CareTalk Podcast – What’s Sexy about Infrastructure Healthcare?

Why does the US infrastructure plan include a $400 billion provision to expand home healthcare? John and David dissect the infrastructure plan and speculate on how it will impact US healthcare as a whole.

David Williams:

John, since when does infrastructure mean shoveling $400 billion into home healthcare?

John Driscoll:

David, hundreds of thousands of people are waiting for care to the home. Let me explain.

David Williams:

Can’t wait to hear.

David Williams:

Welcome to Care Talk, your American made home for incisive debate about healthcare business and policy. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix.

David Williams:

Well, John, we’re talking infrastructure today for some reason. Now my question is I thought infrastructure was all about roads and bridges. What the heck does that have to do with healthcare?

John Driscoll:

Oh, you have narrow thinking. Infrastructure is the capability we have as a country to prevail and succeed in the future. It’s a much broader concept than those simple minded notions from the 60s of the bridges and tunnel crowd. If you really want to invest in America, you’ve got to think about people, you’ve got to think about our capabilities for research and development. You have to think about home care, David. It’s all about care to the home. Remember, we’re CareCentrix focused. It’s not just about bridges and tunnels.

David Williams:

John, I know we’re going to get right to talking about care in the home because that’s actually a lot of what this infrastructure thing is about. Now, the official name of it is the American Jobs Plan, and I do think it’s kind of a euphemism.

John Driscoll:

What?

David Williams:

Yeah, AJP. People are happier to hear about infrastructure because it kind of sounds big and manly as compared to helping a poor person. That’s for wimps.

John Driscoll:

Well, I think that the interesting thing about this infrastructure bill is it’s cleverly called jobs because if we push a couple of trillion bucks through the system, you’d hope a few more people would be employed. And I think the Biden approach is to win over the public and then try to pull the legislators with him.

John Driscoll:

But really this broader concept of infrastructure, of investing in social infrastructure, investing in research, of thinking about the backbone of the country as being people as well as things that people use, is quite, quite powerful. For example, the healthcare piece of it, not just the $19 billion that’s involved with VA hospitals, but the 400 billion, can you count it, David, for home health and care to the home in general, is an investment in improving health care in an aging America.

David Williams:

It makes good sense. It’s actually quite a bold plan. The White House compares it, I think correctly, with something on the scale of the interstate highway system or the space race. But they explicitly say this time it’s also addressing racial injustice. This is a bold move.

David Williams:

As you say, home care is not just some little thing that’s buried into it. It’s actually 400 billion. Now that we have started talking in trillions, it’s 0.4 trillion, I guess, in home care. And it’s very telling that they would call it infrastructure and then focus on care in the home.

David Williams:

I think that the healthcare system here actually has plenty of physical infrastructure. A lot of hospitals, you even had with a High Tech Act back when Obama was coming into office to bring in electronic medical records, no, this is very much focused on people and being at home and being really close to where the action is and really building on this idea of essential workers, meaning home care workers in this case, that they should have a living wage.

John Driscoll:

Well, I think there’s a bunch of things here. First of all, that paying people a fair wage. I mean, the average wage of a home care worker I think is like $17,100. Many of them are paid well under 15, and there’s only two or three cities in America where you can afford to live on anything less than $15 an hour. So to bring people up to a fairer wage, well above that 17,100 would be really important.

John Driscoll:

The other thing about the reason why racial injustice is relevant is a disproportionate number of those essential workers, from unskilled through skilled labor going to the home, nurses, PAs, techs, social workers, they are disproportionately from poor communities and people of color that have been particularly hard hit by COVID.

John Driscoll:

But this is a very big problem, David. We have, I think, 800,000 elderly people who are vulnerable and sick who are qualified for long-term care services in the home who are stuck on a waiting list. This, we could clear the waiting list, pay people fairly and actually start to, in an aging America, build an infrastructure that’s resilient and caring and put the care back into longterm care.

David Williams:

John, you talk about hundreds of thousands, I think 800,000 people on the waiting list. You talk about other countries having waiting lists, so-called, and we have a big one right here. So this goes right at that. It was a campaign promise of President Biden to go after that.

David Williams:

There’s always these weird things with government programs, and I heard this one, maybe you can explain it to me. There’s this concept of a program called money follows the person. I keep looking over the back of my shoulder to see, I don’t see any money following me. What the heck is that?

John Driscoll:

Oh, it probably is, David. It’s just it’s probably crypto and it’s very [inaudible 00:05:26]. No, but seriously David, the money follows the person or the patient is really powerful. We overspend systematically to keep people into nursing homes, long-term care facilities and hospitals, and we under spend, invest, in support the infrastructure and care to the home, whether it’s aging in place, caring for those who suffer from dementia. You’re talking about we systematically spend, let’s say anywhere between three and 10 times as much to keep people in institutions as it would cost for us to carry them in the community.

John Driscoll:

So money follows the person means simply that, for example, for states like Illinois and New Mexico, where they have equalized the payment of care to the home and nursing homes, they’ve been able to keep the nursing home beds flat while the population of people who would be otherwise nursing home qualified has gone up by a factor of 3X because they’ve invested in that infrastructure in the community because the money follows the person or the patient. Let’s be serious if we can get care to the home right, you’re actually allowing people to age and heal in a more dignified way than even the best hospitals and nursing homes can promise.

David Williams:

John, did you write this bill?

John Driscoll:

No, it’s too long and spends too much money. But look at it, David. The healthcare piece is huge, but there are indirect healthcare pieces like research and development, which had huge spillover effects, like the rapid development of the vaccine. Or direct healthcare things that are not considered healthcare spending, modernizing our water infrastructure so that we take more lead out of the pipes and we start to equalize access to fresh water. I mean, there’s a lot in here thinking about the future of our transportation. Let’s not completely ignore the transportation infrastructure. It’s extraordinarily bold.

David Williams:

It is interesting, John. On the one hand, certainly there are many things in here that you could say, “Well, it’s just a wishlist of things,” but it kind of holds together and has a comprehensive approach to it that reminds me in some ways of the Affordable Care Act, which was… You could throw stones at it, but it actually did represent a comprehensive view of how to think about a system.

David Williams:

We talk a lot about social determinants of health here on the show, and there’s a lot of things within this bill that would address that. You mentioned that getting rid of lead pipes, that seems like a good idea. That’s certainly going to help health. There’s also a focus on climate change. It’s not a climate change bill, but some of this R&D is for climate.

David Williams:

I think half of the research infrastructure building is directed at the historically Black colleges and universities. There’s money for public housing, money to build schools and so on. And some explicit targeting, as I said, for people that have previously been harmed. And even undoing some of what had occurred before, like when the interstate highways came in and went right through the middle of minority neighborhoods, there’s actually funds to go and undo that.

John Driscoll:

What do you think the theme is here, David? I mean, because it is a long list of innovative ideas, big and bold innovative investments. What do you think the theme is?

David Williams:

It could be called, John, social determinants of infrastructure. There is money for bridges and stuff, but the bridge is held up by the fact of the trusses and so on. But it’s also held up by the fact that you’ve got people who are healthy and educated and earning a decent wage in order to put it together and to drive over it.

John Driscoll:

See, I see it as almost a fixed grow in support bill. Everyone knows, I think we’re now down to somewhere between 11 and 17th in the industrialized world in terms of our broken infrastructure. And we’ve got to fix that, without a question. I think that there’s a support piece here, which is about schools and colleges, and healthcare and home care and care to the home.

John Driscoll:

And then there’s a growth piece of it. I mean, this massive investment in workforce development, in research and development, in colleges, particularly focusing on the historically Black colleges and universities. I think that by calling it infrastructure, they’ve probably smartly figured out how to position it to get popular support. But I think that there’s more to it. This is a foundational investment in government starting to expand its support to fix, grow and support the country.

David Williams:

John, here’s the thing. We seem to be agreeing with one another too much. You’re almost putting me to sleep by reciting all my ideas, which is fine. But the last president talked about infrastructure too. He even had a whole infrastructure week. How come he’s not getting credit?

John Driscoll:

Well, weak it was. At the end of the day, he neither had a bill that made any sense, nor did he even propose any bipartisan support. Even though the Republicans are uniformly dumping on this plan, I think just in the last week you had Senator Capito from West Virginia saying that she’d gotten a bridge taken care of. Mitch McConnell was quoted as saying he’d gotten a bridge in it. I think Roger Wicker, who is the co-chair of the Republican Senator from Mississippi, said that he and Pete Buttigieg could agree just fine on an infrastructure bill. Certainly on the physical infrastructure parts of it, there’s a lot of interest from a partisan perspective to support it, and it shows that this White House is working a lot harder to bring more of the senators along from both sides of the aisle.

John Driscoll:

So David, what’s not to like in this bill?

David Williams:

Well, John, the thing is, of course it raises taxes, right? Or does it because what Biden said is he wasn’t going to raise taxes on anybody that makes less than $400,000 a year. But if you look at this proposal, it actually does not include any increases for individual income taxes. It’s all about raising the corporate income tax. Or he doesn’t say raising, and he says setting it at 28%. This has gone along with some reporting that says, “Hey, did you know that 91 out of the top 500 companies don’t pay any federal tax and that most pay about 8%?” so it’s interesting that the Republicans actually haven’t gone and bashed it for raising taxes.

David Williams:

And also, you’d think if-

John Driscoll:

Oh, they have. You’re just not paying attention.

David Williams:

All right. But you know what? The stock market’s gone up, even though presumably corporations would be worth less if their taxes were going up. I think Biden’s been very clever about it.

David Williams:

I also think that what you just described in terms of a bridge here and a bridge there, this is an introduction, they could call it the American jobs, healthcare, home care infrastructure, and earmarks act, too.

John Driscoll:

Well. The earmarks, that way that congressional people can actually pick and choose projects in their own districts and states to get supported, which was outlawed by the same Congress, is coming back. But I think when you look at the tax, I think, again, the positioning of this is really shrewd. The corporate income tax went from, I think 28% roughly, to 21% under Trump. And there’s no appreciable gain that we got as a country or an economy from that, at least nothing that anyone can point to. I think most voters agree that corporations and wealthy people should be paying their fair share.

John Driscoll:

And to your point, when 91 of the top 500 companies pay zero in federal tax, when a lot of these internet giants like Amazon are massive tax avoiders, I think Americans are ready to see everyone invest in infrastructure that everyone’s going to gain from.

David Williams:

All right, John. So what do you think the chances are that it’s going to pass? I mean, they’d have to use the reconciliation process presumably, but maybe they can pull it off.

John Driscoll:

Well, the interesting thing is we are really spending a trillion dollars here, a trillion dollars there. Sooner or later, it’s going to add up to real money.

David Williams:

Well, not yet.

John Driscoll:

I think on physical infrastructure, you’re seeing even Roy Blunt, who’s the Senator who’s the number two Republican on the Senate side, didn’t say no to infrastructure. He said, “Let’s take it from 2 trillion to a little over 600 billion.” And when you’re arguing between 600 billion and 2 trillion, I think the White House has already won.

David Williams:

Yeah, nice. All right, John. Well, we always win. Let’s call it a win now. Let’s not even go into overtime. That’s it for another edition of Care Talk. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix. Thanks for listening. If you liked what you heard or you didn’t, please give us feedback and subscribe.