The centralized approach replaces family and community with unionized federal home care workers.

The Biden Administration, as part of its somewhat misleadingly entitled “infrastructure” bill, has proposed an enormous $400 billion program to expand home health services, capitalizing on the justified dissatisfaction with nursing homes resulting from the many deaths in them during the COVID crisis. The implication of the proposal is that there is a binary policy choice between home health services and nursing homes, and that aggrandizement of the home healthcare workforce will stimulate de-institutionalization.

However, only about 6 percent of the elderly reside in nursing homes and long-term care facilities, and the present backlog in the home health services that states are committed to provide is estimated at $150 billion. The proposal thus contemplates an expansion of enrollment in home health services and increased rewards for those rendering them. The plan includes a $5,000 nonrefundable tax credit for families where a relative renders home health services. It also contains measures facilitating unionization of home health workers.

A notable peculiarity of the proposal is its omission of the middle class. State-provided home health services are provided through the Medicaid program to people who have spent down their assets and are effectively welfare recipients. The tax credit benefits only those who pay substantial income taxes, notwithstanding the recent reduction in rates and great enlargement of the standard tax deduction. It thus benefits the relatively well-to-do, but not the struggling lower middle class. The expansion of the Medicaid benefit thus fosters greater government provision of home healthcare, greater “spending down,” and greater dependency on government for all but the well-off.

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Foreign countries have devised other approaches to foster home healthcare within families or through mutual aid organizations of the elderly themselves. Most of the elderly are not totally infirm, but are able-bodied for most purposes most of the time, though more greatly subject to recurrent disabilities than most of the population. Idleness and boredom are a problem for many.

In Japan, under a Law Governing Volunteer Workers in Welfare Services, community care for the aged is organized at the neighborhood association level. Volunteer workers are engaged for three-year terms, each working with the elderly two days a week and receiving a nominal stipend. Organization of old age clubs is encouraged with small tax credits for members. Participation of persons over the age of 60 in such organizations increased from 12.8 percent in 1962 to 47.2 percent in 1973.

While historically there is limited tradition of neighborhood organization below the town and township level in the United States, this situation has altered with the rise of residential community associations and condominium associations since the early 1960s, when creation of such associations to maintain infrastructure was required as a condition of federal mortgage insurance for new developments. Some 74 million Americans now live under the jurisdiction of private community associations, including 58 percent of homeowners. In 2019, 62 percent of newly constructed homes were within homeowners’ associations, with such associations totaling 351,000. Many of these associations maintain amenities such as swimming pools and demand-response transportation, so they can readily organize mutual aid associations.

Another aspect of foreign strategies for care of the elderly is the encouragement of constructing accessory apartments, duplex apartments, and “mother-in-law” flats. There are tax credits for this purpose in Germany, Japan, and Finland. Great Britain has a “rent a room” scheme, which offers tax exemptions for room rentals in what would otherwise be single-family homes. The advantage of these arrangements is that they reduce the number of elderly persons living completely alone in single-family houses requiring third-party assistance that could otherwise be provided by relatives or neighbors.

In general, the only areas in the U.S. with exceptionally high real estate prices have legalized accessory apartments to supply places to live for teachers, police officers, or domestic servants who would otherwise be excluded from them. Otherwise, single-family zoning effectively banishes elderly relatives to the next county—they must either live cheek by jowl with relatives in the same housing unit or accept complete separation.

Sen. Elizabeth Warren (D-MA), among others, has proposed coercive federal legislation to compel or bribe local governments to liberalize restrictive zoning laws. Such top-down approaches are doomed to failure, being akin to an effort to push spaghetti through a keyhole. A modest tax credit of a few thousand dollars for persons installing second kitchens in owner-occupied residences would be far more effective.

The restriction to owner-occupied residences would allay fear of neighborhood change, and the credits would be publicized and promoted by accountants, tax preparers, contractors, and home improvement chains like Lowe’s and Home Depot. It is doubtful that local governments could withstand pressure from below to liberalize their zoning.

The Biden administration is likely to discover that there is no great enthusiasm for creating its proposed army of impersonal federally regulated and unionized home care workers. When choices are properly framed, there will be a preference for measures to foster mutual aid enhanced by family and neighborhood care.

George Liebmann is president of the Library Company of the Baltimore Bar and author of Neighborhood Futures (Transaction Books) and Vox Clamantis In Deserto: An Iconoclast Looks At Four Failed Administrations (Amazon).