Tina Sadarangani, PhD, RN

The COVID-19 pandemic exposed the cracks in America’s long-term care system and further damaged it. Most Americans over 50 did not want to end up in a skilled nursing facility before the pandemic, and the devastating surplus of deaths from COVID-19 in nursing homes have only solidified that preference. As a result, more and more older adults are being cared for at home, relying on friends, families and neighbors to provide the necessary supports to keep them there. Research has repeatedly confirmed that “aging in place” has benefits such as social engagement, dignity, independence, care continuity and cost-effectiveness.

The Biden-Harris administration seemed to understand this. As of August 2022, they were “deeply committed to ensuring everyone is able to get the high-quality care they need — within the comfort of their own home or community.” But that “deep” commitment was called into question when the Centers for Medicare & Medicaid Services almost simultaneously proposed an $810 million cut to Medicare payments for home health services, which, if passed, would force more than half of home health agencies to operate at a deficit or vastly reduce services.

Proponents of these cuts argue that home health agencies have historically been overpaid, but there is scant evidence verifying this. Reducing access to in-home supports for 3 million Medicare beneficiaries nationally and forcing agencies to reduce staff amidst a staffing crisis seems to be more of a short-sighted strategy for balancing the congressional checkbook than it is an approach for creating a stable foundation for home- and community-based long-term care for all Americans.

Cutting resources to the home and community-based agencies providing these services will simply shift the burden to unpaid caregivers — most of whom are women — whose struggles and workload seem invisible to policymakers. It is estimated that the work of unpaid caregivers amounts to $470 billion per year.  Reducing payment for home-based services also adds a financial burden on the caregivers. They are often forced to leave the workforce at a loss of salary and benefits including social security investment, lowering their retirement benefit later in life. Among the 41.8 million people who provide care for an adult over 50, 28% have stopped saving, 23% have taken on more debt, and 25% report their own health has deteriorated as a result of caregiving.

Overreliance on unpaid caregivers, especially in the pandemic era when respite care options are harder to come by, contributes to psychological distress, burden and poor health outcomes for caregivers, and is a largely unsustainable approach to America’s chronic long-term care crisis. The pandemic should have awakened policy-makers to the need for robust high-quality support at home for older adults — whether after a hospitalization or for day-to-day supportive care — so they can remain in their homes for as long as possible. Eventually, cuts to home care will cost health systems more than they save.

Long-term care needs to be viewed as a continuum of services encompassing all the levels of health and personal care needed to help all individuals age successfully and preserve quality of life. A stronger foundation for high quality, cost-effective long-term care begins with providing older adults more support in their communities, not less. This should include simplifying processes for applying for home- and community-based services, expanding access to cost-effective congregate services like adult day care to Medicare beneficiaries, and improving wages and opportunities for professional advancement for home care workers. The Biden-Harris administration can begin to prove the actual depth of its commitment to high quality community-based care by re-thinking its approach. This starts with meeting patients and caregivers where care begins — at home.

Tina Sadarangani, PhD, RN, is an assistant professor at NYU Rory Meyers College of Nursing and an affiliate faculty of the Hartford Institute of Geriatric Nursing (HIGN) for which she co-chairs the Policy Steering Committee. Her research, funded by the National Institutes of Health, focuses on advancing the health of older, vulnerable adults, including leveraging the strengths of community-based adult day health care centers to target health disparities.