Matt and Dara are joined by Vox's Dylan Scott to examine the $400 billion portion of Biden's $2 trillion infrastructure plan that is designated for the "caretaking economy." Is this merely an expansion of Medicaid? Does it actually address fundamental structural issues in the economics of long-term care? Plus, some research is examined that helps illustrate the power of "defaults" in ACA-type health insurance marketplaces.
"White House unveils $2 trillion infrastructure and climate plan, setting up giant battle over size and cost of government" by Jeff Stein, Juliet Eilperin, Michael Laris and Tony Romm, Washington Post (Apr. 1, 2021)
"How Biden's infrastructure plan could leave child care behind" by Anna North, Vox (Apr. 3, 2021)
"Joe Biden is stretching Obamacare as far as it can go" by Dylan Scott, Vox (Mar. 29, 2021)
"Exclusive: Nearly 7 million uninsured Americans qualify for free health insurance" by Dylan Scott, Vox (Apr. 1, 2021)
Matt Yglesias (@mattyglesias), Slowboring.com
Dara Lind (@DLind), Immigration Reporter, ProPublica
Dylan Scott (@dylanlscott), Policy Reporter, VoxCredits:
Erikk Geannikis, Editor and Producer
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This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
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like, while, if you really want it
what comes another episode of the weeds on a box media podcast network, I met places, he would prefer public. His daring land box, TAT comes Dylan Scott. We got Dylan with us to help us understand one aspect of the by jobs and infrastructure proposal, the kind of least infrastructure II in the traditional sense aspect, which is four hundred billion dollar investment in care, work and the care economy, which I guess it's like a big phrase. But then, when you but drill into it, it's like a specific-
Medicaid programme really is that is their right? Am I understand that correctly? Yes, I mean, I think, in all we have right now is basically a white sheep from the vital ministries, and so I think there is from
I can do some experts over the last week. There deftly some details to be filled in later
primarily a big investment in long term care, and specifically,
and community based services. So people who want to be able to age
their homes, rather than going to an institution like a nursing home- and you know prick that the the
main outweighing for those kinds of services. Is your home health aids, whether that
Buddy who just like style
spy. You know a couple times a week to help you with your laundry year with cleaning up around the house or whatever and all the way up to, like you know, a whole mouth head who might be staying with you for the entire day and in taking care of basically all of your needs.
That is the kind of what the care economy is. But really you know this is your and when you talk to export about this debate
get it from the perspective of patients, because you know people like to age at home and in order to
that we need to provide healthcare workers and compensate those healthcare workers, as so that people are able to do that, and I think there are two
important pieces of context for why this provision
is in the in the jobs plan. You know, regardless of its relevance to infrastructure. One of those is like there is kind of a long standing structural problem here. So young people do your broadly speaking,
people like to spend their later years at home, if possible and before
it in on itself? There was already a waiting list of about almost a million people, I think, was
like a hundred and nine hundred thousand people who wanted to be enrolled in their Medicaid programmes, home and community based
services benefits which would provide them with like some home health aids who would come.
Of them out with some of those daily tasks and so,
is like you know, that's that's a big number. It's not a perfect one to one like not every person whose living in a nursing home is
waiting list to be because they would rather be staying at home, but for some contacts, lake
Currently there are one point: two million nursing home residents in the United States, and so nearly as many people who were as are currently living in a nursing home are on a waiting list to get these home based services. So that was a pretty big unmet. Need that eggs
stood before the covert nineteen pandemic and then during code,
as you I'm sure, most
sinners, no, no
homes have just been ravaged by the virus and especially like the big enough
tunisians have had a really difficult time
following the virus. You know they ve got digs ass people who are coming in and out all the time and that's taken a really heavy toll on residence. We got like. I was looking at the numbers this morning. We ve had about a hundred
thirty thousand nursing home residents, death
there's some evidence that people who stay at home or who in maybe like smaller settings like small group homes of elderly people, have seen much fewer covet cases and covert deaths
so I think you combine those things. The kind of pre existing unmet need prior to covered and then the told that covert took on nursing homes
Think that probably help to explain why Biden is placing such an.
This is on this, even though it seems a little bit of a stretch to include this in an infrastructure and and jobs plan. So in terms
it just in thinking about this kind of outside the context of you know infrastructure,
or disposal kind of looking at the problem.
It seems to me that there are a couple, of wit, like I'm, really glad he brought group homes upright, because it's not in practice a choice between
someone aging in place and getting put into this like me,
sadly institutionalized face
less nursing, home bureaucracy. In theory, there are other options people can move in with younger relative small group homes are an option and
I know from my mother who works in elder housing that its inner, even though peoples
preference is always to age at home that that kind of has knock on effects, not just in terms of health care, but also in terms of the housing stock, Cetera, vit aren't always
you know collectively ideal. So to what extent is the effort to meet the demand for aging
place by supporting health care that is home. Based do the experts. You talk to you,
that this is actually is the right
answer normally speaking, or is this just accepting that for better
worse. Everybody wants
the age in the home that they currently have, and because of that, the best thing we can
do you, even though it's not what we would ideally want, and even though it's going to cost,
more money than it otherwise would is to provide this
This is to them where they want to be. I think,
couple ways to think about this, but you eat your deftly like raising the right question sway,
why am I talking to experts? And certainly, if you talk to know, know people who advocate for seniors and people with disabilities or the other important population to keep in mind here they place along
the emphasis on personal agency. You know it is kind of on the front end that, like people should have control over the kind of
care that they receive, especially when their on these vulnerable situations, whether their growing older or whether there to save, have a disability, and so I do think that
like a first principle from which a lot of this flows- and I think they
Certainly point too, you know it's a area. It can be a hard thing to quantify, but they would certainly point to like surveys and other kinds of quality of life measurements that that certainly indicate that people who are able to age at home. You are
happier and have a higher quality of life. I do think it important
Two to note at the top is that there's always gonna be a role for institutions, whether that's people it could.
This is on an individual basis. But you know there are gonna, be people you if you're single, if you're older and your single, maybe you don't want to live by yourself. Maybe he would rather be in and whether that's in a group on setting worrying just like a nursing home or an assistant living facility, you'd want to be around other people and you
I just see a lot of value and being in a bigger,
to show just for your own social needs and then certainly enough with people who have a significant
health needs organ of severe cognitive impairment, living it
home is just you know. It's going to piss like a lot of burden on other members of their family. It's worse is not going to be practical, and so there's going to be a role for Insta
since no matter what I think that what would the way that David Grabowski, whose a prominent Harvard professor,
studied long term care for a long time. Put it to me is what kind of trying to
re balance between home care and institutional care, because you know, as I started thinking about this, it occurred to me that, like
for most of human history if you are lucky enough to age. Of course, you aged at home, like nursing homes in these kinds of institutions, are rarely
Fifthly, recent phenomenon, something that cropped up in the nineteen fit.
These for a variety of reasons, because we had we had more older people. We had.
Your people became a little lest physically kind of stock. Like people start migrating a moving around. You know family members or the people who were offering providing that care but like if your kid moves across
the country because they got a job or that's where they
to raise their family? You know, then. Suddenly, there's nobody around who can provide that kind of informal care and so that without was kind of the need that nursing
Holmes filled and then, with the event year, when Medicaid came on line in the nineteen sixty it had a nursing home benefit, and so on.
We now have a way to pay for that care, and so, like there was a pretty rapid, relatively speaking over a number of decades
pretty rapid institutionalization of of long term care, but that kind of defied what most people actually want, which is largely to to Asia
home? So now we ve been trying to figure out the balance between like if people want to be able to agent home, we want to provide them the support that they
do that. Obviously that, as I was saying, there's still gonna be a role for institutional care and so
does seem to be primarily a matter of resources like you know that
sing homes will tell you already that, like Medicaid under funds, the care that they need to provide for nursing home
residents and so and then, like as those waiting,
Us that I was describing earlier, I think, are evidence of you know. There's a big unmet need for people.
Want to stay at home as well,
and so the folks that I talk to her
I asked several them I was like so like is four hundred billion like, as is the right number like it's a big number like now listening at the top, but is it the right now
more and please just kind of shrugged like no. I don't think anybody knows what the right number is an
and so I think that that they see it as like. This is a worthwhile investment. There is clearly a pretty big unmet need
is some indications that, like people any theirs,
our group settings or in who just live at home are are happier in in the kick in the
of the of covert. They have fared better in terms of health outcomes.
But I think we're still trying to like figure out what that balances. You know it's been a pendulum big swinging back and forth for the last sixty six
in two years, and so I do think that this
a hundred billion would help to move the pendulum back towards some kind of equilibrium, but there are there
trade offs and, and- and I think that we still just you know it would be a start, but certainly not not the end of
figuring out how to balance in our institutional needs versus versus home needs. So I did something to to clarify
as we as we start to talk about these. These nuances is just like how and detailed the White House
proposal on this is reigns over. You know this. This is whole big jobs. Plant package, in any kind of splits into four thematic cluster said, which, like caretaking economy, is wine, and that this is great Washington, Post graphic and it divides these squares up into smaller rectangles, but like there is no
while a rectangle in the caring economy. One just says: Homey community based care for the elderly and disabled people, but not just like the transfer,
Patient one is six hundred and twenty one billion, and they split it up into one hundred and twenty three four thousand five hundred and sixty seven chunks
Plus a catch all eight other category, I didn't like one of those subjects is highways bridges and Bro
and I can tell you as somebody who is like reported on transportation policy, that leg
highways, bridges and road sub element contains a fix. It first mandate.
It supports the outer door, and you know like this, whether you agree or disagree with like the exact numbers attached all the things they reflect.
Fairly specific policy community theories of what it is. We should do about these saying so like in the infrastructure at home. There's an affordable housing
sub element. And then I sub sub element of that is a competitive grant. Programme for zoning reform
so like. I could tell you all about that. The character
to me. It's like
spend more money on the Medicaid Programme for Home Healthcare
and then you like try to ask like what's the balance between com,
Eddie based CARE and home base care. Like does no answer, and inside
four hundred billion, meaning like what like how
How does that we're gonna formula, and they say they haven't you good answer to this, which is that, like you know, these are really congressional decisions by a body which is totally true, but I give it is also true of all the things that they have. A tat threats are buckets and numbers to. Why is it a hug?
in seventy four billion for electric vehicles, rather than a hundred,
you buy shares here, like they pretty obviously just took aim large round number and we're like trying to say that they endorse the concept of spending a large round number and its on this particular thing I mean in part because of covert am the problems at
straight with institutional care, but also I mean, I think, we're saying very specifically because of service employs international you, which represent
A lot of home healthcare workers, a clear like pro union agenda, is like woven through the hole,
spy on and including, like somewhere in the fact
they're, like all also the pro act as part of this we'd, like which, like
it isn't, because that's not in budget reconciling
but like this whole thing is, I got you know it's like Joe Biden, like Labour union friendly jobs plan for America, because caretaking economy is like such a big, interesting subject. Likud, like include you, know, preschool unlike summer camp for twelve, your odds and nursing homes and like eighty million thanks but like this, is one slice of the getting economy and its specifically the size that, like one particular point,
please savvy and influential union represents allotted the members on and one of the aspirations and the plan is that you will raise the pay of the people doing this,
because it's very
I don't know how to say it: it's like it's very inefficient to have like one person in one person's home, helping them out with stuff, so it's both incredibly expensive from a like cost per patient perspective, but also like really really low paid work and you're just constantly squeezed between, like making this job be not terrible.
Making the costs not totally crushing, and so the idea of four hundred billion is like it's
be more and also better, and the balance between those two is not like adjudicated at all in the plan. But there's like a complete trade off between how much of the four hundred billion do you want to spend on increasing compensation and how much of it you want to spend an increasing number of people who get access to these programmes because Ike
that's the whole cost of home health aid provision. Areas like there isn't, like some secret other thing that the money goes to its just expensive, to send somebody to be in your house,
hours a day right so you're saying the light, because your if your increasing the compensation for the home l fades, you are you because we have kind of a firm number here, four hundred billion dollars, your only there's only so many home health aids that you can ire
That number is gonna shrink, the more that you pay for
We do so you can look at apple and he could be like Jim Cook and pay. Those apples target is more money and an apple
just be less profitable because they have like staggering province. I'd like the Medicaid Home Healthy programme doesn't work like that is not the only some other place for that money to come
other. Then you don't higher. As many of you have easy, with four hundred billion, you can hire more people and you can pay them better, but you still have to pick a point on the trade Oscar yeah. No, I think that's fair, but I did, I think, that's fair. I would say
like when you talk to people. This is miss, maybe he's a little dissatisfied, but you know I asked folks like hell are there
is there like programmatic stuff that we need to be doing, or is this a matter of resources in
that at least the folks that I talk to certainly came down inside the lake with we just need to spend. We do need to spend a lot more money and ate it
pretty well established? There was actually Europe a new study out about this. It was focused on institutional care, nursing homes, but the staff turnover in those settings is pretty its astronomical, like the big finding.
That study was that the average nursing home basically sees one hundred percent
and over on a year to year basis.
And, while that's more complicated than just compensation, because obviously this is very- this is very difficult. Work
some of the populations that often do this kind of work may not be sticky necessarily like maybe they're, just moving or finding out going back home or whatever and so yeah. Clearly, they ve kind of dogs, tat, question
that trade off that you raise, but I do think that lake
and maybe this is. This is partly the essay I u influence and partly euro. This is to some extent
The consensus of a policy that exports that like,
if there is wherever a problem where, like throwing money at the problem, is a somewhat palatable solution than me
be this. Is it and I do think that it's worth keeping in mind that, like there is a pretty wide spectrum like it is
there are certainly going to be cases where it is.
Literally pang. Why
the home health worker, to go care for one patience. You know eight hours a day, and that is their job, but you have
there are also people who qualify for these homing computer based services, who have less needs
and so, like you know, if you can.
Pain staff and for those people who have
less needs. No one worker is gonna, be able to provide care to more people. That may be that, though, that
It helps to mitigate the issue that you raising to some extent an you know. Institutional care is very expensive. Your Grabowski, this Harvard professor emphasised this point- that lake, if
Can provide some of the more of the cheaper care to some of these people who may be just have some needs in order to be able to stay at home as opposed to move
bring them. You know if we continued
under fund these programmes. We might have somebody who has read
actively light service needs, but certainly needs those services to be in order to be able to stay at home. Here. If we could,
I'd them those services that is arguably
cost savings. If the alternative is, if they can't get those services and their only option is moving into an institutional setting. So I think there are a lot of like we're,
trade offs that clearly, the bite administration is not interested in getting into with its weight. She
but it it's just it's it's a it's a complicated picture, because this is such a a complex population. I think which is, I think why it's been such a hard problem solved.
This does have me wondering a little bit f and its wild to say this with. You know this incredibly large price tag, defining infrastructure in this very Broadway pack.
But looking at this particular provision and kind of the gap between the idea of including
the care economy in an infrastructure package and the specific proposal that's being made.
Be it is just in addition, as you were saying that, like this is the easiest part of the problem to throw money out, but
there any sense that there is
either that there is a missed opportunity either in defining the either either in addressing other elements of the care economy are defined
the care economy itself more broadly or eat
and in, if you're, defining the care economy as late Health AIDS serving
individual people in unlike residential settings that there could be more to be done with I dont know renovate
physical footprint of you know
of institutional settings of it. Exploring lake creating
incentives for group housing in that kind of thing that that there is stuff that's being left on the table in terms of it as long as you're going to put out this super brought infrastructure plan hears
more revolutionary proposals. You could be putting out there that would have a much bigger impact if they
now that passed into law. Absolutely, yes,
I think anyway, there are certainly missed opportunities here I mean one thing is like obviously the care economy
is just kind of a made up terms. That sounds good but, like I don't think it has any kind of female official or academic definition, and so, like you know, are my colleague Anna nor
wrote something last week about your child care, which is argument, could arguably certainly be incorporated. This
the care economy, is not included in this proposal.
But I do think more importantly, there are just not more importantly, butts even just sticking with long term care. There are some at least two pretty obvious. Missed opportunities
one is that there is a bigger structural problems.
Long term care and the United States that this plan does nothing to address, which is that, like Medicaid
means tested programmed for which only you know, look people with low incomes or are few assets qualify for is the primary pair of long term care and so
the system that we have for long term. Care is basically either you might be. There middle class are wealthy enough to afford your own long term
for a while, but eventually you spend down your money and your assets until you qualify for Medicaid and yes at that point. Medicaid is covering your care, but you have spent down your income and your assets in order to be able to get those benefits and
Is this does not do anything to address that? That is, admittedly, a very thorny problem to try to solve. As I know, man
remembers the Asia, the affordable, correct, tried to introduce a program called the class act that that would have set up a new long term insurance programme,
it was scrapped before it was ever implemented, because it was going to be so extensive and so that
structural problem is pretty much untouched by the bite and plan like people are still going to have to spend our you know basically,
eliminate their assets in order to be able to qualify qualify for these medicate benefits.
And I was interested. This is a bit of a side note. I guess, but I was reading a paper in nature about all this yesterday. Any
spend so much time talking about how your? How much do you
spends on health care as a percentage of GDP relative to other countries, but our long term,
Are we actually dramatically under spend compared to a lease like kind of the best performing countries select? The Netherlands is gonna held up as a model of of long term care in part, because they they opt more for the small. Can a group home settings and they spend
something like three percent of GDP on on long term,
care the. U S spends like zero point five percent so like, and this is a problem across a lot of countries to Australia, which is which its
raw healthcare system is is quite a bit better than the U S, but they also spend your pretty meagre amount,
long term care. So I dont want to make the sound like just to a problem that unique to America, but there's a pretty good.
Is to be made that we are dramatically underfunding, long term care in the? U S, and we ve done nothing to kind of fix this problem of what we of what we require people, despite
on their own before they they fix per hour before they qualify for public benefits and the other piece of this is
there's nothing in here, though. Maybe you know in theory, some more detail. Lang, legislative language could start to address this. There's not a lot in here. Necessarily that would help to
bolster like what are called like non traditional nursing homes, which I think are more of these kind of small group homes that we ve been talking about. Theirs,
a group out there are called greenhouse, it's kind of like a loose collective of now
traditional nursing homes and the day. Look much more like you know, it's more like a
essential house where maybe like ten to twelve people live, they ve got like their own people
bedrooms and then, like kind of some shared living spaces they ve got like
or at least a small nursing.
Staff just dedicated to them, and they have like doctors and
and more specialist come in and visit as needed and to return
the covert issue like there is. There have been some studies that were run in the by the University of North Carolina.
That found that the residents living in those small groups settings war. I think it was
one fifth, as likely to contract covered nineteen in the first place and
times less likely to die from covert nineteenth and somebody was living in a larger institution and so like. You could see that and think, like. Oh my
why are we not investing in this small group home model and,
because right now, like I said before, we have like one point: two million nursing homes,
greenhouse, has I dont have a pulled up in front of you, but they may have a couple thousand residents. So it's like
the meagre meagre meagre percentage
the overall long term care population. So I
necessarily see a ton in here. That is like provide an end. Those those providers will say like we just haven't, made the kind of regulatory
changes, or by programmatic changes or financial investments to to really expect
this model, and you know I think
theory you could imagine how such NEO Congress could take. What's in this this white, she
and try to try to provide more incentives for for those small group settings, but that's that's kind of just a big to be determined with this plan, which again, I think just speaks to the lack of interest in in details and what we ve seen
by the way. How so far, let us take a break, and I want to talk about some big theoretical issues here
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calm, slash, weeds and joined the over one million people who have taken charge of their mental health with the help of an experienced better help professional. So I think you know signal striking about those right that people can sort of disagree like like what is really infrastructure. You know Bob, I think, a lot of it. The discourse around this has that kind of quality
But you can sort of assess certain things to be. A kind of you know like metaphorical infrastructure or extended in,
structure in the sense that they have the characteristic that the up front investment has a long term pay off rain. So, like people might disagree as too, like whether preschool has that character,
stick, but the enthusiasts about preschool believe that it spread. Like that's their case. Sport is that, like every dollar, we invest in educating the youngest
then we'll be returned. She wasn't me not a literal financial return, but that, like the kids, will do, would you better and like them? Have these big long term benefits for the economy, part of which search tricky about this elder care situation? Is it it doesn't have that
characteristic right. The reason why we win
on the show- and I know you wrote about it- for the site: dylan- that study about private equity ownership of nursing homes,
and it's like taking off
the nursing home in making it better does not generate a financial return to the investor like
that's that's why it has that sad outcome rate and the public sector perspective is different, but not all that different readily. If you do a better job of taking care of elderly disabled people they benefit, but linking they don't they don't stop. Being elderly ran like stop needing help right again, it's different from certain aspects of healthcare right, it's like if somebody get sick and you like it,
medicine for them. Then they get better if you fix their broken bone, they get better. But people who are you know in their eighty years and need nursing care like did own recover like even if the facilities really
good. So there's no more like end point at which the investment sort of like stops- or you say we ve- crossed at a cost benefit line. One of the big things about Pombe scare radius, like people, people just like they like it bore the people- would rather have somebody help them, so they can continue staying at home. They be told no you're on the waiting list. You have to go to the nursing home because our Medicaid, what will pay for
and to what they were saying right. It's like if your managing resources from like a state government perspective right. What would you want to say is: ok, how can we find selling the dislike more cost effective, then giving every single person exam
what they want, but like still higher quality experience than everybody is in this, like Medicaid finance.
Institutional setting where private equity barons may take it over and like try to kill everyone to to make a quick but any such a difficult issue, because it's a realm
of fairly sharp cradle of trade like even if the small groups setting is really good, like you just
you're, not going to tell somebody like owner like you're gonna leave your house
and you're gonna live in this other place and you're gonna meet strangers, and that
and be way better right
I mean just like on, you- know, honour on a basic level, there is no government
our to say you have to leave your home or we risk
we're going to stop you from paying a no as elected from from. However, you can finance
this paying for somebody to come to your home, it's just like because
underlying coercion? Isn't there all of the incentive structures in the world?
clearly going to solve the underlying preference, for I want to stay where I lived in. Why there's? U credible path? Tibetans right either
he had started out if Medicaid had never had a nursing home provision and it instead had a sort of entitlement structure.
Home based. Then we would have started with that. Seem the costs, explode and now would be dealing with like the medicate budget crisis.
Wait and what can we do to restructure? The programme to like urge people and institutions or
We do the opposite. If we had never started the home based care like there wouldn't be awaiting last,
because he has not covered by medicated and we'd by be having a policy discussion about. How do you approve the nursing home program, or should we create these innovative community based solutions that may deliver more customers
faction right, but we got into this kind of weird halfway option where dislike patient friendly
I cost option is available, but not on an entitlement basis, because its two weeks,
save so now you know like gadgets. I do more of that. You know like it seems it sounds nice swayed by gets up. The section eight housing programme is is similar. We're like it's great if you get it, but about seventy five percent of eligible people can't get it see. We're just spend more money on it.
But he had some it's always appealingly crude to just be like here's. The thing people like, but they often can't get. It is too expensive, sir, we're to give them more of it,
I got another level it doesn't. It doesn't, like quote, solve anything in terms of like the big dilemmas that afflict this sector right. The premise is just that
you can raise taxes and it's gonna be worth caused right, like we're, helping sympathetic people,
and I do think this is a place where sort of lake ruthless cost efficiency our runs into the humanitarian angle. I guess I do think too,
one? Something that's interesting to your point. Is that cause? I was heartened people it at once. Did somebody had sent me a paper that them just had a line
suck out to me, which was sort of like we don't act,
We know in terms of outcomes how much better at home and community based care is dead, then of an institutional setting. It ain't. No,
we have some measurements of how much more patients might like it. But obviously you know we can't can't depend entirely on, like quality of life, satisfaction to two of that to evaluate a policy,
and there actually are some indications that people who
who stay at home are more likely to end up in the hospital with something, as opposed to somebody who is living in a nursing home, which I think mix some intuitive sense right
the person in their city home is kind of constantly being monitored by medical professionals, whereas you know, if you're, that person who doesn't have a homo fade every day, maybe somebody who's comes by a couple times a week. It's a lot easier for some emergency to slip through the cracks, and you end up in the hospital in that ends up becoming more expensive to all of us, because obviously allow those people all five format of care and medic,
So that's that's coming out of public programmes. I did think
interesting. This is, I don't mean to keep returning to the screen house model, but there was a recent paper and health affairs that showed that that population actually is less likely to end up in the hospital.
Folks who are in a nursing home in a more a larger institutional setting, and so I think, maybe that gets back to
see what I was talking about before of this like this kind of balancing like it is always going to be kind of a very it's a going to be a complex pop,
fashion with a lot of complex needs,
and while it is true that, broadly speaking, people do like to agent home, it's not true for every body and soul.
Can, it seems, like people were true,
to figure out a way to allow people to have the kind of care they want and to feel as if they have some control over their care. While all
being irresponsible responsible, certainly with with public resources, and so it seems like at this point. Like I don't know
anybody really knows kind of what what that balance would would actually look like, and so instead, we kind of keep experiment
and putting of putting our our fee on different lovers to try to figure out what would work best. But you know it's. I dont think I don't know that. I don't know what the kind of like perfect solution to any of this would be given those complexities witches really unsatisfied, but at an end, you're. Never gonna addressed the point that she raised like this is simply a popular
in that year like
Whenever resources we put into it sure, maybe
some marginal savings if people end up in the hospital less or whatever, but you're, not talking about yeah like a pre K programme where you're like preparing people,
a life of of higher earnings and therefore you are paying more taxes in kind of no just building up the public welfare, but you know, isn't
I guess it's also like this
part of living in the society- I guess, like we ve- had these amazing medical breakthroughs that that allow people to live as long as they do now, but we also
figure out a way to let those people live, a life go it's. It doesn't mean much to live longer. If your quality of life is terrible
get out and so, like? I think, that's that's kind of what were membership,
with a clearly we haven't really come out with with quite the right answer. Yet
is there any possibility. You think that lake there could be that the the vagueness of this part of the battle
Who could be an opportunity to you know like it? Does it see
lake, on the one hand and the existing proposal, as at least as we can figure it out from the v way that it's been for that day? It is you know if
three easy, like it's very easy to design PA
seal ever and then, if you look at the broader picture, we run very quick,
into what does it mean to live in a society and how much do you value alive and a lot of things that leg the congressional
All rating process is unlikely to resolve these questions in a satisfactory manner. You have such little face had calmed idea. I apologize to Congress, but do you think
If there is any opportunity to use the euro, will let com
figure it out. I angle that
illustration is taking too maybe figure
a version of a care economy, infrastructure proposal that gets it kind of it.
Media solutions that expand the possibility horizon a little bit more and open up these sort of questions without steering
directly into you know that channels?
I think so I mean Tricia new manner at the Kaiser Family Foundation stays long term care told me, you know this is the beginning of the process there basely, all all the bite administration is really said. His lake there
the amount of money that we are willing to invest in this broad issue, but the specific policy could go a lot of different directions. I mean we do have existing programmes in Medicaid the money for
the person programme, which is just you know, basically fairly YO compensate
people for home base care at the same level that they would be compensated for institutional care. You you could just expand that, but the if you will
to get crazy. She threw up
idea, like maybe
could finally add some kind of long term care benefit in Medicare, which have arguably would make a lot more sense. You know if we ve silo long term care entered the Medicaid programme which, as I said, is, is mean, tested and requires. People too, you know have rarely,
very few assets and income in order to qualify for it.
Maybe we should be thinking about restructuring long term care, so that is provided through Medicare in its more universal. Obviously, that would potentially be very expensive I'm. So I do. I do think that
the policy in a kind of the policy World
ideas about like white. What could potentially can fit in this field,
hundred billion dollar investment and maybe some ways that we could go beyond just propping up
system that has a lot of a lot of problems, structural problems that that are going to be addressed by what the White House, as laid out. So far to your point, I I share your pessimism that both, like you know, anything that would be particularly ambitious would be would be even potentially more expensive than what
the the way houses laying out- and it's always it's always easier to just pump some money into support
that exist? You know we're gonna, keep your gonna incur,
states take to try to
Orton, those home and community based care waiver sway,
Less and, unlike you out, wipe our hands, we did something on long term care and
that great for us. I d always think that that's the more likely outcome than something that's more of a structural reform
it is interesting. You know pitfall here. Right is am before we started. Recording Richard Neil, who chairs has ways and Means Committee, and this is critical to anything happening in Congress ever, but especially this proposal, he wrote a letter calling for child care to be included in infrastructure and jobs package and its aid pitfall of expanding the cut in explaining the concept of infrastructure outside of hard construction projects. Is that
You know from a republican perspective, it's like ha ha ha, that's not really infrastructure. I think from a democratic perspective, it's more like well! This thing is infrastructure like so is this other thing that I happened to care about me
for the rest, I mean if we, if we define infrastructure more broadly, then what you were laying out Matt, which I think is like a decent intermediaries, working definition and the like investment up front results in
down the road like if, by including the care economy, you ve moved
that and just treated infrastructure as investment. That's just another word for government Sunday.
He's so ably very dearly. There isn't necessarily a limiting principle there, but also its eyes
no, a media universe, that is people like like me in and tell Dylan you know like parent,
a little kids are like in the right bracket too. Like do a lot it takes and talk about how good
correct Chairman Neil is about this. How do you like my kid, is like just aging out of like my zone of concern with this particular issue, but I continue to know lots of parents of small talk
is, like obviously has a huge problem for people read and thinking about the kind of like, like Joe Biden like new political coalition, unlike suburban,
man that all that's up like a adjust it? It feels to be like I can see the child cares. Infrastructure bandwagon gaining alive
of enthusiasm to the point where it semi derails this other thing, and I think they may end up wishing that they had just like never
the top and the care economy, because it just like it's a very expensive concept right.
Your answer to like why
care isn't in the package is like by infrastructure we may construction projects
there I do with that. I disagree with that, but, like it's a clear limiting prince,
right so any varies money for school construction in re like construction, part of it and like you could argue that some of that should go to childcare centres or some venture got. It can no longer care facilities if you can do whatever, but it's like once you expand beyond construction projects.
It's like. I, like America, does not have the welfare state of France. The ad
you know it's not even close so like anything like could go in that bucket right and it's like that's it
that's a hard way to get a law through Congress is by telling people that, like you're not addressing their priority, but like you can't give them a clear answer as to why you aren't you just sort of decided not to re. I mean it
The first line of response from the White House to the initial wave of d find infrastructure to broadly attacks, focuses on broadband.
which I think is very interesting, whose broadband is both something that is become the access to
has become much more important in a lot of people's lives and veto
spare ladys that result from unequal access to broadband have become very salient over the last year, but also broadband is something that you can use
construction materials to like bill
right. It is in a certain way built infrastructure, even if it isn't a road or a bridge and the
So it's very interesting to me that in a proposal that defines infrastructure much more broadly than just broadband,
and the White House saying no this. This is definitely infrastructure right here. This thing: do you dig in the ground, though? In it,
he was telling to your point, mad the leg richard I hadn T
Richard meal. It said that, but I didn't know that Anna North had talked to Katy Porter about the child care, the absence of child care and the jobs plan, and that's a pretty broad spectrum inside the House democratic cock. As from right,
obvious progressive in Orange County, and you know somebody
and was seen as pretty moderate. In Massachusetts, and so like, if that is already, you know, those those squeaky wheels or are turning that that I absolutely seems plausible that this could either
I don't know it's a derail. You know, I don't know if it's childcare ends up giving subsumed into the plan, or you know, I'm sure, the for the long term care
looks the fear would be that like I'll write, while fine, like will actually pair this down till I get building things, and that means you're putting all the eggs in whatever you know. The next reconciliation package might be for
some of this cast a flying its top right, because, like the White House, his official position, is it there's gonna, be this third bill right
child care in the third pillar, which, in effect, what happened is it long term care got promoted
bill to the second rate and its,
challenging to find a light. Super principal reason for that which, on one level like doesnt matter, but I think that, like in terms of congressional politics like it actually matters a lot rights instilling one reason Democrats are happy to talk about broadband right is like we just know that Joe Mention is very enthusiastic.
About broadband like he thinks it. That's a good thing to talk about. I have no idea what he thinks about either childcare or long term care, but a lot of this is ultimately get hinge on that because we know from rapporteur. We know from web me all we know from analogue we'd get there just many human beings for whom child care
is a higher priority issue, then long term care for the elderly, I mean there's others or vice versa. Right and ultimately, it comes down to like which members of Congress are like credible, I'm gonna blow this whole thing up over time. Things right
You know, there's gonna, be broadband and write like you're, not that many rural Democrats left, but they are absolutely pivot. All there
a hundred percent willing to walk away from things, because it's good politics for them and they at least Bobby you ve, that, like world broadband spending is good politics for them
whereas the long term care stop, you know it's as yours, angel and right. This is what TED Kennedy like his dying, which was to get this into the affordable care act and it didn't work legates.
It is a lot of money and there was in like the politics to be like tat. We need to just keep shovelling money at this problem
Right- and that is again why you know the motor go back to your point. Dare I like the most likely outcome as yet
do if we get any money, we're just gonna shovel added to stuff that already exists like nobody. No he's trying to set up new long term care programs like that's just that say
that's a Waterloo for any any policymaker lawmaker. State
all right: let's take a break and let's talk about a white paper if the last year has taught us anything, it's that we don't know what will happen next, but there's one thing we can all be sure of the only future is one we can all share and leading the charge and building that fee
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Not a lender terms and programme rules apply. We have today can automatic retention, improve health insurance market outcomes. This is like a super nerdy paper. I think
but one of the authors, Adriana Macintyre, along with marked shepherd admires Wagner, was-
I believe boxes first, in turn way back in the day, so we feel sentimental about agenda just graduated from in turning to the lofty world of research,
but writing absolute? They were looking at the way, the easier worked in Massachusetts and seeing that they tried, which was that, if you don't pay a premium instead of kicking you off your coverage, they would automatically enroll you in a free plan for free. If you were eligible for a free plan- and this made a big difference, it was like fourteen percent
of people like bound up getting insurance. This way, it's like such a small thing. There's no reason, I think for say it's not really to do this. I guess you can save a lot of money, because these are heavily subsidize people, but
RO money right yeah would be now either. I believe the period they studied was like the Prado. A CIA in Massachusetts before the Asia was was actually implemented, began,
in theory. It would just be a matter of of more federal subsidies to cover the costs of people switching into these, these no cost plants. That is the power of DE thoughts, which is like something. I've been learning about a little bit in the welfare state,
and this is like a lot of areas in which we do not
err on the side of enrolling people think they're eligible for you get much less uptake than you
yeah, I mean this- this totally enforced, my prior- that that deep faults are good.
Should be automatic and roman automatic stabilizers automatic retention do at all. As far as I am concerned, I do think this
This was an interesting lesson coming on the heels of war. There was one of the thing that set out to me. Maybe the most about the story was are about the paper. Was they tried to break down kind of like? How much is the people
opting in their premium payments are a result of the actual afforded
quality of the health insurance or the premium, as opposed to you now,
how much of it is literally just people kind of, like forgetting to pay their premiums,
and and they they kind of come down on the side of that. A lot of this is driven by people, the hassle
ass not now, it's not that people find this fine, the health insurance
on affordable they pulled out, were really. I thought provocative example of comparing like looking like a three dollar per month. Plan
how many people ended up defaulting on those premiums in getting switched into a note,
plan and there was a busy huge number was like a quarter of those people move from the three
our plan to the zero dollar plan and, as they say like that, doesn't really
suggests the freed always a month. Broadly speaking, is not gonna be unaffordable. This
seems to be much more a matter of like people, and it seems
Finally, like younger people, may be healthier people to whom,
Insurance is a little less of a priority. Kindly just me,
I guess I just slips their minds: are young people are irresponsible or whatever, and so you know I
that, is a a pretty,
a strong argument that, like you know it's not that that we can keep these people meal enrolled in benefits, I think at a relatively low cost and all I could keep thinking about you know this is not strictly automatic in Rome.
As you like, taking an uninsured person, enrolling eminent healthcare plan but
was just some new federal data that came out last week that showed that like
seven million people already currently right now qualify for free
health insurance under the Asia and to your point, Matt Lake.
The matter of we're not able to reach those people are. We haven't, figured out a way to sign them up, and you know
It does seem like this is, should be like a really ripe area for policy making another all kinds of ASP.
Nations, in the early days of the Asia, about these new,
changes these do marketplaces that they were setting up, but I remember covering the one in Rhode Island as they were due.
Some of their exchange planning and they had all the
ambitions about. Like you know, maybe we can set up like a one stop shop like one portal where, if somebody you know, goes too
who, in role for food stamps or some other kind of public assistance, we're not
gonna roll them in that programme, if they M, although we certainly will, if they qualify Borg and unlike check for all the other public benefits that they might qualify for, and I think that in our states found that pretty hard to do practically speaking, it's hard to integrate all these different programmes and in ituri systems too
unity with one each other, but it just seems like the lowest possible Lang hanging fruit that either we can. You now move people who too far
payments into a no cost plan and keep them ensured that we could enroll people who already qualify for benefits into those benefits,
This is not a matter of, although certainly would end up costing more money. This is not a matter of you know: expanding the welfare state really
meaningful way. This is a matter of providing people with with benefits that they already qualify for, and I think that this disorder retention policy was
a very clearly a very simple and a very effective way of doing it, and so you know you would hope that that policy makers might take the lesson that, like sought, that hard to keep people kind up tethered to the system and make sure they keep receiving the benefits that they are.
Eddie entitled to. I want a drill down a little bit on what you ve, no mention kind of in passing. Their diligence was the nature of the people who were auto switched en masse under this policy, because the authors of the paper find that they were, you know
that they were exactly the sort of people who general.
Lee are less likely to want to seek out health insurance because they are less at risk right. Their younger there are less likely to have
chronic illness. They have lower medical risks, scores, they are spending less money even before they switch and there certainly not spending a ton of money in these euro costs plans after they switch and that kind of steers right
into the fundamental normative question that was posed in there
no years during and after the passage of the Asia about what this does the yacht.
Many of you know young healthy people who might for principled reasons not want to pay money.
Ought and health insurance there. You know they mate. They might reasonably assessed that there
risk is not enough that this is something they need to do it, but it steers right past it right because there
not in fact paying money there and rolling in zero cost programmes? And so, if you, if you can take the anti mandate argument to its logical conclusion, there is not a clear argument for the idea of pulling risk in insurance at all, because if people, if the lowest risk people
are opting out. Then you have the kind of death spiral scenario that so many
Economists have warned about. You have the changed character of the zero cost pool with this infusion of younger healthier people into it, who art spending a ton of money on health costs, but you also don't
The idea that these people are themselves directly subsidizing, the older and sicker, which kind of cuts that gordian
Not in a way I mean it. Doesn't it doesn't get at the kind of fundamental questions of Should government be paying for, but it certainly does take away the argument of. Isn't it hurting these people direct
Lee by forcing them to pay money into an insurance market place at a rate that is going to help them less than it helps older sicker people,
yeah I mean it does seem a we obviously bids beyond the scope of this paper, the kind of do all the calculations and figure out like our, I ultimately by subsidizing these younger people at no cost plans did we kind of make health insurance cheaper. On the whole,
bye, bye, balancing out the with risk pool, but it does seem like a potentially.
Way and easy way in kind of non confrontational way. To your point, Dara too, to combat adverse selection and also you now provide again provide people yoke as people get sick, people get hurt.
No they don't care, salient submit that providing people
at some level of benefits. Obviously you know usually these. These no cost plans are
A bit skimpy are they have higher deductibles, higher cost, sharing, etc, but for a younger and healthier person that might not be that big a deal because, as you say there not really use,
much health care, and so, if you can provide them, those benefits you know,
provide more federal funding to to the health insurers to help strengthen their risk. Poor
seems like a pretty, as you say, a pretty color neat way to cannot absolve that that dilemma I would be
there is. I don't really have any idea. It's proudly something I did it to do some reporting on, but I would be really curious to know whether this was something
that the Asia, architects ever thought of adopting or
either. You know, as were now finally kind of finally a stage of looking for ways to enhance and improve the Asia, whether the sea,
potentially like a pretty promising model for how you might
avoid. A lot of churn in the health insurance market keep its pretty stable these days, but you know it can only help to keep more younger and healthier people in the pool
also Adriana, if you're listening. If you guys want to do a follow up paper on how it has changed the nature of the risk fool, you clearly have a ready made audience that will be back
I wanted to. I wanted to talk a little bit more about the the idea of cross enrollment that the Dylan sort of measured before, because I was recently learned about the sort of uptake
aids of a lot of means. Tessa social systems are really low about eighty four percent of snap eligible people around snap, but only about fifty one percent of am W. I see you know eligible people or on the programme or India come tax. Credit has about a seventy eight percent participation rate so like, if Democrats at least, are looking for ways to sort of further
expand and bolster the welfare state that dont require, like at nine trillion. Dollar, reconciliation bell right, like eight to try to fight to get a little provision
into a bipartisan and you all get out appropriations bill or something creating like a small office in the federal government that, like when somebody registers for snap they go. They take their application. Information and check if they are also eligible for Wick, like would be high level edge in terms of getting more money into people's pockets.
But you would have to like go go! Do the work of this a lot I mean this is beyond the scope of this episode, but I mean there's a lot of questions about how much the new child ex credit like how many people were and are actually getting
money if it'll be as high as the IPCC. Seventy eight percent, but it probably won't be like dramatically higher than that, because you know it's the same thing, it's tax credit and you got a sort of wrangling with with with your tracks
errors and eat. Some, I don't know it just like a bit of an underrated issue when you can see,
each year there was a kind of some talk about this and then nothing ever really. God
Done, and we continue to see a programme where the default matter like an incredible amount but they're just like mostly not that forceful with like what happens you I signed up for Obamacare and it it something bad sign up website or anything like that. But as I can
like a professional policy journalist so like, I knew once I no longer had an player base. Adjourns like I gotta, go to the thing and fell myself out and get the open world
deadline, and even though its in some- I guess it's not mandatory anymore, but like the juicy government, like, I think, like their run by liberal people like they want you to be on it. But they're not like here. You go newly self employed person like check this box and we'll get you your health insurance. It's very much like well, if you really want it,
I guess you could come out here and and that's not disrupt the intention of any of these programmes. I think, like the authors of the general tab, you I see. Legislation like want low income pregnant women to get the benefits.
Like half of them, don't give. No, it seems to me a pretty dramatic failing of the American Well first day I mean, I think, about all this through health insurance. Obviously
there was a new some New Keyser Family Foundation. Estimates came out in the last couple weeks. It showed that more than half of on it
the people in the? U S qualify for some kind of public assistance, whether that is Medicaid or
subsidies through the Asia by private insurance insurance. That many of the rest of the people of this isn't Dar as well,
although some of them, I don't qualify for it,
thing, because of their citizenship status, there's some people who are left in the medicate expansion gap,
but, like you know, that's that's potentially like ten million people
I told you more, like fifteen million people who already qualify for something
and obviously like there's a reason they haven't been involved. You know they may be more
transient are they just don't have. A lot of connections are clearly too to our public welfare infrastructure
sure, but, as your sang Matt like it seems like that, would be such a an efficient way to get people more benefits. If we could, if we could think
some kind of system, that's kind of like cross checking for people
not you see, I don't assigned somebody up for Wick figure out everything that they qualify for, because you know this
with these kind of folks, India, that one kind
you know when they sign up for snap or wicker, whatever that might be kind of here. That's your opening to try to get them. These other benefits too, because clearly the one
Our struggles here, as is just reaching them in and kind of informing
and giving them an opportunity to unroll and its benefits. The flip side for the people who doing wrong and multiple benefits is no reason for the government to be repeatedly verifying,
you write ability you right now. It's like only one thing, as this person shows up, they assert that they have the following income and work history, and so, like you check, if that's true once instead of currently, if you do,
It correctly rightly give your on age you see, and food stamps on all these other things. It's like the government is constantly re, verify that these facts about you true and this so that the same person ours could be reallocated to getting everybody all the help that they need. Instead of repeating the work that other aspects of the bureaucracy wearing
idea. That seems to me crucial, if you're trying to solve this problem, because, like people, if it is true that people have idiosyncratic notions of a lake,
What counts as government assistance, and, do you know, videos
had expenses of what is stigmatized and what is morally unworthy,
senses of what their level of you no privacy
we're exposure. Risk is when it comes to different arms of government, and so, if your requiring
buddy to initiate interactions with a bunch of different
and entities. You are, by definition, proliferating the number of occasions where they can go. Actually, this seems too risky like oh, I don't want to give them. My information
You are also a kind of just encouraging this misunderstanding of how government works and the eight end and encouraging the idea that there is something totally different about qualifying, for wit versus snap. So if you want to you
fire on the back end, you eliminate the kind of friction problem of these idiosyncratic senses of what counts, as welfare and doesn't.
As a rap thanks. So much Dylan Ethics, as always to our sponsors to producer, acknowledges and reads, will be back on Friday.
Transcript generated on 2021-04-28.