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    Biden Takes On Sagging Safety Net With Plan to Fix Long-Term Care

    The proposal to spend $400 billion over eight years faces political challenges and a funding system not designed for the burden it has come to bear.President Biden’s $400 billion proposal to improve long-term care for older adults and those with disabilities was received as either a long overdue expansion of the social safety net or an example of misguided government overreach.Republicans ridiculed including elder care in a program dedicated to infrastructure. Others derided it as a gift to the Service Employees International Union, which wants to organize care workers. It was also faulted for omitting child care.For Ai-jen Poo, co-director of Caring Across Generations, a coalition of advocacy groups working to strengthen the long-term care system, it was an answer to years of hard work.“Even though I have been fighting for this for years,” she said, “if you would have told me 10 years ago that the president of the United States would make a speech committing $400 billion to increase access to these services and strengthen this work force, I wouldn’t have believed it would happen.”What the debate over the president’s proposal has missed is that despite the big number, its ambitions remain singularly narrow when compared with the vast and growing demands imposed by an aging population.Mr. Biden’s proposal, part of his $2 trillion American Jobs Plan, is aimed only at bolstering Medicaid, which pays for somewhat over half the bill for long-term care in the country. And it is targeted only at home care and at community-based care in places like adult day care centers — not at nursing homes, which take just over 40 percent of Medicaid’s care budget.Still, the money would be consumed very fast.Consider a key goal: increasing the wages of care workers. In 2019, the typical wage of the 3.5 million home health aides and personal care aides was $12.15 an hour. They make less than janitors and telemarketers, less than workers in food processing plants or on farms. Many — typically women of color, often immigrants — live in poverty.The aides are employed by care agencies, which bill Medicaid for their hours at work in beneficiaries’ homes. The agencies consistently report labor shortages, which is perhaps unsurprising given the low pay.Raising wages may be essential to meet the booming demand. The Labor Department estimates that these occupations will require 1.6 million additional workers over 10 years.It won’t be cheap, though. Bringing aides’ hourly pay to $20 — still short of the country’s median wage — would more than consume the eight-year outlay of $400 billion. That would leave little money for other priorities, like addressing the demand for care — 820,000 people were on states’ waiting lists in 2018, with an average wait of more than three years — or providing more comprehensive services.The battle over resources is likely to strain the coalition of unions and groups that promote the interests of older and disabled Americans, which have been pushing together for Mr. Biden’s plan. And that’s even before nursing homes complain about being left out.The president “must figure out the right balance between reducing the waiting list and increasing wages,” said Paul Osterman, a professor at the Massachusetts Institute of Technology’s Sloan School of Management who has written about the nation’s care structures. “There’s tension there.”Elder care has long been at the center of political battles over social insurance. President Lyndon B. Johnson considered providing the benefit as part of the creation of Medicare in the 1960s, said Howard Gleckman, an expert on long-term care at the Urban Institute. But the chairman of the House Ways and Means Committee, Wilbur Mills, warned how expensive that approach would become when baby boomers started retiring. Better, he argued, to make it part of Medicaid and let the states bear a large chunk of the burden.This compromise produced a patchwork of services that has left millions of seniors and their families in the lurch while still consuming roughly a third of Medicaid spending — about $197 billion in 2018, according to the Kaiser Family Foundation. By Kaiser’s calculations, Medicaid pays for roughly half of long-term care services; out-of-pocket payments and private insurance together pay a little over a quarter of the tab. (Other sources, like programs for veterans, cover the rest.)Unlike institutional care, which state Medicaid programs are required to cover, home and community-based care services are optional. That explains the waiting lists. It also means there is a wide divergence in the quality of services and the rules governing who gets them.Although the federal government pays at least half of states’ Medicaid budgets, states have great leeway in how to run the program. In Pennsylvania, Medicaid pays $50,300 a year per recipient of home or community-based care, on average. In New York, it pays $65,600. In contrast, Medicaid pays $15,500 per recipient in Mississippi, and $21,300 in Iowa.A home health aide accompanies a patient to a vaccine appointment. Elder care has long been at the center of political battles over social insurance.James Estrin/The New York TimesThis arrangement has also left the middle class in the lurch. The private insurance market is shrinking, unable to cope with the high cost of care toward the end of life: It is too expensive for most Americans, and it is too risky for most insurers.As a result, middle-class Americans who need long-term care either fall back on relatives — typically daughters, knocking millions of women out of the labor force — or deplete their resources until they qualify for Medicaid.Whatever the limits of the Biden proposal, advocates for its main constituencies — those needing care, and those providing it — are solidly behind it. This would be, after all, the biggest expansion of long-term care support since the 1960s.“The two big issues, waiting lists and work force, are interrelated,” said Nicole Jorwic, senior director of public policy at the Arc, which promotes the interests of people with disabilities. “We are confident we can turn this in a way that we get over the conflicts that have stopped progress in past.”And yet the tussle over resources could reopen past conflicts. For instance, when President Barack Obama proposed extending the Fair Labor Standards Act of 1938 to home care workers, which would cover them with minimum-wage and overtime rules, advocates for beneficiaries and their families objected because they feared that states with budget pressures would cut off services at 40 hours a week.“We have a long road ahead of passing this into law and to implementation,” Haeyoung Yoon, senior policy director of the National Domestic Workers Alliance, said of the Biden proposal. Along the way, she said, supporters must stick together.Given the magnitude of the need, some wonder whether there might be a better approach to shoring up long-term care than giving more money to Medicaid. The program is perennially challenged for funds, forced to compete with education and other priorities in state budgets. And Republicans have repeatedly tried to curtail its scope.“It’s hard to imagine Medicaid is the right funding vehicle,” said Robert Espinoza, vice president for policy at PHI, a nonprofit research group tracking the home care sector.Some experts have suggested, instead, the creation of a new line of social insurance, perhaps funded through payroll taxes as Social Security is, to provide a minimum level of service available to everyone.A couple of years ago, the Long-Term Care Financing Collaborative, a group formed to think through how to pay for long-term elder care, reported that half of adults would need “a high level of personal assistance” at some point, typically for two years, at an average cost of $140,000. Today, some six million people need these sorts of services, a number the group expects to swell to 16 million in less than 50 years.In 2019, the National Academy of Social Insurance published a report suggesting statewide insurance programs, paid for by a dedicated tax, to cover a bundle of services, from early child care to family leave and long-term care and support for older adults and the disabled.This could be structured in a variety of ways. One option for seniors, a catastrophic insurance plan that would cover expenses up to $110 a day (in 2014 dollars) after a waiting period determined by the beneficiary’s income, could be funded by raising the Medicare tax one percentage point.Mr. Biden’s plan doesn’t include much detail. Mr. Gleckman of the Urban Institute notes that it has grown vaguer since Mr. Biden proposed it on the campaign trail — perhaps because he realized the tensions it would raise. In any event, a deeper overhaul of the system may eventually be needed.“This is a significant, historic investment,” Mr. Espinoza said. “But when you take into account the magnitude of the crisis in front of us, it’s clear that this is only a first step.” More

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    Biden Plan Spurs Fight Over What ‘Infrastructure’ Really Means

    Republicans say the White House is tucking liberal social programs into legislation that should be focused on roads and bridges. Administration officials say their approach invests in the future.WASHINGTON — The early political and economic debate over President Biden’s $2 trillion American Jobs Plan is being dominated by a philosophical question: What does infrastructure really mean?Does it encompass the traditional idea of fixing roads, building bridges and financing other tangible projects? Or, in an evolving economy, does it expand to include initiatives like investing in broadband, electric car charging stations and care for older and disabled Americans?That is the debate shaping up as Republicans attack Mr. Biden’s plan with pie charts and scathing quotes, saying that it allocates only a small fraction of money on “real” infrastructure and that spending to address issues like home care, electric vehicles and even water pipes should not count.“Even if you stretch the definition of infrastructure some, it’s about 30 percent of the $2.25 trillion they’re talking about spending,” Senator Roy Blunt, Republican of Missouri, said on “Fox News Sunday.”“When people think about infrastructure, they’re thinking about roads, bridges, ports and airports,” he added on ABC’s “This Week.”Mr. Biden pushed back on Monday, saying that after years of calling for infrastructure spending that included power lines, internet cables and other programs beyond transportation, Republicans had narrowed their definition to exclude key components of his plan.“It’s kind of interesting that when the Republicans put forward an infrastructure plan, they thought everything from broadband to dealing with other things” qualified, the president told reporters on Monday. “Their definition of infrastructure has changed.”Mr. Biden defended his proposed $2 trillion package, saying it broadly qualified as infrastructure and included goals such as making sure schoolchildren are drinking clean water, building high-speed rail lines and making federal buildings more energy efficient.Behind the political fight is a deep, nuanced and evolving economic literature on the subject. It boils down to this: The economy has changed, and so has the definition of infrastructure.Economists largely agree that infrastructure now means more than just roads and bridges and extends to the building blocks of a modern, high-tech service economy — broadband, for example.But even some economists who have carefully studied that shift say the Biden plan stretches the limits of what counts.Edward Glaeser, an economist at Harvard University, is working on a project on infrastructure for the National Bureau of Economic Research that receives funding from the Transportation Department. He said that several provisions in Mr. Biden’s bill might or might not have merit but did not fall into a conventional definition of infrastructure, such as improving the nation’s affordable housing stock and expanding access to care for older and disabled Americans.“It does a bit of violence to the English language, doesn’t it?” Mr. Glaeser said.“Infrastructure is something the president has decided is a centrist American thing,” he said, so the administration took a range of priorities and grouped them under that “big tent.”Proponents of considering the bulk of Mr. Biden’s proposals — including roads, bridges, broadband access, support for home health aides and even efforts to bolster labor unions — argue that in the 21st century, anything that helps people work and lead productive or fulfilling lives counts as infrastructure. That includes investments in people, like the creation of high-paying union jobs or raising wages for a home health work force that is dominated by women of color.“I couldn’t be going to work if I had to take care of my parents,” said Cecilia Rouse, the chair of the White House Council of Economic Advisers. “How is that not infrastructure?”But those who say that definition is too expansive tend to focus on the potential payback of a given project: Is the proposed spending actually headed toward a publicly available and productivity-enabling investment?A child care center in Queens, N.Y., last month. For those who support an expansive definition of infrastructure, anything that helps people work and lead productive lives counts.Kirsten Luce for The New York Times“Much of what it is in the American Jobs Act is really social spending, not productivity-enhancing infrastructure of any kind,” R. Glenn Hubbard, an economics professor at Columbia Business School and a longtime Republican adviser, said in an email.Specifically, he pointed to spending on home care workers and provisions that help unions as policies that were not focused on bolstering the economy’s potential.Senator Mitch McConnell of Kentucky, the Republican leader, has called the Biden plan a “Trojan horse. It’s called infrastructure. But inside the Trojan horse is going to be more borrowed money and massive tax increases.”Republicans have slammed the provisions related to the care economy and electric vehicle charging options, and they have blasted policies that they have at times classified themselves as infrastructure.Take broadband, something that conservative lawmakers have in the past clearly counted as infrastructure. Senator Roger Wicker, Republican of Mississippi, has said that the White House’s broadband proposal could lead to duplication and overbuilding. While Mr. Blunt has allowed it to count as infrastructure in a case where you “stretch the definition,” top Republicans mostly leave it out when describing how much of Mr. Biden’s proposal would go to infrastructure investment, focusing instead on roads and bridges.Likewise, Senator Rob Portman, Republican of Ohio, said the proposal “redefines infrastructure” to include things like work force development. But one of Mr. Portman’s own proposals said that skills training was essential to successful infrastructure investment.“Many people in the states would be surprised to hear that broadband for rural areas no longer counts,” said Anita Dunn, a senior adviser to Mr. Biden in the White House. “We think that the people in Jackson, Miss., might be surprised to hear that fixing that water system doesn’t count as infrastructure. We think the people of Texas might disagree with the idea that the electric grid isn’t infrastructure that needs to be built with resilience for the 21st century.”White House officials said that much of Mr. Biden’s plan reflected the reality that infrastructure had taken on a broader meaning as the nature of work changes, focusing less on factories and shipping goods and more on creating and selling services.Other economists back the idea that the definition has changed.Dan Sichel, an economics professor at Wellesley College and a former Federal Reserve research official, said it could be helpful to think of what comprises infrastructure as a series of concentric circles: a basic inner band made up of roads and bridges, a larger social ring of schools and hospitals, then a digital layer including things like cloud computing. There could also be an intangible layer, like open-source software or weather data.“It is definitely an amorphous concept,” he said, but basically “we mean key economic assets that support and enable economic activity.”The economy has evolved since the 1950s: Manufacturers used to employ about a third of the work force but now count for just 8.5 percent of jobs in the United States. Because the economy has changed, it is important that our definitions are updated, Mr. Sichel said.The debate over the meaning of infrastructure is not new. In the days of the New Deal-era Tennessee Valley Authority, academics and policymakers sparred over whether universal access to electricity was necessary public infrastructure, said Shane M. Greenstein, an economist at Harvard Business School whose recent research focuses on broadband.“Washington has an attention span of several weeks, and this debate is a century old,” he said. These days, he added, it is about digital access instead of clean water and power.Some progressive economists are pressing the administration to widen the definition even further — and to spend more to rebuild it.“The conversation has moved a lot in recent years. We’re now talking about issues like a care infrastructure. That’s huge,” said Rakeen Mabud, the managing director of policy and research at the Groundwork Collaborative, a progressive advocacy group in Washington. But “there’s room to do more,” she said. “We should take that opportunity to really show the value of big investments.”Some economists who define infrastructure more narrowly said that just because policies were not considered infrastructure did not mean they were not worth pursuing. Still, Mr. Glaeser of Harvard cautioned that the bill’s many proposals should be evaluated on their merits.“It’s very hard to do this much infrastructure spending at this scale quickly and wisely,” he said. “If anything, I wish it were more closely tied to cost-benefit analysis.” More

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    How Biden Can Move His Economic Agenda Without Congress

    #masthead-section-label, #masthead-bar-one { display: none }The Presidential TransitionliveLatest UpdatesElectoral College ResultsBiden’s CabinetDefense SecretaryAdvertisementContinue reading the main storySupported byContinue reading the main storyHow Biden Can Move His Economic Agenda Without CongressUnion leaders and policy experts say the next administration could do plenty on behalf of workers through regulation and other powers.President-elect Joseph R. Biden Jr. may be able to achieve his goals on labor policy even without a cooperative Congress.Credit…Hilary Swift for The New York TimesDec. 15, 2020, 9:00 a.m. ETPresident-elect Joseph R. Biden Jr.’s ability to reshape the economy through legislation hinges in large part on the outcome of the two Georgia runoffs in January that will decide control of the Senate. But even without a cooperative Congress, his administration will be able to act on its agenda of raising workers’ standard of living and creating good jobs by taking a series of unilateral actions under existing law.“If you pay attention to what Trump did and go about it from a different viewpoint, you can accomplish a lot,” said Thomas M. Conway, the president of the United Steelworkers union. Much of this work will fall to the incoming labor secretary, whose department has the authority to issue regulations and initiate enforcement actions that could affect millions of workers and billions of dollars in income.Mr. Biden’s labor secretary could substantially expand eligibility for time-and-a-half overtime pay. In 2016, the Obama administration extended that eligibility to salaried workers making less than about $47,500 a year, but a federal court suspended the Obama rule, and President Trump’s Labor Department set the cutoff at roughly $35,500 rather than continue to appeal. The Biden administration could make millions more salaried workers eligible for time-and-a-half overtime pay by reviving or expanding the Obama criterion and defending it in court.The Labor Department will also have an opportunity to fill several monitoring and enforcement positions created under the United States-Mexico-Canada Agreement that are likely to go unfilled during the Trump administration. The accord, a revision of the North American Free Trade Agreement, allows the United States to block imports from facilities in Mexico that curtail workers’ rights to unionize and bargain collectively. Pursued aggressively, the enforcement could help mitigate downward pressure on U.S. manufacturing wages stemming from unfair competition with Mexico.Mr. Biden’s Labor Department is likely to be more assertive in a variety of other enforcement efforts than its predecessor, which ended an Obama-era policy of typically trying to collect double the amount of wages that lawbreaking employers failed to pay workers under minimum-wage or overtime requirements.“Just getting back wages in small amounts doesn’t provide any incentives for companies to comply,” said Catherine Ruckelshaus, general counsel of the National Employment Law Project, which has ties to the Biden transition team. The Biden administration is likely to revive the Obama approach.Revisiting Labor RulesUnion membership, which has dropped to 10 percent of U.S. workers from roughly double that figure in the early 1980s, could receive a significant boost during the Biden administration, which has signaled that it intends to work closely with the labor movement.Under Mr. Biden, the National Labor Relations Board is likely to be far more aggressive in punishing employers that appear to break the law while fighting union campaigns. It can issue a regulation making it easier for the employees of contractors and franchises to hold parent companies accountable for violations of their labor rights, such as firing workers who try to unionize.According to Benjamin I. Sachs, a Harvard Law School professor, the board could also seize on a legal provision that allows the federal government to cede jurisdiction to the states for regulating labor in certain industries. That could enable a state like California or Washington to create an arrangement in which gig workers, with the help of a union, negotiate with companies over wages and benefits on an industrywide basis in that state, a process known as sectoral bargaining.Under such a system, a union would have to show support from a fraction of workers in the industry, such as 15 or 20 percent, to be able to negotiate with multiple gig companies on behalf of all workers. By contrast, under federal law, the union would typically have to win majority support among the workers it sought to represent, a daunting challenge in a high-turnover industry like gig work.Other labor experts, like Wilma B. Liebman, who led the labor board in the Obama administration, affirm that the board can cede its authority to states but are more skeptical that it would do so in the case of gig workers.Helping Home-Care WorkersThe federal government, through its control of the Medicaid program, could accomplish something similar for home-care workers, who usually work independently or for small agencies that have little power to raise pay because states set the rates for their services. The agencies sometimes resist union campaigns aggressively for fear that allowing workers to bargain for higher wages will put them at a competitive disadvantage.A handful of Democratic-leaning states, like Washington, have addressed this issue by allowing workers to bargain with the state for rate increases that effectively apply industrywide, eliminating the downside that a single agency would face if it raised wages unilaterally.The Service Employees International Union, which represents home-care workers across the country, believes that the Biden administration could encourage other states to create such industrywide bargaining arrangements — for example, by making additional money available to states that adopt this approach. Hundreds of thousands of additional home-care workers could benefit.The federal government, under a provision in the Medicaid law that requires states to keep payments high enough to ensure an adequate supply of home-care workers, could also intervene directly to raise wages and benefits for these workers.“We look forward to working with the Biden administration to make changes to the Medicaid program that can turn home-care jobs into good union jobs,” said Mary Kay Henry, the president of the service employees union.The Presidential TransitionLatest UpdatesUpdated Dec. 15, 2020, 6:45 p.m. ETBiden will name Gina McCarthy as the White House’s climate coordinator.Dominion’s C.E.O. defends his firm’s voting machines to Michigan lawmakers, denouncing a ‘reckless disinformation campaign.’Biden will nominate Jennifer Granholm for energy secretary.Using Federal Contract CloutOutside of specific agencies like the Labor Department, the Biden administration will have considerable leverage over the working conditions of the roughly five million workers employed by federal contractors and subcontractors.President Barack Obama signed executive orders raising the minimum wage for these workers to $10.10 an hour and entitling them to at least seven days a year of paid sick leave. Mr. Biden could raise the minimum wage for contractors much further — some are urging $15 an hour — while also mandating that they receive paid family leave and paid vacation days, as proposed by Heidi Shierholz, a senior Labor Department official under Mr. Obama.Mr. Biden could also use the federal government’s buying power to create more domestic manufacturing jobs, a goal he highlighted during the campaign. One approach would be to sign an executive order laying the groundwork for a Buy Clean program of the sort that California introduced in 2017.Under the program, contractors bidding on state infrastructure projects, like steel makers and glassmakers, must adhere to a certain standard for so-called embodied emissions, essentially the amount of carbon emitted when the material is produced, transported and used in construction. Tighter limits tend to favor domestic manufacturers over competitors in countries, like China, that are farther away and where production is often less environmentally friendly.“The incoming administration has broad power to put forth an idea like Buy Clean,” said Mike Williams, deputy director of the BlueGreen Alliance, a coalition of unions and environmental groups. That includes establishing a way to measure emissions and creating a database in which manufacturers are required to disclose them.Promoting Job CreationWhile existing law requires the federal government to favor domestic suppliers in procurement, a variety of waivers allow agencies to award contracts to overseas companies. Mr. Biden noted during the campaign that the Defense Department spent billions on foreign construction contracts in 2018, and he has pledged to close such loopholes.The most aggressive version of this approach would be to revoke a broad waiver that allows agencies to treat purchases from dozens of countries with which the United States has trade relations — including Japan, Mexico and many in Europe — as though they were made in America. Mr. Biden has indicated that he is more likely to try to negotiate new rules with trading partners to address this issue.The Biden administration could also instruct contracting officers to broaden the criteria they use to assess bids. A set of contracting rules laid out in a 1984 law, along with Washington’s growing preoccupation with spending cuts in recent decades, led administrations of both parties to focus on seeking the lowest upfront price.But the Biden administration could elevate value over price — under the same logic that says a $30,000 Cadillac may be a better deal than a $25,000 Ford Focus. The approach would favor companies whose workers are better paid but also better trained and more productive than competitors’.Mr. Biden could set some of these changes in motion through an executive order stating that federal agencies should focus more on quality and working conditions when assessing value. But because executing many of these shifts would be a question of day-to-day management rather than sweeping changes, some policy experts have proposed that the Biden White House create a dedicated office to oversee procurement across the administration.Anastasia Christman, an expert on government contracting at the National Employment Law Project, compares the idea to the White House Office of Faith-Based and Community Initiatives that George W. Bush created in the early 2000s, whose goal was to scour the federal bureaucracy for ways that religious organizations could compete for government funds. In this case, Ms. Christman said, the objective would be to ensure that contracting officers across agencies are using the right criteria in awarding contracts.“It would help contracting offices think differently about how to do the assessment,” Ms. Christman said. “How do you ask right kind of follow-up questions? Why is this bid lower than all others? What is that resting on?”AdvertisementContinue reading the main story More