depend on the outcome of two run-off elections in Georgia scheduled for Jan. 5. If Republicans retain control, Biden will almost certainly have to scale back his legislative ambitions and do what he can through regulation.
One opportunity will come if he takes steps to further integrate long-term supports and services and medical care. CMS can move in that direction by increasing the flexibility of managed care plans and fee-for-service health providers to add supports and services to the care they provide patients. Without new congressional authority and funding, Biden would be limited in how far he can expand those programs, however.
Biden also will have to decide what to do about the dozens of temporary regulations the Trump Administration approved on an emergency basis during the pandemic. Perhaps the most important: A waiver of the co-called three day rule that allows Medicare to shift costs for post-acute rehab and other care to beneficiaries if they had not been admitted to a hospital for at least three days before being transferred to a skilled nursing facility. CMS does not have authority to waive that rule permanently, but it could extend it on an emergency basis.
If the GOP retains control of the Senate in two Georgia run-off elections on Jan. 5, it will be very tough for Biden to achieve his legislative goals.
One idea that has the best chance: Supporting family leave for caregivers of frail older adults, an idea that is especially important during the pandemic. Several ideas have bipartisan support in Congress but passage will depend on the willingness of lawmakers to strike compromises. .
Congress is not likely to approve his most ambitious long-term care proposal— a nearly $500 billion increase in Medicaid funding for home and community-based care.
Similarly, it will be difficult, if not impossible, for Biden to convince a Republican Senate to increase funding for Medicare. However, if the Supreme Court overturns the Affordable Care Act, one result would be higher Medicare premiums—a consequence that both Democrats and Republicans could work together to avoid.
Finally, Biden has proposed ambitious reforms to Social Security, including new benefits for very old and very low-income recipients combined with a proposal to impose Social Security payroll taxes on workers making $400,000 or more. While both political parties recognize a need to restructure Social Security, which will be unable to pay full benefits after 2035, it seems highly unlikely that a bitterly divided Congress will be willing to address that challenge any time soon.
Unless Democrats surprisingly win control of the Senate in those Georgia runoffs, Biden’s legislative agenda for older adults is likely to fall far short of his ambitions. But he’ll still be able to use his regulatory authority to make modest—though important—reforms.