Let's Build Some LTC Infrastructure!

 Quick now: what’s the biggest single component of President Biden’s infrastructure plan (a.k.a The American Jobs Plan)?   Fixing roads and bridges?  Upgrading the power grid?  Preparing the nation for electric vehicles?  Giving all Americans access to broadband?  Wrong.  If you guessed home and community services, you’ve been paying attention. 

President Biden is proposing $400b (out of some $2 trillion total spending) for this component, compared to, for example, $115b for roads and bridges or $174b to support electric vehicles.  He wants to improve the pay of home care workers, fund more of those jobs, and ensure more people have access to home and community services.

All laudable goals, but not nearly enough, and not spent on the right things.  I worry that we may miss a generational opportunity to fundamentally rethink the infrastructure for long-term care.

Opponents of the Biden plan argue that this part of the program is not “infrastructure” in any normal use of the word, and cynics believe it is more about satisfying the SEIU.  On the other hand, long-term care advocates worry that it doesn’t do anything to improve nursing homes, nor the existing long-term care financing mechanisms.  

No one is happy with our long-term care system, except maybe the people profiting from it.  We spend well over $300b annually on long-term care services, plus billons more in unpaid care, but that doesn’t seem to be money well spent.  Long-term care makes the rest of our messed-up healthcare system look futuristic.   Since 70% of us are likely to require some kind of long-term care assistance during our lifetime, this is an issue we should all care about.  

Depending on the source, there are currently somewhere between 2.4 and 3.5 million home care workers, with the need to expected to grow 50% by the end of the decade.  They make, on average, just over $12 on hour – less than they could make at Amazon.  The proposal would seek to pay them as much as $20 an hour. 

Credit: The Brooking Institution

Even if we manage to boost wages, it’s not like these jobs are prestige jobs; they often entail unpleasant and difficult tasks.  Caring for people is a calling, and not everyone can do it, at least not well, and even those who can often burnout over time.

Our long-term care infrastructure is failing as badly, or worse, than any of our roads, but simply throwing more money at more people to do the same things is like simply paving over those roads.  It neither addresses the underlying problems nor prepares for the future.

The future is that there are going to be more seniors, living longer, and living those extra years with more chronic conditions.  The future is that we don’t have enough nursing home beds to handle the increased volume, nor enough workers to care for people. 

We need new long-term care infrastructure.  Here are some suggestions:

Rethink Nursing Homes: I’ve written before that we should “blow up” hospitals: rethink them from first principles, revamp them to ensure that only people who absolutely need to be in one are there, and even then only for the minimum time needed.  All of that applies even more to nursing homes.

Let’s admit it: glossy brochures and 5 star rating aside, the quality of care in nursing homes is far from what it should be.  That’s particularly true for nursing homes that predominately serve Medicaid patients.  Staffing issues, lack of oversight, and low payments are part of the problem, but the entire concept needs to be rethought.

When do we need institutional care, for which patients, for long?  How should they be designed and staffed to safeguard patients’ rights and dignity?  What technologies can be used to improve the quality of life for both residents and workers?

What might a nursing home from 2050, or even 2100, look like?

On-Demand Technology: We live in an on-demand society, and need to apply those kinds of technologies to help people remain at home as long as possible.

The Myosuit.  Credit: Eazilee

We can monitor people’s well-being.  We can send support upon request, or when monitors indicate that support is needed.  We can use assistive devices (e.g., exosuits!) to help support/restore capabilities and offer more independence.  We can use AI to pinpoint when what interventions are likely to be needed.

21^st century technologies can keep us at home longer than we’re taking advantage of now, and will only get better at it.

Robots: I have long been advocating that there may be no better use for robots than to support people with long-term care needs.  Watching with unwavering patience and presence, assisting with especially personal needs like bathing or toileting, repeatedly lifting a body weight: all are ideal for robots.    

Yes, people can do all these things, and do.  No, robots are not yet entirely ready to assume most caregiving tasks.  But emphatically yes, they will be – and should.

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Lest anyone think I believe long-term care should only be a technological marvel, let me emphasize that people are and should always be integral to any kind of long-term care. People with long-term care needs need other people.  They do better when there are meaningful social interactions.  But we should design our long-term care system to maximize human empathy and caring, not to rely on humans primarily for caregiving tasks. 

I don’t begrudge long-term care workers better wages and better working conditions.  They deserve it.  I’m just not sure the infrastructure bill is the best way to accomplish this, especially since it appears money will just flow through our deeply flawed Medicaid system.  As Robert Espinoza of PHI told The New York Times, “It’s hard to imagine Medicaid is the right funding vehicle.”  

Financing for long-term care is particularly problematic, since so much of the spending is out-of-pocket, and wipes out assets for more people than any other type of healthcare service.  We need more equitable methods of financing long-term care.  Revamps of Medicare and Medicaid are required.

Let’s not just throw more money at home and community care workers; let’s reinvent the long-term care system in which they work.