Biden Seeks $400 Billion to Buttress Long-Term Care

Biden Seeks $400 Billion to Buttress Long-Term Care. A Look at What's at  Stake. | Kaiser Health News

There’s widespread agreement that it’s important to help older adults and people with disabilities remain independent as long as possible. But are we prepared to do what’s necessary, as a nation, to make this possible?

That’s the challenge President Joe Biden has put forward with his bold proposal to spend $400 billion over eight years on home and community-based services, a major part of his $2 trillion infrastructure plan.

It’s a “historic and profound” opportunity to build a stronger framework of services surrounding vulnerable people who need considerable ongoing assistance, said Ai-jen Poo, director of Caring Across Generations, a national group advocating for older adults, individuals with disabilities, families and caregivers.

It comes as the coronavirus pandemic has wreaked havoc in nursing homes, assisted living facilities and group homes, killing more than 174,000 people and triggering awareness of the need for more long-term care options.

“There’s a much greater understanding now that it is not a good thing to be stuck in long-term care institutions” and that community-based care is an “essential alternative, which the vast majority of people would prefer,” said Ari Ne’eman, senior research associate at Harvard Law School’s Project on Disability.

“The systems we do have are crumbling” due to underfunding and understaffing, and “there has never been a greater opportunity for change than now,” said Katie Smith Sloan, president of LeadingAge, at a recent press conference where the president’s proposal was discussed. LeadingAge is a national association of more than 5,000 nonprofit nursing homes, assisted living centers, senior living communities and home care providers.

But prospects for the president’s proposal are uncertain. Republicans decry its cost and argue that much of what the proposed American Jobs Plan contains, including the emphasis on home-based care, doesn’t count as real infrastructure.

“Though this [proposal] is a necessary step to strengthen our long-term care system, politically it will be a challenge,” suggested Joseph Gaugler, a professor at the University of Minnesota’s School of Public Health, who studies long-term care.

Even advocates acknowledge the proposal doesn’t address the full extent of care needed by the nation’s rapidly growing older population. In particular, middle-income seniors won’t qualify directly for programs that would be expanded. They would, however, benefit from a larger, better paid, better trained workforce of aides that help people in their homes — one of the plan’s objectives.

“This [plan] isn’t everything that’s needed, not by any step of the imagination,” Poo said. “What we really want to get to is universal access to long-term care. But that will be a multistep process.”

Understanding what’s at stake is essential as communities across the country and Congress begin discussing Biden’s proposal.

The services in question. Home and community-based services help people who need significant assistance live at home as opposed to nursing homes or group homes.

Services can include home visits from nurses or occupational therapists; assistance with personal care such as eating or bathing; help from case managers; attendance at adult day centers; help with cooking, cleaning and other chores; transportation; and home repairs and modifications. It can also help pay for durable medical equipment such as wheelchairs or oxygen tanks.

The need. At some point, 70% of older adults will require help with dressing, hygiene, moving around, managing finances, taking medications, cooking, housekeeping and other daily needs, usually for two to four years. As the nation’s aging population expands to 74 million in 2030 (the year all baby boomers will have entered older age), that need will expand exponentially.

Younger adults and children with conditions such as cerebral palsy, blindness or intellectual disabilities can similarly require significant assistance.

The burden on families. Currently, 53 million family members provide most of the care that vulnerable seniors and people with disabilities require — without being paid and often at significant financial and emotional cost. According to AARP, family caregivers on average devote about 24 hours a week, to helping loved ones and spend around $7,000 out-of-pocket.

This reflects a sobering reality: Long-term care services are simply too expensive for most individuals and families. According to a survey last year by Genworth, a financial services firm, the hourly cost for a home health aide averages $24. Annually, assisted living centers charge an average $51,600, while a semiprivate room in a nursing home goes for $93,075.

Medicare limitations. Many people assume that Medicare — the nation’s health program for 61 million older adults and people with severe disabilities — will pay for long-term care, including home-based services. But Medicare coverage is extremely limited.

In the community, Medicare covers home health only for older adults and people with severe disabilities who are homebound and need skilled services from nurses and therapists. It does not pay for 24-hour care or care for personal aides or homemakers. In 2018, about 3.4 million Medicare members received home health services.

In nursing homes, Medicare pays only for rehabilitation services for a maximum of 100 days. It does not provide support for long-term stays in nursing homes or assisted living facilities.

Medicaid options. Medicaid — the federal-state health program for 72 million children and adults in low-income households — can be an alternative, but financial eligibility standards are strict and only people with meager incomes and assets qualify.

Medicaid supports two types of long-term care: home and community-based services and those provided in institutions such as nursing homes. But only care in institutions is mandated by the federal government. Home and community-based services are provided at the discretion of the states.

Although all states offer home and community-based services of some kind, there’s enormous variation in the types of services offered, who is served (states can set caps on enrollment) and state spending. Generally, people need to be frail enough to need nursing home care to qualify.

Nationally, 57% of Medicaid’s long-term care budget goes to home and community-based services — $92 billion in the 2018 federal budget year. But half of states still spend twice as much on institutional care as they do on community-based care. And 41 states have waiting lists, totaling nearly 820,000 people, with an average wait of 39 months.

Based on the best information available, between 4 million and 5 million people receive Medicaid-funded home and community-based services — a fraction of those who need care.

Workforce issues. Biden’s proposal doesn’t specify how $400 billion in additional funding would be spent, beyond stating that access to home and community-based care would be expanded and caregivers would receive “a long-overdue raise, stronger benefits, and an opportunity to organize or join a union.”

Caregivers, including nursing assistants and home health and personal care aides, earn $12 an hour, on average. Most are women of color; about one-third of those working for agencies don’t receive health insurance from their employers.

By the end of this decade, an extra 1 million workers will be needed for home-based care — a number of experts believe will be difficult, if not impossible, to reach given poor pay and working conditions.

“We have a choice to keep these poverty-wage jobs or make them good jobs that allow people to take pride in their work while taking care of their families,” said Poo of Caring Across Generations.

Next steps. Biden’s plan leaves out many details. For example: What portion of funding should go to strengthening the workforce? What portion should be devoted to eliminating waiting lists? What amount should be spent on expanding services?

How will inequities of the current system — for instance, the lack of accessible services in rural counties or for people with dementia — be addressed? “We want to see funding to states tied to addressing those inequities,” said Amber Christ, directing attorney of the health team at Justice in Aging, an advocacy organization.

Meanwhile, supporters of the plan suggest it could be just the opening of a major effort to shore up other parts of the safety net. “There are huge gaps in the system for middle-income families that need to be addressed,” said David Certner, AARP’s legislative counsel.

Reforms that should be considered include tax credits for caregivers, expanding Medicare’s home health benefit and removing the requirement that people receiving Medicare home health be homebound, said Christ of Justice in Aging.

We should be looking more broadly at potential solutions that reach people who have some resources but not enough to pay for these services as well,” she said.

Cartoon – Open the U.S. Now

A. Christian van Gorder: George Washington meets a viral pandemic | Board  Of Contributors | wacotrib.com

How hospital operators fared financially in 2020

“For the most part providers were dependent on that CARES funding. I think they would have been in the red or break even without it,” Suzie Desai, a senior director at S&P Global Ratings, said.

The pandemic weighed heavily on the financial performance of not-for-profit hospitals in 2020, but some of the larger health systems remained profitable despite the upheaval — in large part thanks to substantial federal funding earmarked to prop up providers during the global health crisis. 

Industry observers have been closely watching to see how health systems ultimately fared in 2020. Now, with the fiscal-year ended and accounted for, analysts say the $175 billion in federal funds was crucial for providers’ bottom lines.

Without the stimulus funding, it is very likely we would have seen more issuers [hospitals/health] systems experience either lower profitable margins, or outright losses from operations,” Kevin Holloran, senior director of U.S. public finance for Fitch Ratings, said.  

Still, the pandemic put a squeeze on nonprofit hospital margins last year, according to a recent Moody’s report that showed the median operating margin was 0.5% in 2020 compared to 2.4% in 2019.

The first half of the year hit providers especially hard as volumes fell drastically, seemingly overnight. Revenue plummeted alongside the volume declines as the nation paused lucrative elective procedures to preserve medical resources.

One estimate showed hospitals lost more than $20 billion as they halted surgeries in the early months of the outbreak in the U.S. 

But as the year wore on, the outlook improved as some volumes returned closer to pre-pandemic levels. At the same time, health systems worked to cut expenses to mitigate the financial strain.

Still, some health systems did post operational losses even with the federal funds meant to help them. Moody’s found that 42% of 130 hospitals surveyed posted an operating loss, an increase from 23% the year prior. Yet, the 2019 survey included more hospitals, a total of 282.

Sutter Health, the Northern California giant, reported an operating loss for 2020 and said it was launching a “sweeping review” of its finances as the pandemic exacerbated existing challenges for the provider. Washington-based Providence also reported an operating loss for 2020. However, both Sutter and Providence were able to post positive net income thanks in large part to investment gains.    

Investment income can aid nonprofit operators even when core operations are stunted like during 2020. Though, initially, the pandemic put stress on the stock market as uncertainty around the virus and its duration ballooned. The stock market took a dive and it was reflected in some six-month financials as both operations and investments took a hit. 

“COVID and the stimulus is (hopefully) a once in a lifetime disruption of operations,” Holloran said, who noted analysts have been trying to assess whether the top line losses can be placed squarely on COVID-19. If that’s the case, analysts are typically more apt to keep the provider’s existing rating. 

“For the most part providers were dependent on that CARES funding. I think they would have been in the red or break even without it,” Suzie Desai, a senior director at S&P Global Ratings, said.

For example, Arizona’s Banner Health would have posted an operating loss without federal relief, according to their financial reports. Banner Health was able to work its way back to black after it reported a loss through the first six months of the year. The same was true for Midwest behemoth Advocate Aurora. 

The providers that were able to weather the storm of the pandemic tended to be integrated systems that had a health plan under their umbrella. 

Kaiser Permanente ended the year with both positive operating and net income and returned relief funds it received.   

“The integrated providers, yeah, were one group that just had a natural hedge with the insurance premiums still coming in,” Desai said.  

Still, the hospital lobby is hoping to secure more funding for its members as the threat of the virus is still present even amid large scale efforts to vaccinate a majority of Americans to reach a blanket of protection from the novel coronavirus and its variants.

The COVID-19 relief package: Where the money goes

https://www.politifact.com/article/2021/mar/19/covid-19-relief-package-where-money-goes/?fbclid=IwAR0WSCs9C4Rz9x6n-mlIsg7RY4KYM3byEZ3GdoYp3VWB0AIM8s0p_UUzinU

May be an image of text that says 'American Rescue Plan Act Where the money goes (In $billions) Other $129 Transportation $58 COVID/Public health $143 Stimulus Stimuluschecks checks $410 Schools $169_ Unemployment $242 Families $352 State/local aid $360'

IF YOUR TIME IS SHORT

  • The Democratic bill has $410 billion in stimulus checks and $360 billion in aid to state and local governments.
  • Expanded unemployment benefits cost $242 billion.
  • School spending is nearly $170 billion spread out over 10 years.

There are a few big chunks of money in the American Rescue Plan Act that have generated a lot of news coverage and are pretty well known. In response to a reader’s request, we present the whopping $1.86 trillion spending plan in pie chart form. 

There are the $1,400 checks (or more likely deposits) to many citizens or permanent legal residents and their dependents. That comes to about $410 billion.

Aid to state, local, territorial and tribal governments costs about $360 billion.

The bill boosts and extends unemployment benefits. Add another $242 billion.

Over the next 10 years, the law spends nearly $170 billion on education. That includes $129 billion for K-12 schools — both public and private — and about $40 billion for higher education.

The money for vaccines and corralling the coronavirus became a political talking point. Democrats touted the $20-25 billion they included for vaccine supplies and research. Republicans argued that the bill spent less than 10% of its total cost on COVID-19. 

People will parse the numbers in different ways. Some only count money spent directly on vaccine production. Some look more broadly at the economic damage wrought by the virus. We looked for money that went towards health care, whether that meant improving treatment on tribal lands, adding health care workers at clinics, or anything that reduced the health impacts of the pandemic.

We put the bill’s total public health spending at $143 billion.

Within that, the single biggest line item is $47.8 billion for mitigating the disease, a broad description that includes testing and surveillance. There is also $15 billion for COVID-related health care for veterans, $7.6 billion to help community health centers distribute vaccines, and about the same amount to the Centers for Disease Control and Prevention for roughly the same purpose.

The chart above lays out how the money breaks down.

All of the amounts so far come to $1.3 trillion over 10 years. The bill’s total cost is $1.86 trillion, which leaves about $500 billion dollars to flesh out.

The law has over $40 billion for child care. Money to keep people in their homes and to house the homeless comes to about $44 billion. There is $10 billion to put food on people’s tables. The expected cost of temporarily boosting the child tax credit is $109 billion.

In our chart, we fold all of that, plus subsidies for pensions and health insurance premiums, into the category of support for families. Our total is $352 billion.

Our last distinct category is transportation. Under that umbrella, we put $30 billion for mass transit, $15 billion for the airline industry, $8 billion for airports, and other related activities. That came to $58 billion.

The catch-all bucket of other spending includes items such as $66 billion for businesses, $50 billion for disaster relief at the Federal Emergency Management Agency, and $7 billion to expand broadband internet.

Debt default risk for hospitals drops from 2020 high

UAE firms face default risk as customers delay payments | Business Insurance

The likelihood that U.S. hospitals will default on debt within the next year fell significantly since the 2020 peak amid the early days of the pandemic, according to a March 10 report from S&P Global Market Intelligence. 

In 2020, the median default odds jumped to 8.1 percent. However, as of March 8, the probability of default rate fell to 0.9 percent. 

Samuel Maizel, a partner from law firm Dentons, told S&P Global that many hospitals operate on razor-thin margins, and they are seeing less cash flow amid the pandemic as patients shy away from receiving care, but stimulus funds should help avert a tidal wave of hospital bankruptcies in the next year.

“They’re sitting on a lot of cash, which gives them a cushion, even though they’re continuing to lose money,” Mr. Maizel told S&P Global. 

S&P said that as stimulus funds dry up other pressures may challenge healthcare facilities.

America’s nightmarish year is finally ending

America's nightmare year of COVID is finally ending

One year after the World Health Organization declared COVID-19 a pandemic, the end of that pandemic is within reach.

The big picture: The death and suffering caused by the coronavirus have been much worse than many people expected a year ago — but the vaccines have been much better.

Flashback“Bottom line, it’s going to get worse,” Anthony Fauci told a congressional panel on March 11, 2020, the day the WHO formally declared COVID-19 to be a global pandemic.

  • A year ago today, the U.S. had confirmed 1,000 coronavirus infections. Now we’re approaching 30 million.
  • In the earliest days of the pandemic, Americans were terrified by the White House’s projections — informed by well-respected modeling — that 100,000 to 240,000 Americans could die from the virus. That actual number now sits at just under 530,000.
  • Many models at the time thought the virus would peak last May. It was nowhere close to its height by then. The deadliest month of the pandemic was January.

Yes, but: Last March, even the sunniest optimists didn’t expect the U.S. to have a vaccine by now.

  • They certainly didn’t anticipate that over 300 million shots would already be in arms worldwide, and they didn’t think the eventual vaccines, whenever they arrived, would be anywhere near as effective as these shots turned out to be.

Where it stands: President Biden has said every American adult who wants a vaccine will be able to get one by the end of May, and the country is on track to meet that target.

  • The U.S. is administering over 2 million shots per day, on average. Roughly 25% of the adult population has gotten at least one shot.
  • The federal government has purchased more doses than this country will be able to use: 300 million from Pfizer, 300 million from Moderna and 200 million from Johnson & Johnson.
  • The Pfizer and Moderna orders alone would be more than enough to fully vaccinate every American adult. (The vaccines aren’t yet authorized for use in children.)

Yes, millions of Americans are still anxiously awaiting their first shot — and navigating signup websites that are often frustrating and awful.

  • But the supply of available vaccines is expected to surge this month, and the companies say the bulk of those doses should be available by the end of May.
  • Cases, hospitalizations and deaths are all falling sharply at the same time vaccinations are ramping up.

The bottom line: Measured in death, loss, isolation and financial ruin, one year has felt like an eternity. Measured as the time between the declaration of a pandemic and vaccinating 60 million Americans, one year is an instant.

  • The virus hasn’t been defeated, and may never fully go away. Getting back to “normal” will be a moving target. Nothing’s over yet. But the end of the worst of it — the long, brutal nightmare of death and suffering — is getting close.

THE BIG DEAL—House passes $1.9T coronavirus relief bill

https://thehill.com/policy/finance/542448-heres-whats-in-the-19t-covid-19-relief-package

Will there be a third stimulus check? Biden's Deputy Press Secretary on American  Rescue Plan: 'The time for bold action is now' - ABC11 Raleigh-Durham

The House on Wednesday passed the mammoth $1.9 trillion COVID-19 relief package, which President Biden is expected to sign Friday.

The House approved the relief package in a starkly partisan 220-211 vote, sending the legislation to the White House and clinching Democrats’ first big legislative victory in the Biden era. No Republicans voted for the package and all but one House Democrat—Rep. Jared Golden of Maine—supported it. The Hill’s Cristina Marcos has more here.

The political split: Unlike the previous relief measures enacted last year, Democrats barely bothered to negotiate with Republicans and pushed the relief package through Congress along party lines using the budget reconciliation process. That allowed them to go as big as they wanted to go without running into a Senate GOP filibuster.

  • Republicans argue the use of a process dodging the filibuster shows Biden wasn’t serious about bringing unity, and House GOP lawmakers on Wednesday warned of the bill’s total cost.
  • But Democrats think Republicans will pay for their opposition to the popular bill and argued that they would oppose anything Biden proposed.

What’s in the $1.9T COVID-19 relief packageAlong with $1,400 direct payments to households, an extension of expanded unemployment benefits, and aid for state and local governments, the package is loaded with other provisions intended to speed up the recovery from the recession and help struggling families fight the impact of COVID-19.

  • Tax credits: The bill increases the child tax credit for households below certain income thresholds for 2021 and makes it fully refundable, and also expands the earned income tax credit for the year.
  • Child care: $15 billion for grants to help low-income families afford child care and increases the child and dependent care tax credit for one year.
  • Pensions: $86 billion to bailout struggling union pension funds.
  • Transportation: $30 billion to bolster local subway and bus systems, $8 billion for airports, $1.5 billion for furloughed Amtrak workers, and $3 billion for wages at aerospace companies.
  • Housing: $27.4 billion in emergency rental assistance, another $10 billion to help homeowners avoid foreclosure, $5 billion in vouchers for public housing, $5 billion to tackle homelessness and $5 billion more to help households cover utility bills.
  • Small businesses: The American Rescue Plan broadens eligibility guidelines for the Paycheck Protection Program, allowing more nonprofit entities to be eligible, adds $15 billion in emergency grants and also sets aside more than $28 billion in funding for restaurants.
  • ObamaCare subsidies and Medicaid expansion: The bill increases ObamaCare subsidies through 2022 to make them more generous, a longtime goal for Democrats, and opens up more fully subsidized plans to individuals. It also would provide extra Medicaid funding to states that expand the program and have yet to do so.

The danger of a fourth wave

Change in new COVID-19 cases in the past week

Percent change of the 7-day average of new cases

on Feb. 23 and March 2, 2021

The U.S. could be in danger of a fourth coronavirus wave - Axios

The U.S. may be on the verge of another surge in coronavirus cases, despite weeks of good news.

The big picture: Nationwide, progress against the virus has stalled. And some states are ditching their most important public safety measures even as their outbreaks are getting worse.

Where it stands: The U.S. averaged just under 65,000 new cases per day over the past week. That’s essentially unchanged from the week before, ending a six-week streak of double-digit improvements.

  • Although the U.S. has been moving in the right direction, 65,000 cases per day is not a number that indicates the virus is under control. It’s the same caseload the U.S. was seeing last July, at the height of the summer surge in cases and deaths.

What we’re watching: Texas Gov. Greg Abbott on Tuesday rescinded the state’s mask mandate and declared that businesses will be able to operate at full capacity, saying risk-mitigation measures are no longer necessary because of the progress on vaccines.

  • But the risk in Texas is far from over. In fact, its outbreak is growing: New cases in the state rose by 27% over the past week.
  • Mississippi Gov. Tate Reeves also scrapped all business restrictions, along with the state’s mask mandate, on Tuesday. New cases in Mississippi were up 62% over the past week, the biggest jump of any state.
  • The daily average of new daily cases also increased in eight more states, in addition to Mississippi and Texas.

How it works: If Americans let their guard down too soon, we could experience yet another surge — a fourth wave — before the vaccination campaign has had a chance to do its work.

  • The vaccine rollout is moving at breakneck speed. The U.S. should have enough doses for every adult who wants one by May, President Biden said this week.
  • At the same time, however, more contagious variants of the coronavirus are continuing to gain ground, meaning that people who haven’t gotten their vaccines yet may be spreading and contracting the virus even more easily than before.

What’s next: The bigger a foothold those variants can get, the harder it will be to escape COVID-19 — now or in the future.

  • The existing vaccines appear to be less effective against two variants, discovered in South Africa and Brazil, which means the virus could keep circulating even in a world where the vast majority of people are vaccinated.
  • And that means it’s increasingly likely that COVID-19 will never fully go away — that outbreaks may flare up here and there for years, requiring vaccine booster shots as well as renewed protective measures.

The bottom line: Variants emerge when viruses spread widely, which is also how people die.

  • Whatever “the end of the pandemic” looks like — however good it’s possible for things to get — the way to get there is through ramping up vaccinations and continuing to control the virus through masks and social distancing. Not doing those things will only make the future worse.
  • “Getting as many people vaccinated as possible is still the same answer and the same path forward as it was on December 1 or January 1 … but the expected outcome isn’t the same,” Shane Crotty, a virologist at the La Jolla Institute for Immunology in San Diego, told Reuters.