Can Harris’s proposed ‘at-home Medicare’ end the dreaded ‘spend down’ of senior assets?

A new proposal for “at home Medicare” by the Democratic presidential candidate, Kamala Harris , could help ease the burden of the cost of elder care for many families, experts say.

However, Republicans have already criticized the proposal as too expensive, a reminder of the political difficulties of enacting healthcare expansions in the US.

Paying for a home health aide out of pocket is far out of reach for most families. The median cost of a home health aide, someone who helps elderly people and disabled with basic tasks such as cooking and bathing, is $33 an hour or $6,292 a month, according to the financial company Genworth . The average retirement income of an American is $4,191. Nearly 6 million Americans older than 65 live on less than $1,170 a month .

That means many families rely on Medicaid, the public health insurance for low-income people and families, which often requires a painful “spend down” of a senior’s resources to below the federal poverty level.

Related: Politicians’ proposals would only minimally lower US drug prices, says report

“There’s a misunderstanding about what Medicare will cover today,” said Amber Christ, managing director of health advocacy at Justice in Aging. “People don’t want to think about” the particulars of growing old, she said, adding that the programs covering elder care “are terribly complicated healthcare programs”.

Often, Medicaid steps into the void. The public health insurance program for low-income Americans covers more than half (61%) of all long-term support services nationally, according to the Kaiser Family Foundation (KFF). However, because the program has strict income limits, seniors in some states are forced to “spend down” their money to destitution levels to qualify.

To use the eligibility criteria of one swing state as an example, seniors and disabled people in Pennsylvania can qualify for Medicaid’s at-home long-term care benefit if they are “medically needy”.

To be medically needy, a person must earn an income of no more than $425 a month for expenses beyond healthcare – including housing, food, utilities, transportation and clothing. An individual can have other assets of no more than $2,400.

“Either you’re going to go into a nursing facility or you’re going to forgo care, or alternatively people are providing that care without pay,” said Christ. “That’s why our system is driving people into institutions, and worse health outcomes and impoverishing entire generations of people.”

Even with the spend down, roughly 700,000 people are now on waiting lists for home health care, the KFF reports.

Harris’s pitch is meant to be especially salient to the one-quarter of Americans – especially women – “sandwiched” between an aging parent, a child under 18 or an adult child whom they have helped financially in the last year, according to the Pew Research Center .

Bertha Motta, 64, remembers when she was a member of the “sandwich generation” – caring for aging parents and young children all in one New York City home in the late 1990s.

Without help, Motta worked less to accommodate caregiving – entertaining, cooking and cleaning for little ones and elderly loved ones. Her work as a home health aide in 1199 SEIU was limited.

“In those years, I can’t go to work from Monday to Friday,” said Motta, originally from Peru. “I worked weekends, so I stayed home taking care of my parents and my children at the same time.”

Even though Motta’s parents required her care, they were relatively independent, she said. In her work as a professional caregiver, she has seen far greater indignities. She recalls a disabled and immobilized woman she was forced to leave after only six hours of daily care.

“Six hours was not enough for her, believe me,” said Motta.

Each day, the woman would be left in bed with diapers.

“Imagine how we find her, because she needs to go to the bathroom, but she can’t move – she just had to [stay] there in her bed with the diapers,” said Motta.

Medicare covers many disabled people and nearly all Americans older than 65. Harris’s campaign said the program would help Americans pay for health aides like Motta, to assist with daily tasks such as cooking, eating and bathing, who can otherwise live independently in their homes. Harris’s campaign has proposed a sliding scale cost for families. Because Medicare does not have income limits, it could ease the burden of the spend down.

“We’re talking about declining skills” of older people, said Harris, announcing her plan on ABC’s The View talkshow – “but their dignity, their pride, has not declined”, she added.

Her campaign has said seniors would be independently evaluated by doctors for eligibility and that most program participants would need only about 20 hours of care a week.

An independent report by the KFF estimates that 14.7 million people would probably qualify. The Brookings Institute has estimated the cost at roughly $40bn a year , which the Harris campaign said would be paid for by expanded drug price negotiations in Medicare. Republicans have criticized this as too expensive.

“It is difficult to overstate the irresponsibility, corruption and insanity of this proposal,” wrote Michael F Cannon, the head of health policy studies of the libertarian thinktank Cato Institute, in a blog post soon after Harris announced the proposal. He criticized the proposal for adding to the federal deficit.

A recent report by the nonpartisan Committee for a Responsible Federal Budget found that Harris’s campaign proposals would add $3.5tn to the federal deficit, whereas proposals by former president Trump would add $7.5tn. Trump has also advanced the idea of “at-home senior care” , but has offered fewer specifics.

Harris’s proposal would also eliminate a worst-case scenario for families: a government policy called “estate recovery”. In some situations, an elderly person can qualify for Medicaid benefits while excluding assets such as a primary residence, often the family home.

But after death, the federal government can require states to review assets and attempt to recover the cost of care from families. A bill for tens and even hundreds of thousands of dollars could arrive unexpectedly in the mail, and often soon after a loved one’s death. Democratic representative Jan Schakowsky of Illinois has campaigned against the practice for years.

“Let me just say, beginning with the Medicaid estate recovery, people that I tell about that – including colleagues of mine, members of Congress – are shocked to find out that Medicaid right now is the only program that actually requires states to go after money if someone dies,” said Schakowsky. One of Schakowsky’s constituents is now fighting an estate recovery of roughly $77,000.

State governments are “going to go after the only real asset many people have, which is their home”, said Schakowsky. “It’s just incredible.”

If passed, Harris’s pitch would be the first major expansion of health benefits since Obama’s Affordable Care Act. Harris has also proposed expanding vision and hearing benefits through Medicare, a wildly popular proposal .

Motta is hopeful clients, their loved ones and workers like herself could benefit from the “Medicare at home” proposal.

“I feel so happy because I was thinking that happened to me,” she said. “It should be amazing, really amazing, not only for them,” her clients, “but also for us, the home care workers.”

• This article was amended on 21 October 2024. A previous version stated that Cato Institute was conservative when it is libertarian.