As negotiations grind on between the White House and Senate Republicans, the prospects for a big, bold infrastructure deal look bleak. President Biden’s $2 trillion American Jobs Plan — the first of a two-part package — is being picked apart by Republican lawmakers. They object to its price tag. They object to funding it by rolling back some of the 2017 tax cuts. And they vehemently object to the White House’s redefinition of infrastructure to encompass things like roads, ports, broadband, community colleges, electric-vehicle charging stations and elder care.
Republicans have countered with a radically reduced plan stripped of provisions they do not consider infrastructure. Their biggest target for elimination: Mr. Biden’s call to invest $400 billion in community-based and in-home care for older and disabled people. Characterized as “infrastructure of care” by the White House, the provision accounts for nearly 20 percent of the total cost of the president’s plan. Republican lawmakers are having none of it.
Republicans have a semantic point: The administration’s position that any policy aimed at helping people live productive lives should count as infrastructure stretches the term “infrastructure” to its limit. Within these parameters, it’s hard to think of a measure that wouldn’t qualify.
It is nonetheless hard to fault Mr. Biden for seeking to prioritize elder care. America has long been facing — or rather, refusing to face — the challenges of its rapidly graying population. For decades, experts have been warning that increased life expectancy, falling birthrates and the aging of the huge baby boomer generation were on track to create a rolling demographic disaster: more seniors needing more care, with fewer younger people around to provide it.
Despite this, America’s public investment in long-term care has lagged behind that of many other developed nations. For too many families, professional care options are prohibitively expensive. Tens of millions of Americans provide unpaid care to aging family members, often at enormous cost to the caregivers’ economic, mental and physical well-being.
And yet, as a political issue, elder care has had trouble gaining attention, much less traction. It rarely emerges as a hot topic on the campaign trail or in the halls of Congress — even though seniors vote in disproportionate numbers. The House dissolved its Permanent Select Committee on Aging more than a quarter-century ago, largely as a cost-cutting measure.
The coronavirus pandemic, which hit older Americans especially hard, exposed the inadequacies of the existing system, giving fresh hope that policymakers will at last get serious about dealing with what has been ominously termed the gray tsunami. Mr. Biden jamming the issue into his premier infrastructure bill signals that his team at least grasps the urgency of the situation.
The elder-care crisis is a matter of math. In 2016, 15 percent of the U.S. population was 65 and over. In 2030, when the youngest baby boomers will have turned 65, that number will hit 21 percent. By 2034, Americans 65 and older will for the first time outnumber those younger than 18. In a 2018 report, the U.S. Census Bureau noted, “By 2060, nearly one in four Americans will be 65 years and older, the number of 85-plus will triple, and the country will add a half million centenarians.”
The system is already under strain. As the demand for care has spiked, so too have costs. According to a 2020 survey by Genworth, a long-term-care insurance provider, the monthly cost of a semiprivate room in a nursing home typically runs between $6,000 and $13,000, depending on the state, and the nationwide median for a private room in an assisted living facility is $4,300 a month.
Professional care providers — overwhelmingly women and a majority of them women of color — often face tough working conditions for inadequate pay. The median hourly wage for home health and personal care aides is $13, with a median annual income of around $27,000. Many in the field rely on public assistance. These challenges lead to staff shortages, high turnover, instability and inconsistent care.
For financial or other reasons, more than 40 million Americans have taken on the role of unpaid care provider. While it can be rewarding, the work takes its toll. A 2017 survey of unpaid caregivers in the United States by the advocacy group Embracing Carers found that, among other challenges, 48 percent “have felt they needed medical help/support for a mental health condition due to their role as an unpaid caregiver.”
Many families turn to Medicaid to defray the high costs of care. But that anti-poverty program kicks in only once a person’s countable assets are less than $2,000, forcing seniors to spend down their life savings.
America’s failure to prepare for this crisis is less about math than about culture and psychology. Most people don’t talk about or plan for aging and death. Studies find that while many Americans say they are open to end-of-life discussions, few have them.
People also don’t want to think of themselves as growing old or frail, in part because of pervasive negative attitudes toward the value of older lives. Just think back to early in the coronavirus pandemic, when the message emanating from certain conservative corners was that some older folks would — maybe even should — willingly sacrifice their lives so that younger people could get on with theirs. Baby boomers have most famously resisted the notion of growing old. For them, 60 is the new 40, and as more of them stride into their 70s, many still bristle at the notion that they qualify as senior citizens.
Why don’t the millions of people tasked with looking after their elders demand more help? A few years ago, Washington Monthly found that because people often don’t consider themselves formal caregivers, they also don’t think of caregiving as a matter of public policy. Tending to aging relatives is simply seen as what good sons and daughters do.
Advocates note that the system is so fragmented and difficult to navigate that most people don’t grasp the magnitude of the challenge until they are forced to confront it firsthand. They also contend that because the caregivers are so often low-income women of color, the work itself is undervalued.
From a political standpoint, it typically helps to have a villain to mobilize against. But with elder care, there is no obvious bad guy — only legions of parents and grandparents needing attention and resources. “Instead of feeling anger, which research shows is linked to political activation,” Washington Monthly noted, “people struggling with providing for their parents tend to feel guilt and shame, directing the blame inward.”
Absent political pressure, lawmakers have little incentive to hammer out complex new programs or make big investments in elder care. Now and again, a new idea arises, only to fizzle. The Affordable Care Act created a voluntary, long-term-care insurance program, only to have it dissolve before it ever took effect, over concerns about financial viability.
In more recent years, there has been a smattering of (failed) legislative attempts to establish a national caregiving corps, modeled on the Peace Corps or Teach for America. But such stand-alone programs can be a hard sell in Congress. Often, the key to success is to bundle a neglected issue into a larger proposal with more juice, such as Covid relief — or infrastructure.
Which returns us to the president’s backdoor attempt to confront a spiraling crisis that too many Americans, including members of Congress, are unwilling to face head on. Republicans are right: Elder care does not fit into any but the loosest definition of “infrastructure.” But with an aging nation putting growing strain on the system, policymakers might want to spend less time fretting over how to classify the issue than addressing it.