The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
Andrea Jones hadn’t yet settled on a date to retire from her customer service job at United Airlines when Newark airport started looking like a ghost town in March 2020. After 28 years with the carrier, she still loved her work. But by the end of that month, she had hung up her blue uniform for the last time. She is still struggling with a sense of loss.
“I wasn’t at all ready to leave,” she said. “It hit me right between the eyes.”
Ms. Jones, 68, of East Windsor, N.J., retired to protect the health of her husband, George, who has multiple myeloma, a form of cancer. Fortunately, the Joneses had a nest egg, and United offered a retirement package that enabled her to keep their health insurance.
Patricia Scott has not been so lucky. Ms. Scott, a special-education teacher in Stockton, Calif., retired in January to preserve her own health. A grandmother of 10, she survived breast cancer in 2016; her oncologist told her she couldn’t risk catching Covid-19 by returning to the classroom. Now, at age 66, she is on financial quicksand. “My income is half what it was,” she said. She is single and in debt. “I’m stressed, I’m depressed and I’m terrified.”
For many of the nearly three million workers ages 55 to 70 who have left their jobs since March 2020, retiring during the pandemic has inflicted two traumas. Like Ms. Jones and Ms. Scott, most felt they were forced out of work before they wanted to go, said Teresa Ghilarducci, a professor of economics and policy analysis at the New School for Social Research. Among that subset, the majority, like Ms. Scott, were financially unprepared, Ms. Ghilarducci said.
research from the New School, far more older workers retired during the pandemic than during other recessions. After the 2008 financial crisis, for example, 1.9 million older workers left the labor force in the first three months of the recession. In the first three months of the pandemic last year, 2.9 million left the work force. The latest data shows that 1.7 million of the newer wave of retirees left despite financial uncertainty, Ms. Ghilarducci said.
Their departures generally were not a bid for a few extra years of bird-watching. “A lot of people were pushed out of their jobs,” Ms. Ghilarducci said; she attributed that push partly to age discrimination. “It used to be that employers would let the ones they just hired go first in a recession, but this time older people who have been in their jobs the longest have been hit hardest.”
Lack of enforcement of anti-discrimination laws was a factor, she said. So was what some employers saw as a rare opportunity created by the pandemic to get rid of older workers, who are perceived to be less productive and more expensive.
Regardless of the reason, the new army of reluctant retirees, disproportionately made up of Black workers and those who lack a college degree, according to June data from the New School, is in trouble. One key reason: Debt rates among Americans 65 and older are the highest they’ve ever been, Ms. Ghilarducci said. And they are likely to rise as more people are forced to draw down their assets to make ends meet. Collecting Social Security earlier than anticipated will add to their vulnerability, since claiming earlier will permanently reduce their benefits.
Even for people with a financial safety net, the hurdles can be significant. “There’s a lot of stress that comes with having retirement forced on you,” said Malcolm Ethridge, a financial adviser in Washington who has several newly out-of-work older clients. “It takes time to get past the disruption.”
Jovan Johnson, a certified financial planner in Atlanta, said Ms. Scott and others in her situation should start looking for a pro bono financial adviser who can help make sense of their money. “There are a lot of us out there who will help people out for free during a crisis,” he said. He recommends searching sites like the XY Planning Network.
The primary benefit of sitting down with a professional may be relief from panic, he said. But the 15 new retirees who have contacted him for pro bono help since the pandemic started, among them nurses and teachers, have also gained a better understanding of how to manage limited funds. “Everybody deserves to have a plan,” he said.
Pen and Brush after 23 years as executive director, the stress started last year, when she contracted Covid-19 and spent several weeks in an intensive care unit. She was not psychologically ready to retire, but because she has still not fully recovered, she felt she had to. “I was one of those people who was going to have to be wheeled out of there, I loved it so much,” she said.
Now she is adjusting to what she said was a more limited routine. Sunday nights and Mondays flummox her the most. “It’s like when you have that dream where you have a final exam and you’ve never been to class, or you forget your locker combination. I keep thinking, I have to go to work.” Instead, she takes walks with her husband, Wallace Munro, a retired actor, and visits the grocery store more than she thought she would ever want to.
“It’s something to do,” she said. “You have to restructure your life when something like this happens to you. It’s so easy to get depressed.”
Managing money in a sudden retirement
Mr. Johnson, the financial planner, offered tips on juggling your income and expenses when you’re thrust into joblessness with little warning.
Make sure that you do not have any old pension or 401(k) money out there from previous employers. People who have rolled over retirement accounts from previous employers often forget about them.
Don’t feel guilty for taking Social Security early — especially if you have no other option. You can begin claiming your benefits as early as age 62. However, the downside to claiming before your full retirement age (you can look it up on the Social Security website) is that your total monthly payments will be permanently reduced. If your income is below a certain threshold, your full Social Security payments might be tax-free.
Use Social Security payments for your nondiscretionary, fixed expenses and retirement assets for discretionary expenses, such as travel and entertainment.
Bridge the gap to Medicare, because the age of eligibility is 65. Consider plans under the Affordable Care Act. Typically, if your income is low enough, you may receive premium tax credits and other benefits if you choose a plan on the marketplace.
If Social Security and retirement savings cannot sustain your lifestyle, it’s time to consider Medicaid, Supplemental Security Income and similar programs.
Isabella Casillas Guzman, President Biden’s choice to run the Small Business Administration, inherited a portfolio of nearly $1 trillion in emergency aid and an agency plagued by controversy when she took over in March. She has been sprinting from crisis to crisis ever since.
Some new programs have been mired in delays and glitches, while the S.B.A.’s best-known pandemic relief effort, the Paycheck Protection Program, nearly ran out of money for its loans this month, confusing lenders and stranding millions of borrowers. Angry business owners have deluged the agency with criticism and complaints.
Now, it’s Ms. Guzman’s job to turn the ship around. “It’s the largest S.B.A. portfolio we’ve ever had, and clearly there’s going to need to be some changes in how we do business,” she said in a recent interview.
When the coronavirus crisis struck and the economy went into a free fall last year, Congress and the Trump administration pushed the Small Business Administration to the forefront, putting it in charge of huge sums of relief money and complicated new programs.
confusing, often-revised loan terms and several technical meltdowns — the program enjoyed some success. Millions of business owners credit it with helping them survive the pandemic and keep more workers employed.
Economists are skeptical about whether the program’s results justify its huge cost, but Mr. Trump and Mr. Biden both embraced the effort as a centerpiece of their economic rescue plans. As the pandemic stretched on and the economy plunged into a recession, the Paycheck Protection Program morphed into the largest business bailout in American history. More than eight million companies got forgivable loans, totaling $788 billion — nearly as much money as the government spent on its three rounds of direct payments to taxpayers.
Fraud is a major concern. Thousands of people took advantage of the rushed program’s minimal documentation requirements and sought illicit loans, according to prosecutors, to fund gambling sprees, Lamborghinis, luxury watches, an alpaca farm and a Medicare fraud scheme. The Justice Department has charged hundreds of people with stealing more than $440 million, and scores of federal investigations are active. (During her confirmation hearing, Ms. Guzman promised that she would “prioritize the reduction of fraud, waste and abuse.”)
There were other problems. Female and minority business owners were disproportionately left out of the relief effort. A last-minute attempt by Mr. Biden to make the program more generous for solo business owners came too late to help many of them. This month, a new emergency popped up: The program ran short of money and abruptly closed to most new applicants.
“There was no warning,” Toby Scammell, the chief executive of Womply, a company that helps borrowers get loans, said of the latest debacle. His company alone has more than 1.6 million applicants caught in limbo.
low-interest disaster loans of up to $500,000 and new grant funds, created by Congress, for two of the hardest-hit industries: the Shuttered Venue Operators Grant for live-event businesses and the Restaurant Revitalization Fund. (The hotel industry is pushing for its own version.)
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Each required the agency to create policies and technology systems from scratch. The venue program has been especially rocky. On its scheduled start day, in early April, the application system completely failed, leaving desperate applicants hitting refresh and relying on social media posts for information and updates.
“I turned to my associate director and said, ‘I figured something like this would happen,’” said Chris Zacher, the executive director of Levitt Pavilion, a nonprofit performing arts center in Denver. The Small Business Administration revived the system three weeks later and has received 12,200 applications, but it does not anticipate awarding grants until late May.
have turned into primal screams of pain. (“I SERIOUSLY CANNOT TAKE THIS WITH SBA ANY LONGER” is one of the milder replies.) She said she understood the urgency.
“It’s definitely unprecedented — across the board, across the nation — and we are seeing multiple disasters at the same time,” she said. “The agency is highly focused on just still responding to disaster and implementing this relief as quickly as possible.”
This is Ms. Guzman’s second tour at the Small Business Administration. When President Barack Obama picked Maria Contreras-Sweet in 2014 to take over the agency, Ms. Guzman went along as a senior adviser and deputy chief of staff. The women had met in the mid-1990s. Ms. Guzman, a California native with an undergraduate degree from the University of Pennsylvania’s Wharton School of Business, was hired at 7Up/RC Bottling by Ms. Contreras-Sweet, an executive there.
“I was always impressed with her ability to handle jobs with steep learning curves — she has a quick grasp of complex concepts,” Ms. Contreras-Sweet said.
Ms. Guzman spent her first stint at the agency focused on traditional projects like its flagship lending program, which normally facilitates around $28 billion a year in loans. The time, the job is radically different.
community navigators” program, which will fund local organizations, including nonprofits and government groups, to work closely with businesses owned by people with disabilities or in underserved rural, minority and immigrant communities. It’s an expansion of a grass-roots effort by several nonprofits to get vulnerable businesses access to Paycheck Protection Program loans.
Ms. Guzman said she was bullish about that effort and other agency priorities, like expanding Black and other minority entrepreneurs’ access to capital — but first, like the clients it serves, the Small Business Administration has to weather the pandemic.
And to do that, it has to stop shooting itself in the foot.
The much-awaited second attempt at opening the Shuttered Venue Operators Grant fund was preceded by one final debacle: The agency announced — and then, less than a day before the date, abandoned — a plan to open the first-come-first-served fund on a Saturday. For those seeking aid that has not yet arrived, the incident felt like yet another kick in the teeth.
Ms. Guzman said she was aware of the need for her agency to overcome its limitations and rebuild its checkered reputation.
“This is a pivotal moment in time where we can leverage the interest in small business to really deliver a remarkable agency to them,” she said. “I value being the voice for the 30 million small and innovative start-ups around the country. What I always say to my staff is that I want these businesses to feel like the giants that they are in our economy.”
In the late 1990s, Boston expanded its public pre-K program, but it did not have nearly enough spots for every 4-year-old in the city. So it used a lottery to help determine which children could enroll.
That lottery created an opportunity for academic researchers. It meant that thousands of otherwise similar children would have different life experiences based on random chance. And random chance is a powerful way for social scientists to study cause and effect. It may be the closest thing to a laboratory experiment in the real world.
Pre-K was a particularly good subject to study, because there has been a long-running debate about how much it matters. In the 1960s and ’70s, studies of two small preschool programs — known as the Perry and Abecedarian programs — showed major benefits for the children who attended them. But some experts pointed out the two programs were of a higher quality than most pre-K programs. For that reason, a community that enacted universal pre-K could not expect to replicate the benefits of Perry and Abecedarian.
The evidence about larger pre-K programs — like the federal Head Start program — was more mixed. Graduates of Head Start seemed to do better on math and reading tests during the early years of elementary school. As they got older, though, the positive effects often faded, leaving the value of universal pre-K unclear.
calling for the federal government to subsidize state pre-K programs. About two-thirds of 4-year-olds and half of 3-year-olds now attend such programs. Biden wants to make them universally available, at an additional cost of about $20 billion a year (or less than 1/30th of what the federal government spends on Medicare). He would pay for it by raising taxes on the wealthy.
In today’s newsletter, I want to tell you about the results from the Boston pre-K study. They are being released this morning by three economists, from the University of Chicago, the Massachusetts Institute of Technology and the University of California, Berkeley.
mixed evidence on Head Start.
But test scores are mostly a means, not an end. More important than the scores are concrete measures of a student’s well-being. And by those measures, the students who won the lottery fared substantially better than those who lost it.
also found that early education had a bigger effect on long-term outcomes than short-term metrics.
How could pre-K have these positive effects without lifting test scores? It seems to improve children’s social and emotional skills and help them mature more than it helps in a narrow academic sense, the researchers told me.
The findings are a reminder of how complex a process schooling is. We can’t simply give up on test scores. Measurement and accountability are vital parts of education, just as they are with most human endeavors. Without them, society ends up tolerating a lot of mediocrity and failure. But measurement often needs to be nuanced to be accurate.
“An important implication of our study,” Walters, a Berkeley economist, said, “is that modern large-scale public preschool programs can improve educational attainment.”
For more: How child care became a top issue in Biden’s Washington, by The Times’s Emily Peck; and why Republicans are abandoning their past support for universal child care, by Elliot Haspel, in The Washington Post.
recipe that lets time do most of the work, no kneading necessary.
The technique led to an explosion in amateur baking and changed professional baking as well, the chef J. Kenji López-Alt writes. It changed his life, too. “Learning how time can do the work for you turned me from someone who baked perhaps one or two loaves a year into someone who throws together dough on a whim before bedtime several times a month,” he writes.
Skeptics have warned of government overreach and the risk that deficit spending could ignite inflation, but Mr. Biden and his team of economic advisers have, nonetheless, embraced the approach.
“It’s time to grow the economy from the bottom and middle out,” Mr. Biden said in his speech to a joint session of Congress last week, a reference to the idea that prosperity doesn’t trickle down from the wealthy, but flows out of a well-educated and well-paid middle class.
He underscored the point by singling out workers as the dynamo powering the middle class.
“Wall Street didn’t build this country,” he said. “The middle class built the country. And unions built the middle class.”
Of course, the economy that lifted millions of postwar families into the middle class differed sharply from the current one. Manufacturing, construction and mining jobs, previously viewed as the backbone of the labor force, dwindled — as did the labor unions that aggressively fought for better wages and benefits. Now, only one out of every 10 workers is a union member, while roughly 80 percent of jobs in the United States are in the service sector.
And it is these types of jobs, in health care, education, child care, disabled and senior care, that are expected to continue expanding at the quickest pace.
Most of them, though, fall short of paying middle-income wages. That does not necessarily reflect their value in an open market. Salaries for teachers, hospital workers, lab technicians, child care providers and nursing home attendants are determined largely by the government, which collects tax dollars to pay their salaries and sets reimbursements rates for Medicare and other programs.
They are also jobs that are filled by significant numbers of women, African-Americans, Latinos and Asians.
WASHINGTON — The next phase of President Biden’s $4 trillion push to overhaul the American economy will seek to raise taxes on millionaire investors to fund education and other spending plans, but it will not take steps to expand health coverage or reduce prescription drug prices, according to people familiar with the proposal.
Administration officials had planned to include a health care expansion of up to $700 billion, offset by efforts to reduce government spending on prescription drugs. But they have decided to instead pursue health care as a separate initiative, a move that sidesteps a fight among liberals on Capitol Hill but that risks upsetting some progressive groups that have pushed Mr. Biden to prioritize health issues.
The president is set to outline his so-called American Family Plan, which includes measures aimed at helping Americans gain skills throughout life and have more flexibility in the work force, before his first address to a joint session of Congress next week. Its details remain a work in progress and could change in the days before the announcement.
But after weeks of work, administration officials have closed in on the final version of what will be the second half of Mr. Biden’s sweeping economic agenda, which also includes the $2.3 trillion American Jobs Plan the president described last month. That plan focused largely on physical infrastructure spending, like repairing bridges and water pipes and building electric vehicle charging stations, and was funded by tax increases on corporations.
expanded tax credit for parents — which is essentially a monthly payment from the government for most families — that was created on a temporary basis by the $1.9 trillion economic aid package Mr. Biden signed into law last month. The duration of that extension was earlier reported by The Washington Post.
Democrats on Capitol Hill have urged Mr. Biden to instead make permanent that credit, which analysts say will drastically cut child poverty this year. Those pushing Mr. Biden include Senators Michael Bennet of Colorado, Cory Booker of New Jersey and Sherrod Brown of Ohio, along with Representatives Rosa DeLauro of Connecticut, Suzan DelBene of Washington and Ritchie Torres of New York.
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“Expansion of the child tax credit is the most significant policy to come out of Washington in generations, and Congress has an historic opportunity to provide a lifeline to the middle class and to cut child poverty in half on a permanent basis,” the lawmakers said this week in a joint statement. “No recovery will be complete unless our tax code provides a sustained pathway to economic prosperity for working families and children.”
The family plan will also include some type of extension for an expanded Earned Income Tax Credit, which was included in the earlier aid package on a one-year basis.
The plan’s spending and tax credits will total around $1.5 trillion, according to administration estimates, in keeping with early versions of the two-step agenda first reported last month by The New York Times.
To offset that cost, Mr. Biden will propose several tax increases he included in his campaign’s “Build Back Better” agenda. That starts with raising the top marginal income tax rate to 39.6 percent from 37 percent, the level it was cut to by President Donald J. Trump’s tax overhaul in 2017. Mr. Biden would also raise taxes on capital gains — the proceeds of selling an asset like a stock or a boat — for people earning more than $1 million, effectively increasing the rate they pay on that income to 39.6 percent from 20 percent.
The president will also propose eliminating a provision of the tax code that reduces taxes for wealthy heirs who sell assets they inherit, like art or property, that have gained value over time. And he would raise revenue by increasing enforcement at the Internal Revenue Service to bring in more money from wealthy Americans who evade taxes.
Administration officials were debating other possible tax increases that could be included in the plan this week, like capping deductions for wealthy taxpayers or increasing the estate tax on wealthy heirs.
All of the tax provisions would keep with Mr. Biden’s campaign promise not to raise taxes on individuals or households earning less than $400,000 a year.
Previous versions of the family plan, circulated inside the White House, also called for raising revenues by enacting measures to reduce the cost of prescription drugs bought using government health care programs. That money would have funded a continued expansion of health coverage subsidies for insurance bought through the Affordable Care Act, which were also temporarily expanded by the economic aid bill earlier this year. Speaker Nancy Pelosi of California had pushed for that continued expansion.
Mr. Biden’s team was under pressure from Senator Bernie Sanders, independent of Vermont and the chairman of the Budget Committee, to instead focus his health care efforts on a plan to expand Medicare. Mr. Sanders has pushed the administration to lower Medicare’s eligibility age and expand it to cover vision, dental and hearing services.
A growing number of retirees and those approaching retirement are in debt.
The share of households headed by someone 55 or older with debt — from credit cards, mortgages, medical bills and student loans — increased to 68.4 percent in 2019, from 53.8 percent in 1992, according to the Employee Benefit Research Institute. A survey at the end of 2020 by Clever, an online real estate service, found that on average, retirees had doubled their nonmortgage debt in 2020 — to $19,200.
Susan B. Garland reports for The New York Times on what to do if you’re in this position:
Consult a nonprofit credit counseling agency, which will review a client’s expenses and income sources and create a custom action plan. The initial budgeting session is often free, said Bruce McClary, senior vice president for communications at the National Foundation for Credit Counseling. An action plan could include cutting unnecessary spending, such as selling a rarely used car and banking some proceeds for taxi fare.
Tap into senior-oriented government benefits, such as property tax relief, utility assistance and Medicare premium subsidies. The National Council on Aging operates a clearinghouse website for them, BenefitsCheckUp.org. “The average individual 65-plus on a fixed income is leaving $7,000 annually on the table” in unused benefits, said Ramsey Alwin, the council’s president.
Avoid using high-interest credit cards to fill income gaps. Medical bills typically charge little or no interest but turn into high-interest costs if placed on credit cards, said Melinda Opperman, president of Credit.org. Instead, she said, patients should call hospitals or other providers directly to work out an arrangement.
Avoid taking out home-equity loans or lines of credit to pay off credit cards or medical bills, said Rose Perkins, quality assurance manager for CCCSMD, a credit counseling service. Though tapping home equity carries a lower interest rate than a credit card, a homeowner could put a home at risk if a job loss, the death of a spouse or illness made it difficult to pay off the lender, she said.
President Biden’s $400 billion proposal to improve long-term care for older adults and those with disabilities was received as either a long overdue expansion of the social safety net or an example of misguided government overreach.
Republicans ridiculed including elder care in a program dedicated to infrastructure. Others derided it as a gift to the Service Employees International Union, which wants to organize care workers. It was also faulted for omitting child care.
For Ai-jen Poo, co-director of Caring Across Generations, a coalition of advocacy groups working to strengthen the long-term care system, it was an answer to years of hard work.
“Even though I have been fighting for this for years,” she said, “if you would have told me 10 years ago that the president of the United States would make a speech committing $400 billion to increase access to these services and strengthen this work force, I wouldn’t have believed it would happen.”
knocking millions of women out of the labor force — or deplete their resources until they qualify for Medicaid.
Whatever the limits of the Biden proposal, advocates for its main constituencies — those needing care, and those providing it — are solidly behind it. This would be, after all, the biggest expansion of long-term care support since the 1960s.
“The two big issues, waiting lists and work force, are interrelated,” said Nicole Jorwic, senior director of public policy at the Arc, which promotes the interests of people with disabilities. “We are confident we can turn this in a way that we get over the conflicts that have stopped progress in past.”
And yet the tussle over resources could reopen past conflicts. For instance, when President Barack Obama proposed extending the Fair Labor Standards Act of 1938 to home care workers, which would cover them with minimum-wage and overtime rules, advocates for beneficiaries and their families objected because they feared that states with budget pressures would cut off services at 40 hours a week.
“We have a long road ahead of passing this into law and to implementation,” Haeyoung Yoon, senior policy director of the National Domestic Workers Alliance, said of the Biden proposal. Along the way, she said, supporters must stick together.
half of adults would need “a high level of personal assistance” at some point, typically for two years, at an average cost of $140,000. Today, some six million people need these sorts of services, a number the group expects to swell to 16 million in less than 50 years.
In 2019, the National Academy of Social Insurance published a report suggesting statewide insurance programs, paid for by a dedicated tax, to cover a bundle of services, from early child care to family leave and long-term care and support for older adults and the disabled.
This could be structured in a variety of ways. One option for seniors, a catastrophic insurance plan that would cover expenses up to $110 a day (in 2014 dollars) after a waiting period determined by the beneficiary’s income, could be funded by raising the Medicare tax one percentage point.
Mr. Biden’s plan doesn’t include much detail. Mr. Gleckman of the Urban Institute notes that it has grown vaguer since Mr. Biden proposed it on the campaign trail — perhaps because he realized the tensions it would raise. In any event, a deeper overhaul of the system may eventually be needed.
“This is a significant, historic investment,” Mr. Espinoza said. “But when you take into account the magnitude of the crisis in front of us, it’s clear that this is only a first step.”
The PACE provider manages all of a person’s health care needs that are covered by Medicare or Medicaid. “It becomes your form of health care coverage,” said Peter Fitzgerald, executive vice president for policy and strategy at the National PACE Association, a membership and advocacy organization.
States decide whether to offer PACE programs; currently 30 have programs serving about 55,000 people, Mr. Fitzgerald said.
Where change is happening
Some states and regions are moving to address the needs of their aging citizens.
In January, Gov. Gavin Newsom released a master plan for aging for California. It calls for creating, over the next decade, millions of housing units for older residents, one million high-quality caregiving jobs, and inclusion goals such as closing the digital divide and creating opportunities for work and volunteering. Colorado, Massachusetts, Minnesota and Texas have already established master plans, and a number of other states are working on them.
California’s plan also calls for a new state office focused on finding ways to innovate using Medicare funds, especially for low-income, chronically ill seniors who also participate in Medicaid.
“We think this can really help our state by bringing together medical and nonmedical services for people who want to live well in the place they call home,” said Gretchen E. Alkema, vice president of policy and communications at the SCAN Foundation, a nonprofit focused on elder care that has worked with California and other states on age-friendly models.
In the Atlanta metropolitan area, which began tackling these issues head-on in 2002, one in five residents will be 65 or older by 2050, according to the Atlanta Regional Commission, a planning organization. The group has responded by developing a “lifelong communities initiative” to raise awareness in local government of the need for housing that is affordable and convenient to sidewalks, shopping and transportation.
Atlanta and four suburbs have joined an AARP-sponsored network of age-friendly communities, and several city neighborhoods have created plans.
It’s a dismal ritual of American life: A mass shooting occurs — sometimes more than one, in quick succession. The country mourns the victims. And nothing changes.
I expect the same will happen following the killings in Atlanta and Boulder, Colo. But it is still worth taking a few minutes to lay out the basic facts about gun violence. The key one is simply this: The scale of gun deaths in the United States is not inevitable. The country could reduce the death toll, perhaps substantially, if it chose to.
1. The toll approaches pancreatic cancer’s
When gun violence is counted as a single category — spanning homicides, suicides and accidents — it kills about 40,000 Americans a year.
That’s far behind the country’s biggest killers, like heart disease (about 650,000 annual deaths) or Alzheimer’s (about 125,000). But it is broadly comparable to the toll from many well-known causes of death, including an average flu season (35,000), vehicle accidents (39,000), breast cancer (42,000), liver disease (43,000) or pancreatic cancer (45,000).
dismissed calls for restricting gun availability, saying, “There’s not a big appetite among our members to do things that would appear to be addressing it, but actually don’t do anything to fix the problem.”
But there is overwhelming evidence that this country has a unique problem with gun violence, mostly because it has unique gun availability.
Michael Siegel of Boston University’s School of Public Health says.
“The main lesson that comes out of this research is that we know which laws work,” Siegel says. (Nicholas Kristof, the Times columnist, has written a good overview, called “How to Reduce Shootings.”)
one out of every 400 gun deaths was the result of a mass shooting (defined as any attack with at least four deaths). More than half of gun deaths are from suicides, as Margot Sanger-Katz of The Times has noted.
Still, many of the policies that experts say would reduce gun deaths — like requiring gun licenses and background checks — would likely affect both mass shootings and the larger problem.
4. Public opinion is complicated
Yes, an overwhelming majority of Americans support many gun-regulation proposals — like background checks — that congressional Republicans have blocked. And, yes, the campaign donations of the National Rifle Association influence the debate.
But the main reason that members of Congress feel comfortable blocking gun control is that most Americans don’t feel strongly enough about the issue to change their votes because of it. If Americans stopped voting for opponents of gun control, gun-control laws would pass very quickly. This country’s level of gun violence is as high as it is because many Americans have decided that they are OK with it.
5. The filibuster is pro-gun
Gun control is yet another issue in which the filibuster helps Republican policy priorities and hurts Democratic priorities. On guns (as on climate change, taxes, Medicare access, the minimum wage, immigration and other issues), Republicans are happier with the status quo than Democrats. The filibuster — which requires 60 Senate votes to pass most bills, rather than a straight majority of 51 — protects the status quo.
If Democrats were to change the filibuster, as many favor, it isn’t hard to imagine how a gun-control bill could become law this year. With the filibuster, it is almost impossible to imagine.
a song by Kermit the Frog.
Lives Lived: Jessica McClintock dressed generations of women in calico, lace and beribboned pastiches known as granny dresses. Her clients included Vanna White and a 27-year-old Hillary Rodham for her 1975 wedding to Bill Clinton. McClintock died at 90.
ARTS AND IDEAS
Ian Parker writes in The New Yorker. “The latest streaming-video subscriptions have been sold on the promise of content that is remarkable.” HGTV, as Parker notes, “is low-budget and unassuming.”
Torn Down for What.”
HGTV is now part of the Discovery+ streaming platform, which is tiny compared with Netflix and Disney+. But HGTV’s value also lies in the size of its library, which includes hundreds of episodes of popular shows like “House Hunters” and “Fixer Upper.”
For more: Discovery+ brings a cable-era way of watching TV to streaming.
PLAY, WATCH, EAT
What to Cook
today’s Mini Crossword, and a clue: Frequent flier (five letters).
If you’re in the mood to play more, find all our games here.
Thanks for spending part of your morning with The Times. See you tomorrow. — David
P.S. Priya Krishna, a food writer who previously worked at Bon Appétit, is joining The Times, where she will write and appear on NYT Cooking’s YouTube channel.
You can see today’s print front page here.
Today’s episode of “The Daily” is about the vaccine rollout. On “Sway,” Glennon Doyle discusses misogyny, the power of apologies and more.
Lalena Fisher, Claire Moses, Ian Prasad Philbrick, Tom Wright-Piersanti and Sanam Yar contributed to The Morning. You can reach the team at email@example.com.
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