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**APRIL 24, 2023**

Kuttner on TAP

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**** Who Cares About Care?

Biden's latest order is well-intentioned, but the caring economy needs
a lot more money.

Last week, the Biden administration announced what the White House press
office called the "Most Sweeping Set of Executive Actions to Improve
Care in History
<[link removed]>."
If only.

The actions are a series of directives to government agencies "to expand
access to affordable, high-quality care, and provide support for care
workers and family caregivers." The problem, of course, is that better
care costs money.

It costs money to build more facilities, money to subsidize the ongoing
expenses of child care and home care, money to increase the pay of care
workers, whether in Medicaid-funded nursing homes, or in day care
programs for kids. And while Biden's latest order tweaks what agencies
are directed to do, in the absence of more congressional funding the
White House cannot cause more money to flow.

Indeed, in the context of House Republicans holding the debt ceiling
hostage for deep cuts in social outlays, such spending is already on the
defensive. House Speaker Kevin McCarthy even wants to add work
requirements to Medicaid. Since the largest single category of Medicaid
outlays is nursing home care, one can only imagine how work requirements
would be applied to residents who are physically incapacitated or in
memory care units.

Biden's heart is in the right place; and it is tragic that the White
House is reduced to the sort of tokenism in the latest executive orders.
When the administration last August finally succeeded in persuading
Manchin, Sinema et al. to enact much of what began as Biden's Build
Back Better program via budget reconciliation, rebranded as the
Inflation Reduction Act
<[link removed]>,
what remained on the cutting-room floor was over a trillion dollars of
outlays to expand support for the entire range of caregiving. The
earlier American Rescue Plan Act of 2021 did provide over $60 billion
for expanded child care and Medicaid home care.

Biden's FY2024 budget includes the scale of outlay for the care
economy that could begin to make a difference: $600 billion over ten
years for affordable child care and free universal pre-K; as well as
$150 billion for better home care under Medicaid. But Congress will
approve outlays like these only if Democrats take back the House and
gain a couple of seats in the Senate.

Thus Biden's dilemma. It's important to keep the spotlight on the
need for more and better caring services. I'm not sure it's smart
politics to make exaggerated claims for executive actions that will make
only a marginal difference.

One thing that Biden could do by executive action is not in last
week's set of directives: He could direct Medicaid to crack down on
for-profit nursing home chains, especially those owned by private equity
companies.

Medicaid reimbursements to nursing homes are insufficient to provide
both decent earnings for caregivers and high-quality care for residents.
When profits are added to the mix, both care and worker earnings suffer.

Studies have thoroughly documented that resident outcomes are worse in
for-profit homes
<[link removed]>. These homes
should be subject to stringent audits for quality of care, to the point
where they cease to be profitable, and private chain operators would
leave the field to ethical not-for-profits. That at least would be an
executive order worth bragging about.

~ ROBERT KUTTNER

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