S-5270-119
Read twice and referred to the Committee on Finance.
Sponsored by Andy Kim (D-NJ)
What it does
This bill would create a new Medicare Part B benefit covering personal home care services for eligible beneficiaries. Covered services would include help with activities of daily living (bathing, dressing, toileting, transferring, and eating) and instrumental activities of daily living (meal preparation, medication reminders, and light housekeeping). Eligibility would require a physician-certified need for assistance with at least two such activities, and the benefit would be capped at 20 hours per week. The cost would be financed through an adjusted Part B premium, with the exact premium impact to be determined by a CMS actuarial report within 180 days of enactment.
Who benefits
The approximately 10 million Medicare beneficiaries who currently need help with activities of daily living and lack coverage for it. Older adults and people with disabilities who want to remain in their homes rather than move to institutional care. Unpaid family caregivers — estimated to provide over $1 trillion in informal care annually — who would receive relief from caregiving burdens. Home care workers, who would benefit from a wage floor built into the payment methodology. Home care agencies that would gain a large new pool of Medicare-covered clients. Hospitals and the broader health system, to the extent the benefit reduces avoidable hospitalizations linked to unmet care needs.
Who is hurt
All Medicare Part B enrollees — including those who do not use home care — would pay higher monthly premiums to finance the new benefit. Medicaid programs and state budgets could see indirect effects if the benefit reduces "spend-down" enrollment, though the bill excludes individuals already receiving duplicative Medicaid long-term services. Private pay home care agencies and workers operating outside the Medicare enrollment system may face competitive displacement. Taxpayers broadly, through the federal subsidy that offsets Part B premiums for lower-income enrollees. Nursing homes and assisted living facilities could see reduced demand if more beneficiaries age in place.
Supporters argue
Supporters argue that Medicare's failure to cover personal home care is a structural gap that forces millions of older adults and people with disabilities into a painful choice: pay more than $60,000 per year out of pocket, deplete their assets to qualify for Medicaid, or go without needed care. They contend that covering home care is both more humane and potentially more cost-effective than the alternative — avoidable hospitalizations and premature institutionalization — and point to polling showing 93% of Americans believe Medicare should cover these services. They further argue the 20-hour weekly cap and physician certification requirement create a fiscally bounded, clinically grounded benefit rather than an open-ended entitlement.
Opponents argue
Opponents argue that adding a major new benefit without a dedicated funding source beyond premium adjustments places an unsustainable burden on Medicare's already-strained finances, and that the actuarial cost of covering 10 million or more beneficiaries could drive premium increases that harm lower-income seniors on fixed incomes. They contend that the 20-hour cap and eligibility criteria may prove difficult to enforce consistently, creating pressure for future expansions that compound the fiscal risk. They also argue that home care workforce shortages — already severe in many regions — mean demand could far outpace supply, resulting in coverage that exists on paper but is inaccessible in practice.
Constitutional context
Congress has broad authority to establish and modify Medicare under the Taxing and Spending Clause (Art. I, §8, cl. 1), and the Supreme Court in NFIB v. Sebelius (2012) affirmed wide congressional latitude to structure benefit programs funded through taxes and premiums. No significant constitutional challenge is apparent on the face of this bill, as it expands an existing voluntary program rather than compelling participation or imposing conditions on states. Post-Loper Bright (2024), however, the broad regulatory delegation to HHS — including setting worker qualification standards, agency enrollment rules, and a wage floor — would face independent judicial scrutiny rather than automatic deference if challenged.
Checks and balances
Congress gains authority by creating the new benefit and setting its parameters; HHS and CMS gain significant rulemaking power to define worker qualifications, payment methodology, and the wage floor, subject to post-Loper Bright independent judicial review of any regulatory interpretations.
Historical precedent
Medicaid's Home and Community-Based Services (HCBS) waivers have funded similar personal care services for low-income individuals since the 1980s, but no prior federal law has established a universal home care benefit under Medicare for all eligible beneficiaries.