Federal Discussions on Aging Move Center Stage

May 17, 2024 | Catherine Jones

Close-up of a nurse and an older patient holding hands. ASTHO's Helath Policy Update banner is in the lower right cornerAs the November elections approach, aging remains a key topic for the candidates themselves as well as for the capacity and quality of nursing homes, assisted living facilities, and the long-term care workforce, which by all accounts is desperately in need of reserves. Congress, the Biden-Harris administration, and federal agencies are racing to keep up with the growing demands and costs of quality of care, and fully addressing inequities and inequalities. It is vital for public health to advocate for healthy aging over the life course and to be inclusive of older adults in all population health efforts.

As of 2020, 56 million—or 16.8% of—U.S. adults were ages 65 or older. By 2060, that number will exceed 94 million and represent nearly 25% of the entire population. The older population is becoming more racially and ethnically diverse. Between 2019 and 2040, the proportion of Hispanic or Latino, Black or African American, American Indian or Alaska Native, and Asian American older adults is expected to increase by 115%; the non-Hispanic white older adults’ group will grow by 29%. The U.S Census Bureau projects that, by 2034, older adults will outnumber children for the first time in U.S. history. Social Security and Medicare expenditures will increase from a combined 9.1% of gross domestic product in 2023 to 11.5% by 2035 because of the larger share of older adults.

Recent Congressional Hearings

In January, the Senate Special Committee on Aging held a hearing focused on assisted living facilities (ALF) and other aspects of long-term care. There are currently more than one million Americans living in ALFs. Witnesses pointed to exorbitant costs and hidden fees (average annual cost is $54,000), lack of transparency and accountability, negative and harmful experiences for patients and family members (including financial exploitation), workforce shortages, inadequate staff training, and lack of additional or specialized care for people living with dementia and Alzheimer’s.

Senators sharply questioned the impacts of private equity takeovers and real estate buying sprees of ALFs, public payments, such as Medicaid waivers, and lack of data being collected to guide reforms. Since federal agencies regulate nursing homes, ALFs receiving federal dollars can arguably be held accountable to federal standards.

In March, the Senate Committee on Health, Education, Labor and Pensions held a hearing to examine the Older Americans Act (OAA), which passed in 1965, was last reauthorized in 2020, and needs to be reauthorized by the end of 2024. With 10,000 Americans turning 65 every day over the next 20 years, there was bipartisan agreement that the OAA needs to be fully funded. Research shows that the OAA saves money by reducing emergency department visits, nursing home admissions, and preventing complications from chronic diseases.

The committee agreed that older Americans are not getting enough support to age in place, including daily meals, adequate nutrition, physical activity, socialization, medical care, fall prevention, transportation, employment, protection from abuse, and housing. One in four older Americans has an annual income of less than $15,000; a near equal proportion lives in poverty. With 40% of OAA funding going to Meals on Wheels and other nutrition programs, it remains a lifeline for many.

In April, the Senate Special Committee on Aging held another hearing to address shortages and improve the long-term care workforce. The vast majority (80%) of long-term care facilities report significant staffing shortages, affecting their ability to provide services, accept new clients, or even remain open. In 2022, the median hourly wage for direct care workers was just above $15. The hearing also highlighted bipartisan solutions to improve pathways to enter the workforce, compensation, and the working environment.

Biden-Harris Administration Unveils Workforce Rules

Nationally, seven million older adults and people with disabilities rely on home- and community-based services (HCBS) under Medicaid at an annual cost of $125 billion. Approximately 2.8 million workers provide in-home care, and predictions are that the industry will need an additional one million workers by 2030.

On April 22, the Biden-Harris administration unveiled The Ensuring Access to Medicaid Services final rule aimed at improving job quality and pay for direct care workers. This CMS ruling (sometimes referred to as 80/20) requires that, in six years, states ensure a minimum of 80% of Medicaid payments for services go toward compensation for direct care workers furnishing these services, as opposed to administrative overhead or profit. The rule calls for more transparency in how facilities pay for HCBS, as well as how they set rates. Boosting the low pay will entice qualified workers and lower turnover; home health agencies warned it could drive them out of business.

The Biden-Harris administration also set nationwide minimum staffing ratios for registered nurses and nurse aides for nursing homes. The rule requires nursing homes to have a registered nurse on site 24 hours, seven days a week. Facilities must also ensure registered nurses work a certain number of hours per day based on the number of residents. CMS has phased in the requirements, with limited, temporary exemptions. Experts call the rule a significant step toward bolstering nursing home quality and safety, but again, a understaffed nursing homes forced to hire more workers claim they cannot take on the financial burden.

Reframing Aging Summit in Washington, D.C.

The Gerontological Society of America’s Reframing Aging Summit kicked off in April with a dynamic discourse on reframing aging through a wider, more inclusive and compassionate lens, poignantly summed up by Kina White, DrPH, MHSA, FACHE, Office Director, Office of Community Health Improvement, Mississippi State Department of Health. “As you take a breath you age. We must normalize age and integrate it across all public health systems. Embed it in all funding. There is no room for ‘othering’ when we’re all aging with every breath,” said White.

ASTHO’s government affairs team will continue to track policy and legislation related to healthy aging and share the latest news.