The Long, Winding Road to Long-term Care Reform

The COVID-19 pandemic has shaped a growing national consensus that long-term care is harmfully inaccessible due to lack of coverage, long wait lists and inconsistent quality, and that direct care workers working in homes and communities are unprotected, underpaid and undervalued. However, the spring and summer have proven to be a frustrating time for long-term care–reform advocates.

The Promise of the American Jobs Plan

As part of the Biden administration’s “Build Back Better” vision, the American Jobs Plan is the first of two proposals to follow the American Rescue Plan. The original proposal released in March by the White House allocated $400 billion (spent over eight years) toward Medicaid’s home- and community-based services (HCBS). On the heels of the American Rescue Plan, which included a one-year, $12 billion increase in federal spending toward Medicaid HCBS, this is the largest expansion of Medicaid HCBS in American history.

What Happened (to HCBS and Long-term Care Reform)?

In the first iteration of the Jobs Plan, infrastructure is broadly defined to include not only “traditional” physical infrastructure, but human infrastructure in the form of affordable education and childcare, expanded access to long-term care services, and transforming caregiving work from precarious and low-paying to middle-class jobs with benefits and collective bargaining powers.

Between April and June, Senate Republicans presented three counter proposals that consistently opposed the original proposal’s breadth, cost and corporate tax increases, and each proposal left out long-term care reform. When negotiations between the Biden administration and Senate Republicans collapsed in June, negotiations changed hands to a bipartisan group of Senators. The bipartisan agreement reached on June 24, at $1.2 trillion, while being the largest infrastructure investment to date, still leaves out human infrastructure initiatives (including the $400 billion investment in Medicaid HCBS).

Moving Forward

Despite increasingly limited proposals and the latest omissions of caregiving infrastructure initiatives in bipartisan negotiations, the conversation on long-term care reform and investment in caregiving infrastructure is far from over.

A scaled back version of HCBS investment may still be on the table. The Senate expects to consider the bipartisan package in July and the Biden administration’s larger proposal will not see final votes until the fall. During that time, the Biden administration and Democratic leadership have announced they will pursue “two-tracks”: a bipartisan bill and reinstating cast-off initiatives through budget reconciliation (a parliamentary strategy that bypasses the filibuster process and allows a simple majority to pass legislation).

This approach is mired in uncertainty. Progressive Democrats have signaled they will not support the bipartisan bill without securing a broader infrastructure package through budget reconciliation. And some Republicans have indicated they will withdraw support from the bipartisan bill if it is linked to a reconciliation package.

Better Care Better Jobs Act

The same day that the bipartisan group announced a compromise agreement on the American Jobs Plan, a group of Democrats introduced the “Better Care Better Jobs” Act (BCBJA) in the Senate and the House. The BCBJA absorbs many of Biden’s proposals for increased HCBS funding and strengthening and expanding the HCBS workforce. It would permanently increase by 10 percent the Federal Medical Assistance Percentage (FMAP) for states. A condition for states to receive this increase is that they promote recruitment and retention of direct care workers by addressing HCBS payment rates. The legislation would also make permanent both the spousal-impoverishment protections in Medicaid and the Money Follows the Person program. The bill has already garnered support from more than 40 co-sponsors in the Senate.While the ultimate path toward much needed reform remains uncertain, the national conversation on long-term care isn’t over.


  • March 11, 2021: The American Rescue Plan is passed.
  • March 31, 2021: The American Jobs Plan (“Jobs Plan”) proposal is released by the Biden administration.
    • April 5, 2021: The Senate Parliamentarian decides that the Budget Act could be used to create multiple reconciliation bills within one fiscal year.
    • Would allow Senate Democrats multiple attempts to pass legislation through the Senate on a majority vote.
  • April 7, 2021: Made in America Tax Plan is released.
    • Sets forth tax proposals to pay for infrastructure investments, and proposes a raise to the corporate tax rate and global minimum tax (measures that would largely reverse the 2017 Trump administration’s tax plan).
  • April 22, 2021: Senate Republicans issue a counterproposal.
    • Total: $568 billion.
    • Cuts initiatives toward care for older adults and disabled people, and funding for affordable housing, among other things. Focuses on physical infrastructure.
    • Changes the funding mechanism to joint spending from state and local governments and encourages private-sector investments and financing.
    • Does not propose any corporate or international tax increases and leaves the 2017 tax cuts passed under President Trump.
  • April 28, 2021: The American Families Plan (“Families Plan”) is announced. 
    • May 21, 2021: Biden issues a counteroffer in response to Senate Republican counterproposal. Cuts his original proposal down to $1.7 trillion.
    • May 27, 2021: Senate Republicans issue a second counteroffer. Total: $928 billion.
      • Includes $604 billion for physical infrastructure.
      • An agreement was not reached.
  • May 28, 2021: The Senate Parliamentarian makes another decision that a revised budget reconciliation must pass through “regular order,” meaning it must go through committee and have floor amendment votes during a “vote-a-rama.”
    • This thwarts Senate Democrats, who were hoping to use reconciliation to achieve infrastructure goals.
    • Reconciliation can still be used, but the process is onerous because they would need at least one Republican on the Senate Budget Committee to vote with them; a “vote-a-rama” might be a moment where the Democratic Party divides; and the Senate Democrats have only one more reconciliation vehicle to pass Biden’s key legislative priorities this year.
  • June 4, 2021: Biden rejects the third counteroffer from Senate Republicans that would add $50 billion to the $928 billion in the second counterproposal.
    • Rejected because the Republican counterproposal did not grow the economy, tackle the climate crisis or create new jobs.
    • At $978 billion, Senate Republicans did not include human infrastructure, and did not include a plan on how to pay for an infrastructure bill.
  • June 8, 2021: Biden ends his infrastructure negotiations with Senate Republicans, and begins new negotiations with a bipartisan group of senators (G10).
    • The G10 drafts an $880 billion infrastructure bill, which was circulated to a broader group of more than 20 centrist Senators for support.
  • June 10, 2021: Bipartisan group of Senators reached a compromise on infrastructure.
    • This would allot $1.2 trillion over eight years.
    • The deal does not increase taxes, though it includes an option to index the gas tax to inflation.
      • This might be a tough sale for the broader Senate Democratic Caucus.
  • June 24, 2021: A bipartisan agreement (G21) on a pared-down infrastructure plan is reached.
    • Total: $1.2 trillion over eight years.
    • Does not include any funding for human infrastructure, i.e., improving the working conditions and wages of workers involved in the care economy and more.
    • The question remains: how to pay for this?
    • This is not the final iteration. A congressional budget process called reconciliation might allow other White House priorities to be tacked on later.
  • June 24, 2021: The “Better Care Better Jobs Act” is announced.


Pallavi Podapati is ASA’s Program Development intern and a pursuing her doctorate in history at Princeton University. Her research covers labor, disability and social policy.