Human Infrastructure Needed for an Aging America

Both presidential candidates have called for infrastructure investments. The general idea is that this will create jobs while making America both more competitive in business and an overall better place to live. The call for infrastructure spending also fits with the drumbeat of some economists and central bankers that believe such "fiscal" policies are needed to generate more jobs and economic growth. In light of these political priorities, it appears we may see substantial infrastructure initiatives being launched from Washington in 2017.

Disclosure: I am not an economist! But, as a physician and health care executive I must point out that at the same time we're considering traditional infrastructure enhancements like roads, airports and bridges we are hitting the critical zone for planning and preparing for an aging America. While the number of Americans in their eighties and older is growing rapidly, we are also seeing a decline in the relative number of younger people to care for them. While good medicine and good behavior can help extend and improve people's lives, we still haven't found the Fountain of Youth. Our growing group of older Americans will need planning and assistance to age in the comfort of their homes with independence and dignity. Preparation will also be needed for our country to avoid unnecessarily straining the Medicare and Medicaid system with billions of dollars of potentially avoidable hospital and nursing facility expenses. The key to our success will be strong family caregivers and high quality, affordable home and community care. And, the keys to value-creating home care are well-trained people working on well managed and supported teams.

From a jobs creation standpoint, home and community care has some great qualities too: 1) most of the money spent goes to people rather than facilities, materials or technology, 2) there are a wide range of job types and possibilities for advancement, 3) the workers are disproportionately women and minorities. Investing in the human infrastructure for an aging America will improve the quality of life of our elders and help us to truly honor our fathers and mothers. If done right, it will help family caregivers and create jobs and careers in home care in a business friendly fashion. Here are 10 ideas to consider including in an infrastructure bill:

1) Allow individuals and family caregivers tax free withdrawals from tax deferred retirement accounts for expenses for home care aides and nurses, care managers, and for basic home modifications that make homes safer and more livable for older people.

2) Create special individual and family caregiver dependent savings accounts for home care needs (similar to 529 plans for college savings and Health Savings Accounts).

3) Suspend payroll taxes and expand tax credits for special categories of home care workers and their employers such as older workers, rural workers, workers in high poverty urban areas, veterans and certain minorities. The goal should be both higher take home pay for the workers and lower costs to employers and purchasers. Policies that only seek to increase wages (such as minimum wage hikes and eliminating the companionship exception) without other mechanisms to lower consumer and small business home care costs should be avoided because they will reduce access to care and reduce the number of legitimate jobs.

4) Award a broad range of home care, geriatrics, and gerontology training and education grants to colleges and universities, private healthcare service delivery organizations, and private businesses and non-profit organizations. Support entry level and early career training as well as physician education, management training and leadership development. Both traditional programs as well as innovation and demonstration concepts should be supported.

5) Create student loan repayment & forgiveness programs for all levels of professionals working in home care, aging services, geriatrics, and gerontology; include physicians, nurses, social workers, physical therapists, and certain administrative professionals.

6) Add flexibility to the Medicare home health program to allow more career opportunities for nurse practitioners and physician assistants to order and oversee home health care.

7) Add flexibility to the Medicare home health program to allow more of a role for home health aides in teaming up with nurses to deliver home care beyond just basic tasks like bathing and personal care.

8) Update the Medicare home health program to better support "hospital at home" and "emergency department to home" concepts.

Expand the Medicare Independence at Home Program nationally with broader eligibility criteria and grants or stipends to cover start-up costs and practice transformation costs. All older Americans that need high quality home visiting medical care should be able to receive it.

10) Provide Medicare payment bonuses, tax credits, and other incentives for home care and aging services entities of all types that adopt electronic information systems that improve care coordination, quality, and consumer experience.

Creating a healthy marketplace that allows the vast majority of older Americans to age in the comfort of their own homes with dignity and independence should be a top priority. Marrying these investments in human infrastructure with sound vetting and waste prevention mechanisms, and aligning them with Medicare and Medicaid value-based payment changes could go a long way to responsibly achieving this goal. The roads and bridges for successful aging at home are generally caring and talented people and teams with supportive policies and technology--investments in these people and teams should be prioritized in our near term infrastructure building efforts.