Miriam Allred (00:00)
Hey everyone, welcome back to the Home Care Strategy Lab. Today in the lab, I'm across from Eric Reinerman, the VP of Government Relations at the Home Care Association of America. Eric, it's a pleasure. Welcome to the show.

Eric Reinarman (00:14)
Miriam, thank you for having me. I'm excited. This is my first podcast actually. yeah, this is my first one. I'm excited.

Miriam Allred (00:21)
first podcast giddy up. was just telling you though, it's a lot like other public speaking. It's just more of the same. We just happen to be recording it as a podcast. So, I have been looking forward to this. You and I, have rubbed shoulders at different events and different things, but I am excited to officially have this one-on-one time to sit down with you and learn from you. And we're just going to tackle some of the hot button items on Capitol Hill in regards to home care. So I'm not going to.

I'm not going to spare you. I'm honestly just going to take it right as it comes and we're going to get right after it. before we do that though, tell everyone a little bit about your background and how you landed in your current role at the Home Care Association of America.

Eric Reinarman (00:49)
Yeah, course.

Sure, so I'm a recovering attorney as many attorneys are. I've kind of, don't practice anymore. For a while I did some labor law, I did some family law for a while. I worked for the attorney general's office in Florida for a little bit. Now I am government relations specific. So I worked for another association in the hospitality sector before this. know, similar role in terms of.

advocacy and actually some of the issues did overlap with hospitality and work, you know, with workforce and all the other ⁓ issues that are home care is facing now. And I was there for about two or three years and now I'm with the Home Care Association of America. I love it. Love the space. I think I really enjoy the agency owners that I'm able to work with every day. It's a very collaborative industry, which I really appreciate everyone,

There's not a real sense of any cutthroat competition, as there was a little bit of that in hospitality and in home care, it's really a lot more collaborative, which I really appreciate. Everyone is trying to help everybody else and I enjoy that. So I, and here I am. So yeah.

Miriam Allred (02:06)
Amazing. I like what you're saying there about it being very collaborative. think that's what draws me to home care and has allowed me to stay here is there's just a lot of good natured people. And we're all working towards solving the same common goal. There is a supply and demand issue around home care and there is enough demand to go around and we're all trying to chip away at solving that problem in our local market. And that'll kind of bleed through this conversation today is how do we do that and what do we.

How do we accomplish that at like a federal and a state level as well? So like I said, we're going to jump right into some of the topics that you spend a lot of time thinking about. And I think a lot of owners, operators are thinking about as well. But I want to get an update on each of these issues and get a sense of your take on these issues. And then also talk about what providers need to know.

but also what they need to do about this information. So we're going to talk about immigration and expanding the workforce. We're going to talk about affordability of care, bills to watch out for, non-compete, know, FTC, what's happening there, Medicaid 80-20, like we're just going to kind of tackle these big issues. Let's just start with immigration. I think that is on a lot of people's mind. It's in the news. There's just a lot of buzz around this topic. so, um,

Eric Reinarman (03:05)
Big one.

The big ones. Yeah.

Miriam Allred (03:22)
Home care needs labor and there is a shortage and immigration has often been a labor pool that these home care companies are tapping into. So let's just start with an update on where things are at with that issue.

Eric Reinarman (03:35)
Yeah, it's a timely one right now, obviously. It's always a challenge in Washington immigration reform is, no matter what the political climate is, that's always one that folks are a little bit wary to touch and pick up in terms of elected officials. But for the first time, I think in a while we're seeing genuine bipartisan recognition, if not progress, probably more like I would use a different term recognition that our long-term care system

can't function without more workers, right? We need that. There is a visa category that does apply to home care. It's not specific to home care and caregivers, but there's an EB3 visa, right?

The system is slow, it's clunky, it's outdated. We have met with, for example, the Department of Labor. We've met with, you know, this always comes up in our meetings with elected officials as to how to make that EB3 visa process smoother. There's a lot of really archaic.

hoops you have to jump through in order to qualify. One is you have to post the opening for a caregiver in a newspaper. mean, that's not how people are hired anymore. I mean, that's just not how things work in 2025.

That's just one small example of like why it's so clunky. know, the submission process is just unbelievably slow. It kicks visa applications out for reasons that aren't delineated clearly. So we have, enumerated all of these sort of shortcomings in a white paper and then we presented it to DOL for their portion. It's not all DOL's fault. I don't mean to lean on them too aggressively because they have been very open to discussions with us, particularly recently. So we're very thrilled about

that. But that's just, you know, one way we're looking at it is trying to reform that EB3 process.

We also have drafted our own sort of, it's not really a white paper, but our own home care visa. And it's something we circulate around Capitol Hill. That one would be specific to home care. would not provide a path to citizenship because I think that's a little too fraught right now with the political realities being what they are. That's just not something I think that would be able to get passed right now, but it would be specific to home care. more importantly,

socializes the issue of the fact that we need more workers and we need to address this through immigration. That's one really good way that we can try to address this problem. So we've been leading advocacy for these types of targeted reforms. ⁓

Miriam Allred (05:59)
Are home care

companies taking advantage of the EB3 or is it just so implausible that it doesn't make sense?

Eric Reinarman (06:07)
It's not implausible. do know caregivers that are coming through the EB3 process. It is very slow. It does take a long time. Some of the backlogs can be years. I mean, it's wild. But we do know folks that are having success through EB3. So there's hope there, but I don't want to pretend that

You know we can see we can really see the light at end of the tunnel and that it's going to get better soon. I can't predict that. You know I think that you're seeing on both sides of the aisle the recognition that this is a serious problem that needs to be addressed that will help the economy right? I more caregivers coming here through this process will be you know advantageous to the tax base. It will be advantageous to local economies and the national economy as a whole, you know.

But it's it's tough. There's also a bill. I don't know if you want me to get into that now that we're that we're supporting. But it's it's HR 5494. It's been filed a couple of times before by Rep Smucker out of Pennsylvania. I believe it's the 11th district out of Pennsylvania. That bill is called the Essential Workers for Economic Advancement Act. That would create a new visa category. So.

it would create, I think it's an H2C, I believe the title is, I can't remember exactly, but it would create a new visa category that would be specific for caregivers. It's bipartisan, which is good. I think it's got 10 co-sponsors now, so it's got Dems and Republicans on it. But again,

Right now, the political climate being what it is with immigration being a very controversial topic. Do I see that bill passing in the 119th Congress, which is the Congress we're in right now? Probably not, right?

Miriam Allred (07:48)
And you mentioned a minute ago about a home care visa that you all have been putting together. How long have you been working on that specifically?

Eric Reinarman (07:56)
That's a couple

years in the making that one is really drafted to our specifications, right? The age to see would be for a variety of different workers where caregivers would fall under the penumbra of an age to see, but it wouldn't be just for caregivers. The one that we're working on would be just for caregivers that hasn't been filed or anything like that, but really.

The important thing to remember on both of these, both the bill that I just mentioned, Smucker's bill and our home care visa is we're socializing these issues, right? People are getting more more accustomed to hearing about the home care shortage, right? The caregiver shortage, why we need to increase immigration in this particular industry and,

How it can be made easier to get workers in without you You don't even necessarily need legislation if you were to reform the EB3 process that would help a lot so we are making people aware of what a problem this is and ⁓ That's really half the battle because you know when you want to make progress in Washington sometimes it takes multiple Congresses right to in order to actually get something passed because you've got to get everyone familiar with the issue first

Miriam Allred (09:00)
Mm-hmm.

Eric Reinarman (09:00)
So that's why it's important to be out front on these types of things. Which speaks to your... Yeah, go ahead.

Miriam Allred (09:05)
Yeah,

and I'll continue to ask that throughout this conversation is how long you've been after it and kind of where we are today because the timelines here are all relative. And, if we've been at an issue for two years or four years and where we're at today, because like you just said, things take a long time and it's not just short-term fixes. It's like we're socializing issues. We're creating like long-term solutions and that's nothing that can't happen overnight.

Eric Reinarman (09:31)
That's right. That's right. It really takes time for these electeds and their staff to get used to seeing things come across their desk. Once they do, then it becomes a lot easier to then they start talking about it amongst themselves like, yeah, I know that bill, you know. interesting. Yeah, I remember when we met with HCAOA about that. That's why advocacy is so important. And I know we'll get into that ⁓ a little later. But yeah, it's it's it's crucial that we keep talking about it and keep it keep it, you know, in everybody's ear about this topic.

Miriam Allred (09:58)
Speaking of, I think you said Smucker's bill coming out of Pennsylvania, what if anything can we do to support that or to push that forward?

Eric Reinarman (10:08)
One thing that could be done is you could contact your your congressperson and just give them the the the bill number and the name which is HR 5494 the essential workers for economic advancement act and just say I want I want my you know as a constituent of you know representative X I want you to support this bill this is a good bill we need you know we need this bill here's why and you you tell the story.

Advocacy is all about stories. And explain to them that, you know, look, I'm a constituent, this matters to me, and I think you should support this bill, so cosponsor it so that you can ask your congressperson to cosponsor it. I think that would be the best thing somebody could do.

Miriam Allred (10:52)
we essentially need more people doing that. You talk to home care companies, I talk to home care companies. I need to do more of this, but asking them about their advocacy efforts because I think it's, you don't want to hear this, but I don't know that it's top priority for these home care companies. They are putting in a lot of work, putting out a lot of fires. Like their day to day is so pressing and there's a lot of like urgent issues that I think advocacy oftentimes isn't in their highest priority, but.

Eric Reinarman (11:08)
care.

Miriam Allred (11:18)
I think between you and I, it needs to become higher priority. If we want to see changes made at the state level and at the national level, we all need to have advocacy become higher priority for us.

Eric Reinarman (11:28)
That's right. And you're right. Agency owners have a lot on their plate every day, right? All the way up and down the food chain in terms of where you are in the pecking order of a home care agency. And it can be frustrating. Advocacy can be frustrating. Why? Because the pace is glacial, right? it just takes a long time to see progress on these things. And it's frustrating because it's like, well, why should it take so long? It's like, well...

That's a good question. That's that's above my pay grade. I mean, why? Why is Washington, the way it is? There's a lot of reasons for that, right? More than I can speak to, you know, here. But I think realizing that it's that it is important that your voice does matter and that elected officials and their staff, the staff is really important, do want to hear from you. think realizing that and embracing that is one way to at least get your voice heard.

And they do want to hear from you. mean, believe it or not, it's not an annoyance when you call their offices. I mean, they want to hear from constituents. They want to hear from folks in their district, what matters to them, how they can make your life easier. And bringing specific legislation to them matters, I think.

Miriam Allred (12:35)
And I think immigration is actually a really good example of storytelling. There are a lot of immigrants that are caregiving in this country and their stories are profound, profound. I have heard some of them firsthand from people that have come from Africa, from South America, and it's life-changing. And they are humble and grateful and have beautiful stories to tell. And so actually capitalizing on the life-changing

profession that this can be for them is a way that we can get that message across to these legislators.

Eric Reinarman (13:09)
Totally agree. That's absolutely right. was recently in Ghana actually and I met someone who had been a caregiver in the United States for over, I think she said it was eight years or so. And I know just from the stats on the industry, it was, I want to say more than a third of our workers are foreign born. So that's very high. you're right. It shows how important immigration policy is to the home care industry.

Miriam Allred (13:36)
I was just going to ask you that. I was going to put you on the spot with that. But any numbers to quantify this issue? Yeah, how many workers are currently immigrants? any other kind of like stats or data points on immigration specifically?

Eric Reinarman (13:39)
Yeah.

Stats are always tough to come by. I know that we're more than a third of our workers are foreign born. I know that one. It's probably, it's definitely over 33. It's probably closer to 40%. But don't quote me on that. other stats related to immigration, I don't have them off the top of my head and obviously I don't wanna make something up, but it really is.

an industry where immigration policy really, really matters as opposed to certain other industries where it's important. I think it's important to every sector of the economy, but think healthcare, it's really paramount.

Miriam Allred (14:20)
We talk a lot about the amount of people turning 65 plus every day. A stat that I read recently was about the shortage, the actual like labor shortage. And I saw it quantified around 700,000 caregivers will be needed by 2030. And it's 2025. We're talking five years from now, we're gonna be pushing a shortage of a million care workers. And that's staggering. And so again, that's why immigration and this policy specifically,

Eric Reinarman (14:38)
Wow.

Miriam Allred (14:48)
is as timely as it's ever been because this shortage is, exponential at this point. And what are we going to do about it?

Eric Reinarman (14:56)
It's really, it's scary when you look at the demographics and how much we're aging. And, you know, it's a cliche at this point, at least in this industry to a lot of listeners, but it's the silver tsunami, right? And that tsunami is starting to crest and it's starting to come down on us. And, you know, what is that gonna look like? What does that mean for us? It's a lot. think elected officials are starting to get that.

And we'll go over some bills that are showing that people are realizing how important home care is to Americans in general and how they want to age in place, how they don't want to be institutionalized. But we're not there yet. It's clear we're not. The impression has not been made on our policymakers because too often Washington and our state capitals are reactive rather than proactive. We've all heard this one as well.

Sometimes it's just, it's too reactive and it feels like there's gonna be a reaction to it, but it'll be, I don't wanna say too little too late, but it will be, if we're not more aggressive, we will find ourselves in a real pickle, I think.

Miriam Allred (16:02)
Let's keep talking about this next issue, which is affordability. Again, this is like top of mind for every home care leader in this industry is affordability of care, families being able to afford private pay home care. There are a variety of tax policies, that go into this. So what is in place and

what has the best chance of moving forward in coming months and year.

Eric Reinarman (16:29)
Yeah, so there's a bill that we've been supporting for a while. It's mainly being run by AARP, but we've been very active on it. It's called the Credit for Caring Act. That is, it's been filed a couple times now, at least three sessions in a row. This year's ⁓ bill number is HR 2036, I think. It's Representative Carey out of Ohio. He's carrying it in the House. Senator Capito out of West Virginia is carrying it in the Senate.

That's Senate Bill 925 for folks following at home. I know it's a lot of numbers and a lot of jargon, but that's Washington for you. I would say that's the most promising bill right now. We pushed really hard to get it into Trump's quote unquote big, beautiful bill. I think we were somewhat close. had meetings with

Senate Finance Committee staff on the House side as well. had meetings to try to get it in that bill. Unfortunately, that bill was mostly about getting things in there that cut costs instead of costing money, and this bill would cost money. What this bill would do is it would give family caregivers up to a $5,000 non-refundable tax credit to help offset home care expenses, transportation, medical supplies, etc.

So it would make it more affordable for the millions of middle income families who earn too much for Medicaid, right? But can't shoulder the private pay costs. So it would at least, there would be some tax relief there. I would say that's the bill that has the best chance of passage in some form. Now it might not pass on its own as a standalone bill. It might be part of a larger package, right? Or omnibus, as they call them in Washington. But I would say that's our best bet.

There are other bills, Home Care for Seniors Act, the HOPE Act. Both of those bills expand eligibility for using pre-tax dollars on home care. The HOPE Act, that one's interesting, that one's new. So it has less of a chance of passing just because it hasn't been.

discussed all that heartily around the Hill, but that one's interesting because it creates a new kind of tax-favored savings account called a HOPE account. HOPE stands for, what is it, health.

out-of-pocket expense account or something like that, HOP account. What that would do is that would be, ⁓ so money that you would contribute into that account could be used tax-free as long as it's used to pay for a qualified medical expense, and home care would qualify as a medical expense under that bill. So it's sort of like an HSA, but you would be able to spend it on specific things, and it would be tax-free.

use it on those specific things. Yeah.

Miriam Allred (19:06)
One question on that is that connected

to Medicaid specifically or that would be that could go towards private pay care as well?

Eric Reinarman (19:16)
Yep, that could that that would be able to go to private pay care as well. Yes. Yep, sure.

Miriam Allred (19:21)
Okay. Just wanted to make sure I understood that. And

the first bill that you mentioned, the credit for care, that is geared towards family caregivers, which is kind of a bucket of its own, correct?

Eric Reinarman (19:30)
Right, that's right, exactly right. Yeah, it would go for, it would be for family caregivers, right? And it would be $5,000 non-refundable tax credit. So it's a credit, not a deduction. So it's a little bit more valuable, but that makes it more expensive, which makes it harder to pass.

Miriam Allred (19:45)
And then what was the third, the Senior Care Act?

Eric Reinarman (19:49)
Yep, Home Care for Seniors Act. That also helps HSA money to be spent on home care. And FSA money, Archer accounts, things like that.

Miriam Allred (19:56)
Okay.

Okay. And with credits and policies like these, there anything, I guess this is maybe at the state level because there are state policies and state programs, is there anything in existence today that looks kind of like one of these bills that maybe that you're aware of that may be going well that we're trying to kind of like replicate on a larger scale?

Eric Reinarman (20:21)
So in Washington State has something interesting. They have a long-term care trust program.

There's another bill that I wanted to mention too that relates. It's called the WISH Act and it's HR 2082. That would create a national version of Washington's Long-Term Care Trust Program. So essentially what it would do is it would establish a public insurance fund financed through small payroll contributions to help cover the cost of long-term care, like basic long-term care.

So a little bit different, but still helps with the affordability crisis that we're seeing, because home care, private pay, it's expensive. So that's, guess, Washington's program just kind of stands out a little bit to me as something that's sort of working, I think.

Miriam Allred (21:11)
Yeah, that's a great example. I'm not familiar with that, but that's where my mind goes is again, states have a little bit more liberty to try and test some of these policies. And again, assuming things go well and there's outcomes, then how do we take that to the national level, replicate it based off the outcomes of a program at a state level?

Eric Reinarman (21:16)
Mm-hmm.

Yeah.

Yeah. Absolutely. Well said. Yeah.

Miriam Allred (21:35)
And when you think about just affordability of care, high level in general, again, that's an issue that every home care leader is thinking about is how do we position this and how do we sell this and how do we overcome that barrier? When you think about affordability, any other advice or thoughts for home care leaders as to how they can approach this or things that they should be thinking about?

Eric Reinarman (21:59)
It's a tough one because we do talk about that a lot and I travel to a lot of state chapter meetings, you know, in our various active chapters. And we talk a lot about affordability, but I don't often hear true solutions because the labor market is what it is, right? It's not like these agencies are doing too much of a cash grab and, you know, charging too much. mean, labor is expensive right now. And that's keeping prices

inflated and to try to deliver a good solid continuity of care, of quality care for a quote unquote affordable price. I affordable is relative, right? And I hesitate to step into the shoes of these operators because...

I'm not an operator and I don't know exactly where I would try to fine tune things to increase profitability because I know that they're already doing so much of that. So yeah, I don't know. That's a tough one. I'm stumped. I'm stumped on that one.

Miriam Allred (23:03)
That's okay. The one thought that comes to mind for me is I think more and more home care providers are trying to become a holistic solution, offering additional services, rounding out their home care offering with additional layers. You think of care management, you think of financial planning, you think of estate planning. There's all these kind of like wraparound services to the home care itself. And then you think about profitability and billing and revenue.

Eric Reinarman (23:19)
Yeah.

Miriam Allred (23:30)
How do you create more of like a package that is more attractive to these families, but also as a business, you can charge more for more of a holistic service offering. And I think more and more large providers that I talk to are thinking like that. How do we supplement our home care services with additional offerings that are attractive and make sense for these families, but also help increase our margins and our profitability?

Eric Reinarman (23:42)
Sure.

Yeah, that's a good point. Like providing continuum of care, you know, and yeah, that's a good point. guess another that comes to mind that just came to mind while you were talking, maybe, you know, leveraging AI. Now that's such a broad thing to say, right? But there are increasing number of companies who are operating in that space within home care. I think there are certain efficiencies.

that can be leveraged. And I think in five years, who knows what'll be possible? And who knows what we can do with AI? I think really, anyone that claims to know what it's gonna look like in five years is not telling the truth entirely, but I think you're gonna see it become more more present in home care. And I think maybe that could be something that could lower costs too.

Miriam Allred (24:42)
I think the key word you said is efficiency. How can we do more with less? And in home care, there's just a lot of manual documentation. There's just a lot of tedious tasks that are still taking place. And how do we bring in technology, AI to reduce a lot of that manual burden and give talk about, you know, focusing on advocacy and that being a higher priority. It's again, it's a lot of just like that manual workload that's taking leaders away from bigger picture.

Eric Reinarman (24:44)
Yeah. Yeah.

Yeah.

Miriam Allred (25:10)
tasks and projects and mindsets. And so how do we free up their time so they can focus on these bigger issues at hand? So yeah, I think that was good on the affordability piece. Again, it's a tough nut to crack. It's the issue that every home care company is up against, but we're all just doing our best to try and of carve a path through that. Let's talk about the FTC non-competes. That's something we've been talking about for a while now. So what's just kind of a current state

Eric Reinarman (25:28)
Absolutely.

Miriam Allred (25:36)
of that issue.

Eric Reinarman (25:38)
So the FTC recently released an RFI, which is a request for information, again, about non-compete agreements. There was a big RFI, I guess it was probably more of a rulemaking in April of 2023 when we submitted a long formal comment to the FTC. And we explained that home care is unique.

Caregivers work one-on-one with vulnerable clients. They form deep, really trusted relationships over time. Our point was that if those caregivers can be recruited away immediately, it can disrupt care, create safety risks, undermine client trust. But we also made clear that we're a unique industry.

in terms of FTC regulation in that non-competes are incredibly rare in home care, right? Our agency members are not forcing caregivers to sign non-competes and thus tying up their ability to change jobs. As we all know, caregivers often work for different agencies, which is fine. We certainly don't wanna hog-tie anybody and prevent that. think when these types of...

quote unquote non-competes, we're using that term generally and that's really a pretty specific legal term. I would say that when they do exist, they apply normally to key managerial or clinical staff and certainly not caregivers. So we were a little bit hesitant on FTC's proposal to apply sweeping restrictions.

to a problem that doesn't really exist in our sector. And we didn't wanna get caught up in something that didn't really apply to us. And we didn't want anyone to think that we have a lot of non-competes in the industry because we just don't. So, we made clear in our comment to the FTC that these are very rare and that...

we are a unique industry and have to be treated as such. So perhaps non-solicitation agreements, which is something completely different, right? Those should be carved out, I would say, and allowed to stand as opposed to a sweeping ban on any sort of employment restriction.

Miriam Allred (27:41)
And I think you tackled this, but this is my big question around this issue is, are the non-competes defensible for management roles, office roles versus caregiver roles? And it sounds like that's the distinction that we're trying to draw here.

Eric Reinarman (27:55)
That's right. I think most people admit that there are certain times when non-competes make sense from an economic efficiency standpoint and just industry by industry. You know, there are things that you want high level staff to keep to themselves and you don't want them running from, job to job spilling, trade secrets, et cetera.

That's not really the case in our industry. Now there is some of that, of course there are high level folks at some of the bigger franchises, etc. that would be subject to some of these. But really what we're focused on is making sure that we don't get swept up into anything that doesn't really apply to our industry.

Miriam Allred (28:36)
And you mentioned traveling state by state to these different chapter conferences and things. What are some of the comments you've heard providers share about this specifically? What concerns do they have? What are they doing to mitigate some of the risks with this?

Eric Reinarman (28:50)
⁓ I think that.

They are definitely reviewing any anything that that they think might be a restriction on employment and they're they're reviewing it with their attorneys as they should. So if you have any of those, you know with any employees, I would I would review them with it with an attorney and have them, looked at and have and have someone look at the you know the rule the FTC's rule and and this new RFI and see what makes sense and see if if it needs to be changed if it needs to be.

if you need to notify anybody that there's, that it's no one void, et cetera. But I don't hear a ton about it from our members. I hear a lot more about immigration, about 80-20, if they do Medicaid work, things like that. But I haven't heard a ton on the non-compete stuff, to be honest.

Miriam Allred (29:36)
I think it's been in effect for a while and it's been, you know, it's maybe like we're pushing through as it's not as like urgent or top of mind because it's been a couple of years. I don't know if you mentioned it, but what's the timeline on the RFI and that process?

Eric Reinarman (29:39)
Mm-hmm.

the comments on that RFI that were released recently, those are due on November 3rd, I believe at 1159 PM Eastern. So you have to submit them by then and then they go through, know, it's a pretty arcane, the federal rulemaking is a pretty arcane process. So they, you know, they're gonna take their time reviewing the comments, seeing what they came up with. But I will say that the administration is definitely low to embrace these

of employment restriction clauses in any form. They worry that they're not economically efficient and they are hurting workers. So I think that they're thinking about a ban, yeah, or a broadband. But I don't see it having a tremendous effect on our industry.

Miriam Allred (30:35)
Okay, let's move on and talk about 80-20. I don't know if there could be a more controversial topic in the home care industry. I'm trying to think how many months ago was it that that came out? Was that this spring?

Eric Reinarman (30:41)
Yeah.

It's a while ago. I think it was last spring, wasn't it? I mean, it wasn't this spring. It was a long time ago. Yeah, it was in 24, I think we saw that. ⁓ Yeah.

Miriam Allred (30:57)
Okay. I think it feels,

it still feels so fresh because people are still talking about it and concerning over it that I, guess I was thinking it was six months ago, but yeah, maybe it was actually last spring, but I think it just really like shook the industry at its core a little bit. People thinking about the reality that we would be up against. And I know it's years in the making and nothing's going to happen overnight, but I think people just are so worried about the implications. ⁓

Eric Reinarman (31:01)
Yeah, it does. Yep.

Miriam Allred (31:20)
I think most people are familiar with just the issue as it is, but what's kind of the current state of where it's at.

Eric Reinarman (31:27)
Sure. So obviously, one of the most, consequential regulatory changes in years in terms of Medicaid in the home care industry. We, we let a really coordinated, national response. We work closely with the Alliance and with others file the seventy five page comment letter.

met with CMS, met with OMB, met with all stakeholders in the federal government that had anything to do with this, met with the Domestic Policy Council and the White House during the last administration. As it stands right now, I think there's been no new rulemaking that would suggest that this is, well, that would invalidate this. But.

I think it's clear that the current administration is hostile to this, doesn't like 80-20. I think they are receptive to our argument that it is a one size fits all approach to a rubric that is done 50 different ways, makes no sense. In some states, 80-20 might not be that unbelievably onerous. In some states, it is incredibly onerous. That right there shows you that it makes no sense to have a one size fits all approach to something like this.

So, where it stands now, I would say, I'm not sure it'll ever go into effect, to be honest. It's certainly possible. I think the long runway they gave, if the rule, so let's pretend in this world right now where the rule was definitely going to come into effect, it wouldn't even start until July of 2030. So that's under five years, but not that much under five years. we're looking at what,

four years and eight months from now. That's a long time. Generally federal rules aren't, they don't have that kind of runway. I think that was interesting that they decided to put it out that far. I think it shows that this was sort of like, let's throw this out there and see what happens. Let's throw it at the wall and see what sticks. I'm not sure this is ever going to come to pass. I'm not saying it's not, but I'm saying that I think particularly with this administration, we are going to be and have been being aggressive

in order to make it clear that, know we know you guys don't like this, but we don't want to rest on our laurels and assume that 80-20 is going to go, it's going to disappear by itself. It won't. We need agency action in order to make this go away or legislative action, arguably, but probably agency action would be an easier lift than getting something through a divided Congress. So, you know, where it stands now, still scheduled to go into effect,

in July of 2030, but that's a long time to know and a lot can happen. And there is a large coalition of folks pushing against this right now. And we have a monthly meeting set up with CMS officials who speak directly to the White House on a regular basis. So we are doing everything we can to.

not let this get lost in the shuffle of a new administration and just assume that because we know they don't like the rule that it'll go away on its own because it won't. Action has to be taken. So we have certainly not forgotten that and we will be advocating aggressively against it.

Miriam Allred (34:19)
I hear both sides of the coin on this issue specifically. hear some providers say it's absolutely not going to come to pass. Don't lose sleep over it. On the other hand, I hear providers that are thinking that it's going to pass and preparing now for it passing. What do we need to do to tighten up our processes? How do we become more efficient? How do we make changes now that will tee us up to be able to execute on the 80-20?

It's such a divisive issue that again, I hear from both sides of the coin, people that don't think it's gonna pass, don't even think about it, but others that are like, this is gonna pass and we need to prepare for it. It's just amazing how again, of like divisive this issue alone can be. And to hear you say, it may not pass, it may pass, but it actually will take a good amount of work for us to advocate against it. But it also doesn't mean that providers, I guess,

The camp that I'm in is like, if it does go into effect, how are you preparing now? we should always be preparing for the worst and being proactive. It's not enough to rest on your laurels, to be comfortable and sit back and wait for things to happen to you. Again, this could go into effect and could absolutely rock some businesses. And so what are they doing now to prepare for it?

Eric Reinarman (35:34)
Yep, I completely agree. The good news is that there is a lot of time between now and July of 2030, but you don't want to get caught unprepared. Being prepared is always the best route to go. So I would say definitely start paying attention to it. Start thinking what an 80-20 split would look like for your agency if you do Medicaid work.

it's going to vary at the state level. There's some states where folks have told me like, there's just no question. We will just exit the Medicaid space in droves, which of course gives the lie to the formal name of the 80-20 rule. So 80-20 is just a segment of a larger rule called the Medicaid Access Rule. So it's supposedly it would increase access to Medicaid.

services including home care. Of course, we know that it will not do that and it will decrease access, right? It's clear that that is where what will happen if 80-20 is rolled out nationally in July of 2030 or tomorrow. That's what's going to happen. Folks will find themselves out of home care and they will be very upset with their elected officials as they should be. So I guess my advice would be

I wouldn't start making dramatic changes to your operations now, considering that it wouldn't go into effect for over four years, but I would definitely keep an eye on it. I would definitely, watch what is happening, advocate when we send out, if we send out alerts or advocacy, emails that encourage you to reach out to somebody, to an agency, to make a comment, I would definitely fill those out and engage with those.

Yeah, and one other thing that's interesting is that we've seen so the 80 20 split, there are some states that have taken up this idea of mandating a certain percentage go to caregiver wages. For example, Indiana did a 70 30 split. Now we worked really hard with their agency that administers.

their Medicaid dollars, FSSA in Indiana. And we worked hard to make sure that the definitions were very broad in terms of what counts for the 30 % of overhead, right? And what would count towards wages. So it is a more bearable rule, but it's still a 70-30 rule in Indiana, which you wouldn't think necessarily Indianapolis would pass something like that.

Because it's a fairly red state and generally the GOP is they're loathe to mandate certain types of spending for businesses. Let's put it that way. ⁓ Yeah, yeah. Pretty recently, I want to say. I think earlier this year, I think it was earlier this year, but it was this was recent. This was recent.

Miriam Allred (38:07)
Is that live in Indiana? When did that go live?

So it's early days.

How much do know about the rollout and the execution of that? Like what impact it really had on home care companies in Indiana?

Eric Reinarman (38:29)
Luckily, through a lot of advocacy and with help from the state association there, the Indianist Home Care and Hospice Association, believe it is, Evan Reinhart, big shout out to him. He's been really great in keeping us informed about what is going on there. It's definitely been troubling, but luckily we did get the definitions. We got it defined such that it is not as onerous as an 80-20 would be on the national level.

Because we made it clear to folks what it would do and they were like, oh, we didn't really think that through. We didn't realize it would be that onerous. So they wrote the definitions in a way that are advantageous to home care agencies. a lot is included. You can include a lot of the wage in that 70 % for wages.

Miriam Allred (39:18)
And I guess my mind goes to the extreme case and it might be too early to tell, has it wiped out any businesses? Has it drastically affected operations, the number of businesses? Any thoughts on that? Or again, it might be too early if it's just been a handful of months.

Eric Reinarman (39:33)
Little early, I wouldn't say that it's been super dramatic or drastic, but it's very troubling to agencies. And I think what it will do is it'll have a chilling effect on folks that want to go into that space, that want to offer Medicaid services, that want to expand in Indiana, right? And that's not good for the economy. That's not, know, and I think regulators started to realize that, or elected officials rather, excuse me. And the folks at FSSA realized that, and that's not the kind of climate they want to create.

So you saw them sort of change tact a little bit once we began to advocate, which shows the power of advocacy.

Miriam Allred (40:08)
Yeah, this is a prime example again of looking at a state who's made a change that now they're trying to kind of replicate and take out a national scale and how do we learn and adapt and evolve based off what we learn, you know, at a specific state level. So that's a good example. One more question about the 80-20 at the national level. You talked about it going into effect in 2030. I read somewhere about a phase in period starting as soon as 2028. What...

Eric Reinarman (40:19)
right.

Miriam Allred (40:35)
Is that true? And what does that phase in period look like and can changes be made in that phase in period or an extreme case, things aren't going well in a phase in period and they can actually change or remove the policy before 2030. Like, can you explain what that phase in period looks like and what happens there?

Eric Reinarman (40:55)
So, so I think the phase in has something to do with some reporting requirements and I don't, I can't, I can't, I don't have it in front of me. Um, and it's fairly complex. I don't think that the 80 20 provisions specifically would have to be adhered to in terms of 80 % to wages, 20 % for everything else until July of 2030. But you're right. There are certain parts of the Medicaid access rule that would come into effect a little earlier.

But a lot of that is reporting requirements. In terms of changes that you mentioned, changes could always be made. They could be made tomorrow by CMS. And all they would have to do is do another rulemaking, essentially. If they did another rulemaking...

that they could delete the 80-20 provision altogether. They could make any change they wanted to. They could change the proportion to 50-50 or 70-90-10. They could do whatever they wanted as long as they adhere to the Administrative Procedures Act, et cetera. This is just legal jargon that they'd have to follow. But assuming they did all of that, they can pretty much write whatever rule they want. So changes could be made for sure between now and then. And I would anticipate that you

will be made between now and then.

Miriam Allred (42:01)
Okay, to me that like logically makes sense that phase in period where there can be learning and adapting before it gets rolled out, in like a concrete form. So I think that's softens the blow a little bit and doesn't remove the issue but softens the blow and that there is a period of time where they can adapt and improvise.

Eric Reinarman (42:15)
Yeah.

Absolutely.

Miriam Allred (42:24)
⁓ I think that's all that I kind of wanted to hit on, on 80 20. I guess maybe one more thing. I don't know if you could speak to this, but the implications that'll have on larger agencies versus smaller agencies, we talk a lot about the number of home care companies in the U S and I don't have the crystal ball of exactly how many they are, but maybe, maybe in the ballpark of like 30,000 home care companies. And you said a minute ago about it, this deterring companies from entering the space and

that impacts the smaller companies. And there's a lot of mom and pop home care companies that, yeah, this may dissuade them or put them out of business. so any, guess, just general thoughts on the implications for larger businesses versus smaller businesses.

Eric Reinarman (43:04)
of 80-20 in particular? ⁓ I think we covered them, but I do think that it was just a very, let's just call it naive, how they labeled this rule, the access rule, in terms of increasing access. And it's not going to do that. It's going to have the opposite effect. It's going to have a chilling effect on companies' ability to offer this.

Miriam Allred (43:05)
Mm-hmm. Yeah, of 80-20.

Eric Reinarman (43:29)
the, care in this segment of the industry. And I just don't see that as a good thing. And I think that every operator I've heard says essentially they're going to stop, they just won't provide these services at all if they are providing them at all, you know, at this time. But I know a lot of other folks want to get into Medicaid work. A lot of times it's more profitable at scale, as we know, ⁓ but

I know a lot of folks that want to do this and depending on what state you're in, it can be more or less appealing of a business line to be in. it's really a shame and it's a poorly thought out rule and it will have a chilling effect on the home care industry and thusly the ability of Americans to get the care that they need in their homes as they age.

Miriam Allred (44:17)
I can see both sides, the concept being we want to pay care workers more and that's at the surface, you know what they're trying to accomplish, but at the expense of the businesses that are operating to make this feasible for both the clients and the caregiver. So I guess my take is I don't envy you or people that are trying to navigate these policies because it's really complex and that's why it takes years in the making to fine tune.

these types of issues because there's no easy answers. It's always complicated and it has implications for both sides.

Eric Reinarman (44:52)
That's a great point. I'm glad you brought that up because we want to raise wages, right? But the best and most efficient way to do that is to raise reimbursement rates. That's where you're going to see increases in wage wages. It's not going to come from mandates where many states are already provide a paltry reimbursement rate as it is. if you raise those reimbursement rates, then you're to see increases in wages. That's the way to increase wages. you're if you're serious about

If policymakers are serious, they're going to increase reimbursement rates.

Miriam Allred (45:23)
And that's where a lot of our state advocacy needs to go is raising reimbursement rates at the state level. I completely agree. And I think we've made headway there. We've seen that happen in certain states, but it's just cumbersome to get that across the finish line, state over state.

Eric Reinarman (45:38)
That's right. Yep, absolutely.

Miriam Allred (45:40)
We've talked about a lot of the bills that I had on my list. I think the only other one that we haven't touched on is the Elizabeth Dole Home Care Act. I know that again has been in the making for a good amount of time. And I think there's been finalization on that, but any, any thoughts on kind of present state of that and why it might be relevant.

Eric Reinarman (45:57)
Yeah, we got that got passed. So we got that as part of a big veterans bill. So it removed that cap. You know, want to I won't go too much into into it. But it removed a cap that sort of ⁓ favored institutional settings for care for veterans as opposed to home care. So it allows the veterans to receive as much care in the home as they would have in institutional settings. So no longer does federal

policy favor the nursing home, for example. So that was passed. We're starting to see that trickle out and seeing caregivers more apt to be hired for veteran care, which is great. But yeah, that was our big win. Of the last couple of years was getting that passed. That was a big one.

Miriam Allred (46:48)
And we need to hold onto the winds because again, I think that one's been four, five years in the making, maybe three to five years. And that's just a good reminder that everything that we're talking about today is maybe one, two, three years in. Not everything is a five year timeline, but it's, it's oftentimes maybe a three to six year timeline. And so these things don't happen overnight, but it comes back to where I want to end this conversation again, is just getting owners to advocate. Again, none of this happens.

Eric Reinarman (46:50)
We do.

Yes. Yes.

Truly.

Miriam Allred (47:17)
on its own. And I think we all can say that we don't want legislators just overhauling decisions. And that's where we need to get involved. And so I want to maybe put you on the spot and thinking about, again, leaders that you've met out in the industry that are doing advocacy well, like what, what specifically are they doing that's moving the needle in their local market, in their state, or even at the national level?

Eric Reinarman (47:42)
⁓

Getting to know, I would say getting to know their state local officials, so their state senator and their state member of their state house, you in their capital. So let's use Texas as an example. I know you're in Texas. So whoever represents you in the Texas Senate and the Texas House, you know, getting to know them, because that's, you can really form a really good relationship with those folks, because they often get forgotten. Folks, you know, we need more civics in this country, and I think the home care

industry

is pretty good at understanding this, but when I was at the other association and when I worked for the state legislature, I worked for the Florida state legislature for a while in the Florida Senate, it was amazing how much people misunderstood what goes on at the state level and how important it is in your state capital what goes on, how much that affects you every day. So I think the best thing they could do is look up who represents them in their state capital and set up a meeting with them. Say I'm a small business owner in your district and I want to talk to you

about home care. They you'd be shocked. They'll be like absolutely and it won't necessarily be with staff. A lot of times when you try to meet with with the congressperson you have to meet with their staff because they're so busy half the time they're back in the district you know you never know where they are but

or in Washington, you know, or one or the other. But these state folks, when they're not in session, they're just regular people. They're accountants, they're home care owners, they own three Burger King franchises, they are nurses, doctors, lawyers. They're just regular people.

And you can meet with them and you and they will listen to you and their staffs will listen to you. You can form a real relationship where I know, I know owners that text with their state rep or their state center on a regular basis. Hey Steve, hey Amy, know, ⁓ this is, this is happening, you know, can you help me with this? help me get it, get in a line with the Medicaid agency in my state, you know? so I think that's something that is really.

you'd be shocked how willing they are and how happy they are to hear from their constituents at the state level. So that's something you could really do.

Miriam Allred (49:40)
And everyone,

everyone has a voice and everyone can build that relationship. I think back to a couple of weeks ago, I interviewed Bob Roth and he was saying he is an independent home care company in Arizona, but he was saying, thank you to the right at homes. Thank you to the senior helpers. Thank you to the visiting angels. Thank you to all of the large national franchisors that have done so much work to advocate for home care at the national level. But I love this call to action that you're stating, which is

Any owner, any operator listening to this big or small independent or franchisee can go out, meet their Senator, build that personal relationship and become an ally, become a partner, become an advocate with that individual. And we just need more people doing that. And the second comment I want to make is you talk to these home care leaders, you and I both, they want to make an impact. And the best way they can do that is by taking care of their clients and taking care of their caregivers.

But the next way is advocacy, making an impact, building those relationships. Think of the impact you can have at the state and the national level. Another just great way to make a long lasting impact is advocacy. You being an advocate to make changes on the local level and the state level, you could be impacting clients, caregivers, families for generations. And so I guess my call to action to leaders listening to this is

Eric Reinarman (50:58)
Absolutely.

Miriam Allred (51:01)
Advocacy is the next best way that you can make an impact. And so make it a priority to get out there, develop these relationships.

Eric Reinarman (51:09)
Yeah, and I completely echo what you're saying and I love the energy and the positivity and you're absolutely right. And I would just say that, you know, a lot of times I hear that folks are nervous or folks don't know what to say or they wouldn't know what to say in a meeting. It's just storytelling, you know, A. And B, remember that, you know, as a voter, you're kind of their boss, you know, and obviously you're not going to go in there and be dictating terms and, ordering people around, but they want to hear from you because they want to learn what's going on in their districts. And it's just, it ends up being storytelling.

Tell them what your day in day out looks like. Tell them, how many people you employ in their district. That really matters to them. And that's all you need to do is just say who you are, say what you do and tell them what you want, which is, you you want it to make it easier for folks in your district to access your services and people want your services and they need help doing it. So if that means I need the Medicaid rate increased, boom, do that. If there's a bill that clarifies the scope of home care within

within your state, support that bill. Explain to them what home care is as opposed to home health, right, as opposed to hospice and other types of care that is brought into people's homes. So there's a lot you can do when you advocate and it doesn't need to be intimidating. You don't need to know the ins and outs of the process of the arcane, legislation process. You don't need to know about that. Just go in, tell your tale, and they'll be thrilled to have a meeting with you, honestly.

Miriam Allred (52:31)
we've both probably seen this when you talk about storytelling, bring a client with you, bring a caregiver with you, talk about impact and storytelling and getting through to the heart of the Senator. You bring a veteran there and have them tell their story and tell the impact that home care has had on their life and the life of their family. I mean, I get chills just saying that, but you hear these stories.

And that is the best way to get through to the senators. are people too. They have families too. They're all aging too. They're all going to need home care down the road. And so what better way to kind of level with them is to tell that story. And again, I would encourage bring a client, bring a family member, bring a caregiver to tell their personal story as well.

Eric Reinarman (53:15)
It's a great point. Absolutely couldn't say it better myself and never, never, fail to tell yourself as the economic engine that you are, you're an entrepreneur. You make this country go round. You are the ones that make that district, you know, ⁓ you pave the roads, right? You pay for the schools, the stoplights, the stop signs, et cetera.

make it clear to them how many people you employ. That stuff, that really moves the needle for legislators because they deal with a lot of numbers. So, you telling them the economic effect you have on top of the more heart rendering aspects of home care, which we do have, right? We could be another industry that we could be the American Chemical Society, right? There's not much heart in advocating for chemicals. We might need them, right? And they might play an important role in all of our lives.

There's no heartwarming aspect to that. So you have the great ⁓ blessing of it being ⁓ an industry that has not only an economic effect on these districts, but the effects on people's hearts and minds. So never forget that either ⁓ when you're advocating with them.

Miriam Allred (54:22)
Last question, Eric, why should people engage with the Home Care Association of America? What is it that you all do that adds value to these home care companies? I think many of people listening to this are engaged, but there might be a handful that aren't. But tell us about the impact that being associated with and involved with HCAOA can have.

Eric Reinarman (54:41)
Yeah, I mean, just the fellowship and the camaraderie, that's one thing that I think folks love about HCAOA and our conferences and our state chapter meetings, etc. Education is a big aspect to it. We have a schedulers conference every year where we help educate on the best way to run scheduling. We have all sorts of other educational offerings that are behind the paywall for members only. Advocacy and knowing what's going on in your state.

is another reason why you should join us. We're doing our best to keep our fingers on the pulse of what's going on in your state. We have eight state-level lobbyists, so we have eight lobbyists in states across the country. We have a federal lobbyist, so we're out there working for you, pushing for you, and for policies that make,

providing home care easier and more manageable.

We welcome all comers. We are looking to expand always. Everybody's welcome. We're a big tent association. So, anyone that has any questions can feel free to reach out to me, can reach out to our membership coordinator, Kristen. We would love to, explain how we can, and why it's a good idea to join HCAOA. Yeah.

Miriam Allred (55:51)
Fantastic. And I think

my last two cents is you all do a great job of disseminating all of this information. What we talked about today, these policies, these topics are hairy and complex. And I think that's kind of the initial hurdle for owners to get over to is just how do I learn about these things? Where do I go to learn about these things? How do I get kind of like unbiased, unfiltered information? And you all do a good job of disseminating this information down to the leaders of this industry. And so that's where a lot of the value is as well as just understanding these policies.

and where you all are positioned on them. So Eric, this has been a great session. Again, I think there's nuances to everything that we talked about today. And so again, I encourage people to reach out to Eric and spend more time with him and ask more specific questions or even state specific questions. And he can be a resource, but also point you to people that can be a resource as well. So Eric, thank you for joining me in the lab. Great session today.

Eric Reinarman (56:39)
Thank you so much. I really appreciate you having me on.