Building the Nation’s Eldercare Direct-Care Workforce: Policy Implications

This article was adapted from a talk presented at the 2012 Annual Conference of the American Society on Aging, Aging in America, held on March 30, 2012, in Washington, DC.

^aSince this talk was given, the Supreme Court of the United States has upheld the constitutionality of the ACA while leaving the expansion of Medicaid in the hands of the states. Many surmise that most states will be unable to turn their backs on the infusion of federal Medicaid dollars. Full implementation of key elements of the ACA, such as the geriatrics workforce provisions under Titles VII and VIII, is still dependent upon annual appropriations, and Congress has yet to send a 2013 appropriations bill to the president.
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The paraprofessional direct-care workforce in the United States, which serves elders and people with disabilities, includes home health aides, certified nurse aides, and personal care workers. These individuals currently number 3.4 million—more than all registered nurses in the country and more than all child-care workers and elementary school teachers combined. Even more dramatic, the number of direct-care workers nationwide is now projected to grow to 5 million by the end of this decade.

Given the scale and importance of this workforce, the American Society on Aging (ASA) asked the American Geriatrics Society (AGS) to speak to the public policy forces—past, present, and future—that impact the quality of these frontline jobs and the resulting quality of services for elders.

Policy Past

We direct your attention to the Winter 2010–2011 issue of the ASA’s quarterly journal, Generations, and specifically to the article on eldercare workforce policy that was cowritten by the AGS, the Eldercare Workforce Alliance (EWA), and the Paraprofessional Healthcare Institute (PHI) in 2011. That article recounts how the modest—but very important—eldercare workforce policy elements that finally found their way into the Affordable Care Act (ACA) were not a last-
minute stroke of luck. Instead, they were the culmination of more than a decade of model building, research, coalition organizing, and lobbying. The article also underscores the strategic role that philanthropy—in particular the John A. Hartford Foundation and The Atlantic Philanthropies—played in that process.

Our point being: even modest advances require an astonishing amount of time, creativity, trust, and cooperation.

Policy Present

The current congressional gridlock predictably leaves us little hope for federal legislative advance—prospects are dim for reauthorizations of the Older Americans Act and the Workforce Investment Act—and so we are all left to fight a rather defensive battle: attempting to protect what we’ve achieved and shape the implementation of those achievements.

Specifically from the direct-care workforce perspective, we first want to underscore that, since most direct-care workers have low incomes, the general provisions of the ACA are the ones that will have the most impact and, thus, are critically important to protect. For example, the ACA’s expansion of Medicaid to 133% of the federal poverty level would extend public insurance coverage to nearly 400,000 currently uninsured workers.

As to specific direct-care workforce provisions, there is good and bad news. First, the good news: the United States Department of Health and Human Services (HHS)–funded Personal and Home Care Aide State Training grants have placed $15 million into six states to develop model curricula and recommend core competencies for the personal care workforce. The bad news: the collapse of the Community Living Assistance Services and Supports Program. This was a profound disappointment on many levels, and the loss of the Personal Care Attendants Workforce Advisory Panel was a particular blow for direct-care worker advocates. A very strong panel was named and primed to begin, and that panel would have offered the highest-ever government forum exclusively focused on direct-care workforce issues. Its “suspension” is definitely a setback we regret.

Still, we believe the most profound explicit healthcare workforce accomplishment resides in the “Funding Opportunity Announcement” from the Center for Medicare & Medicaid Innovation (CMMI), in which the CMMI included a very thoughtful workforce development requirement within the framing of the invitation. As we called for in our Generations article, we do hope all forthcoming HHS grant opportunities will acknowledge the importance of investing in eldercare and disability services and, similarly, acknowledge the centrality of all staff who deliver care—and that those staff deserve explicit strategies for training, support, and genuine team building.

Yet for direct-care workers this year, the most important policy advance at the federal level was not legislative or administrative, but regulatory. Currently, the home care workforce in the United States does not enjoy what most all other wage earners are guaranteed, which is minimum wage and overtime protection under the Fair Labor Standards Act.

The Obama Administration’s Department of Labor targeted this indefensible exemption early on and issued a strong proposal for “narrowing” the exemption, extending protection to hundreds of thousands of aides. Not only that, but President Obama personally announced the proposed regulatory change in the White House, surrounded by 20 home care aides from across the country, making good on his campaign commitment to redress this inequity. This is a big deal.

Still, if we only consider federal activity, we are missing more than half of the story, because great changes are occurring at the state level across the country—Medicaid reductions in particular—that are resulting in significant cuts to a range of programs serving elders.

These cuts are extremely serious, yet often overlooked is a different type of institutional weakening: reductions in agency staffing levels within state health departments across the country. Not only is there fewer staff, but many state agencies are now losing precious expertise and institutional knowledge. It is difficult to imagine how these weakened agencies can be expected to manage the growing complexity and massive changes in health funding and service delivery.

Fortunately, not everything is in decline at the state level: one shining, positive example for the direct-care workforce is that last year, New York State passed a home care aide minimum wage law that will benefit more than 80,000 home health aides in New York City and surrounding counties. While the state’s minimum wage is currently $7.35 per hour for all workers, Governor Andrew Cuomo signed legislation in 2011 that has moved all Medicaid-funded home care workers, starting in March 2012, to $9.00 per hour plus health insurance, rising to $10.00 per hour in 2014. While that is still shockingly low, it means that $250 million more—annually—will be placed in the paychecks of home care workers. Another pretty big deal!

Policy Future

And now to the subject of policy future. Who knows, right? Will 2013 find us with a new president, a new Congress, and an entirely new budget? Will the U.S. Supreme Court uphold the constitutionality of the ACA?^a

One thing we will predict: the battle ground for where policy will be shaped will shift—indeed is already shifting—away from the federal and state governments and into the hands of managed-care payers. Even as you read this, deals are being struck in states across the country. Pressures to reduce costs and integrate services are pushing the states to contract with managed-care plans for their Medicaid populations—particularly for high-need, high-cost individuals—and it will then be up to these plans to determine how services will be delivered. For example, if you are interested in care coordination for low-income elders receiving long-term care services, over the next 5 years, no matter who is president, it will increasingly be the managed-care organizations (MCOs) that will determine the design of care coordination teams, not the federal or state governments. While government policymakers will work to regulate care outcomes—and we support aggressive attempts to do so—the design of service delivery inputs (which have the greatest impact on eldercare workers) will be left primarily to managed-care plans within broadly capitated reimbursement frameworks.

It is fascinating that, in this age of “transparency,” we are entrusting our service delivery system design to an exceedingly opaque structure. And we are not against MCOs in principle—the PHI sponsors Independence Care System, a Medicaid-managed long- term care plan in New York City. It is just that each MCO is a bit of a black box, and the values that you pour into that box determine what pours out. Therefore, we support policy efforts to ensure consumer engagement and more explicit state contracting standards and reporting requirements, but we also call for direct engagement in building MCOs that model best practices in service delivery design.

The PHI and the AGS, in our fieldwork with homecare agencies and nursing homes, teach direct-care workers, supervisors, and administrators that you can’t really control other people, but can only control yourself. So in that spirit, we would like to argue that we have the greatest chance of shaping future policy if we don’t focus so much on what others are or are not doing—but rather that we take a hard look at ourselves.

And here is where we’re sure we will get into serious trouble. But we believe it is worth taking some risks, for when looking to the future, we are genuinely concerned that those who care about the quality and availability of eldercare services remain unnecessarily divided, and those divisions in turn diminish our effective advocacy.

(1)       First, it is our experience that the aging community remains quite separate from the disability community—to the detriment of both. From the aging perspective, we would simply submit that the disability community has accomplished enormous policy change in how all of us now think and talk. After all, the core concepts of “consumer direction” and “person-
centered care,” and even the language of “long-term services and supports,” all originated from the disability community—even though the disability community has 1/100th of the resources (no Administration on Disability, no equivalent of the John A. Hartford Foundation). We have much to learn from the assertiveness and courage of the disability community.

(2)       Second, family caregiver advocates and paid caregiver advocates still need to coordinate more closely, to make sure that we are not pitted against one another. There has been significant progress in this area over the past 5 years, due to relationship-building across organizations, but we still have a long way to go. We simply shouldn’t compete against one another to determine who is the more worthy of attention and
resources—we must combine forces more explicitly.

(3)       Third, there remains enormous distrust between organized labor and much of the rest of the eldercare community. We acknowledge that there is a whole lot of history there, but any hope that the field can make systemic progress on workforce issues—particularly direct-care workforce issues—without thoughtful cooperation between organized labor and other advocates seems fruitless. This will take more than serving on a few coalitions together. This will take genuine communication, trust-building, and, ultimately, change—across all parties.

(4)       Fourth and finally, gaps remain between professionals and paraprofessionals within eldercare services. Again, there is progress here—notably the Institute of Medicine’s report on the eldercare workforce dedicated an entire chapter to the direct-care workforce—yet we still have a long way to go. Technically, this divide will be played out along questions of where and how to draw the line on scope of practice issues—50 different lines drawn within 50 different states. But more systemic and more hidden are our own biases. There is often a class and race divide here, between the professionals and the paraprofessionals, and it limits all of us in solving the challenges we face. Just one example: in a funding proposal that we recently reviewed, two roles were described, one for a professional, the other for a paraprofessional. In a brief description of each, the proposal noted that the paraprofessionals would be drug-tested, but curiously, no mention of drug testing was in the professional’s description. We are blind to our own prejudices, and they, in turn, blind us.

So, now that we may have succeeded in annoying almost everyone, let us simply restate the plea for policy future: that we can and must fight against budgets and all other forces that attempt to constrict resources for elders. We have the greatest chance of succeeding, particularly in the long run, if we focus on ourselves and work to determine how we can build more trust and confidence in one another. The EWA is a very good example of that—we’ve bridged many a divide around that table—and we have only just begun. If you are not yet part of the EWA, we urge you to join us. Find more information at www.eldercareworkforce.org.

Our thanks!