Harris proposes that Medicare cover more in-home health care, filling a large gap for older Americans and their caregivers

Vice President Kamala Harris has outlined a proposal to allow Medicare to expand its coverage of home health care^[1] for older Americans. The Democratic presidential nominee announced this plan on the television talk show “The View.”

Harris explained that she aimed to take the burden off members of the “sandwich generation^[2],” who are taking care of their kids and aging parents at the same time. She said the cost of this additional paid care could be paid for with the money the government will save by negotiating with pharmaceutical companies to reduce^[3] what Medicare pays for prescription drugs. Harris is also calling for Medicare to cover more hearing and vision care^[4].

The Conversation U.S. asked Jane Tavares^[5] and Marc Cohen^[6], scholars of long-term care, to assess what’s known so far about the plan.

Why is long-term care significant?

Long-term services and supports^[7] are one of the most significant expenses for older adults. They range from nonmedical assistance with food preparation, bathing, dressing and other activities of daily living to medical care in a skilled nursing facility.

Today’s 65-year-olds have a 70% chance of eventually needing some kind of long-term care^[8] as they age, and 20% will need long-term care for more than five years^[9].

The costs associated with even one year of long-term care can prove to be unaffordable for most people. In 2023, the median yearly cost of a private room in a nursing home was US$116,796 and that of a home health care aide was $33 per hour^[10]. That’s $96,360 yearly for eight hours of daily in-home care.

The National Council on Aging^[11] has found that 80% of older adults would be unable to absorb a financial shock — such as the need for long-term care — without impoverishing themselves. The council noted that 20% of older adults had no assets at all, and another 60% would not be able to afford more than two years of either nursing home care or care in their own homes. The average length of a long-term care stay is just over three years^[12].

Medicare currently does not cover any long-term care, but it does cover short-term professional in-home care^[13] for recovery after a qualifying illness or injury for up to 21 days and a maximum of 100 days in a skilled nursing facility^[14] after a qualifying hospital stay.

Medicaid currently covers about 61% of the country’s total long-term care costs^[15], over 70% of which are for home-based services. However, Medicaid has strict income and asset eligibility requirements. Although Medicaid eligibility and coverage vary by state, those who qualify for the program are at or near the federal poverty level^[16] and have less than $2,000 in individual assets, or $3,000 as a couple^[17].

Only 15% of Americans who were 65 and older were covered by Medicaid^[18] as of 2022.

Adding to the challenge, there is a shortage of long-term care workers^[19]. In 2022, about 700,000 people were on Medicaid waitlists for home- and community-based services^[20], and 10% of those with skilled medical needs were waiting^[21] in hospitals for spots to open in nursing homes.

What would be the impact of increasing the number of older people getting care?

An estimated 77% of older Americans desire to stay in their homes^[22] as they age, but 1 in 5 need assistance^[23] with activities of daily living. With the high costs of long-term care and few coverage options, unpaid family caregivers^[24] typically provide this care.

Expanding Medicare coverage to include professional in-home long-term care, as Harris proposes, would make it easier for older adults to stay in their homes without impoverishing themselves. It could also help alleviate burdens born by unpaid family caregivers^[25].

Although it will depend on details that weren’t immediately available, expanding long-term care coverage beyond the people who are enrolled in Medicaid has the potential to help many vulnerable older adults.

For example, getting professional assistance with eating or bathing could prevent health complications associated with malnutrition or poor hygiene. And this care would not be at the expense of a family caregiver who might otherwise have to leave their job or take on additional physical and mental stress to provide that care.

How much will this cost the government?

Clearly, the costs associated with any new program depend on many factors. The most important in this case would be who would qualify, the circumstances under which they could get these benefits, and how generous those benefits would be.

Harris has indicated that the new Medicare home care benefit she’s proposing would be paid for by the savings from reductions in Medicare drug costs. A relatively recent estimate for that savings in 2026 is $6.3 billion^[26].

To raise more money to pay for benefits, however, Harris plans on^[27] expanding Medicare drug negotiations, increasing the discounts drug manufacturers cover for certain brand-name drugs in Medicare and cracking down on pharmaceutical benefit managers^[28] – intermediaries that operate as middlemen between pharmacies, insurance companies, drugmakers and drug wholesalers.

Aggressive Medicare drug negotiations could save about $450 billion^[29] over 10 years, researchers have predicted. This would be enough to cover the Brookings Institution’s $40 billion estimated cost of an impactful Medicare in-home care benefit.

The Harris campaign also identified other potential savings by simplifying the prescription drug supply chain^[30]. Current efforts are estimated to save Medicare $16 billion over the next 10 years.

Harris’ proposed plan would also allow Medicare to provide routine vision and hearing coverage. This could reduce out-of-pocket medical costs for older adults^[31] with relatively little cost change to Medicare. Research also shows that stepping up vision and hearing care would indirectly reduce Medicare costs^[32]. That’s because it would help prevent falls and reduce depression and cognitive decline^[33].

Why hasn’t Medicare covered in-home care until now?

When it was originally launched in 1966, the Medicare program^[34] was intended to cover acute medical care services. At that time, life expectancy was lower than it is today – meaning that fewer Americans over 65 were eligible for its benefits^[35] and would live long enough to require long-term care.

In the following six decades, no public insurance program like Medicare has emerged to help people pay for this care.

But as far back as 1994, lawmakers were drafting proposals^[36] to cover long-term care. More recently, legislators have introduced bills^[37] that could fill this gap. However, many prior efforts have failed^[38] due to a lack of agreement on how to pay for these benefits and whether everyone should be eligible, or just low-income people.

Because the federal government hasn’t stepped up, some states have introduced their own policies^[39].

Washington state is the furthest along in this effort^[40]. It has created a public long-term care insurance program where working Washington residents contribute a small percentage of their income into the fund and can then access earned benefits to pay for services. However, due to a ballot measure^[41] that Washington voters will weigh in on during the November 2024 elections, the program may become voluntary. We believe that letting people opt out would likely make that program unsustainable.

California^[42] has also made headway, completing two feasibility studies to examine the potential of a statewide long-term care insurance program. In 2024, California also eliminated the financial asset limits for Medicaid eligibility^[43] to help expand the program so it can cover more of the state’s older residents.

This article was originally published on Oct. 8, 2024. It was updated the next day with further details about Harris’ proposed changes to the Medicare program.

References

1. ^{^} expand its coverage of home health care (mailchi.mp)
2. ^{^} sandwich generation (www.michiganmedicine.org)
3. ^{^} negotiating with pharmaceutical companies to reduce (theconversation.com)
4. ^{^} hearing and vision care (www.ncoa.org)
5. ^{^} Jane Tavares (scholar.google.com)
6. ^{^} Marc Cohen (scholar.google.com)
7. ^{^} Long-term services and supports (www.nia.nih.gov)
8. ^{^} 70% chance of eventually needing some kind of long-term care (acl.gov)
9. ^{^} need long-term care for more than five years (acl.gov)
10. ^{^} US$116,796 and that of a home health care aide was $33 per hour (www.genworth.com)
11. ^{^} The National Council on Aging (www.ncoa.org)
12. ^{^} average length of a long-term care stay is just over three years (acl.gov)
13. ^{^} cover short-term professional in-home care (www.aarp.org)
14. ^{^} maximum of 100 days in a skilled nursing facility (www.ncoa.org)
15. ^{^} covers about 61% of the country’s total long-term care costs (www.kff.org)
16. ^{^} federal poverty level (aspe.hhs.gov)
17. ^{^} less than $2,000 in individual assets, or $3,000 as a couple (www.medicaidplanningassistance.org)
18. ^{^} 15% of Americans who were 65 and older were covered by Medicaid (www.medicaid.gov)
19. ^{^} shortage of long-term care workers (www.kff.org)
20. ^{^} about 700,000 people were on Medicaid waitlists for home- and community-based services (www.kff.org)
21. ^{^} 10% of those with skilled medical needs were waiting (www.ahcancal.org)
22. ^{^} 77% of older Americans desire to stay in their homes (livablecommunities.aarpinternational.org)
23. ^{^} 1 in 5 need assistance (www.ncbi.nlm.nih.gov)
24. ^{^} unpaid family caregivers (www.ncbi.nlm.nih.gov)
25. ^{^} burdens born by unpaid family caregivers (www.ncbi.nlm.nih.gov)
26. ^{^} $6.3 billion (www.brookings.edu)
27. ^{^} Harris plans on (mailchi.mp)
28. ^{^} pharmaceutical benefit managers (doi.org)
29. ^{^} Medicare drug negotiations could save about $450 billion (medicine.stanford.edu)
30. ^{^} the prescription drug supply chain (mailchi.mp)
31. ^{^} reduce out-of-pocket medical costs for older adults (jamanetwork.com)
32. ^{^} reduce Medicare costs (www.michiganmedicine.org)
33. ^{^} cognitive decline (www.nia.nih.gov)
34. ^{^} Medicare program (www.cms.gov)
35. ^{^} fewer Americans over 65 were eligible for its benefits (www.ncbi.nlm.nih.gov)
36. ^{^} lawmakers were drafting proposals (www.congress.gov)
37. ^{^} legislators have introduced bills (www.congress.gov)
38. ^{^} prior efforts have failed (www.healthaffairs.org)
39. ^{^} some states have introduced their own policies (www.ltsscenter.org)
40. ^{^} Washington state is the furthest along in this effort (theconversation.com)
41. ^{^} ballot measure (washingtonstatestandard.com)
42. ^{^} California (www.milliman.com)
43. ^{^} eliminated the financial asset limits for Medicaid eligibility (justiceinaging.org)