Do you know who is going to care for you when you are old and frail? By current standards, it’s likely to be a middle-aged immigrant woman, with maybe a high school education and little if any training, making $20,000 a year.
And that’s if you are lucky. If you live in rural America, you may already have a hard time finding somebody to look after you. Paul Osterman of the Massachusetts Institute of Technology’s Sloan School of Management calculates that if nothing is done to draw more workers into the field, there will be a shortage of at least 350,000 paid care providers by 2040.
This, I’m sure you’ll agree, makes little sense.
How to provide long-term care for a fast-aging population poses one of the more convoluted challenges of the U.S. labor market. Care providers — home health aides, personal care attendants and certified nursing assistants, in the government’s classification — are expected to be among the nation’s fastest-growing occupations. The Department of Labor’s economists expect about 1 million more will be added from 2014 to 2024.
And yet despite their critical importance to the well-being of tens of millions of aging Americans, one-fourth of these aides live in poverty. The jobs are so unappealing that it is hard to keep workers in them: 4 in 10 leave the occupation entirely within a year. Many prefer the fast-food business.
“Home care is absolutely the bottom rung on the ladder, but home-care workers are the people that spend the most time with the client,” said Adria Powell, who runs Cooperative Home Care Associates, a worker-owned long-term-care agency in New York.
As President Donald Trump promises to recover the jobs of an ancestral age populated by well-paid coal miners, steelworkers and assemblers of air conditioners, he is missing one of the most critical challenges of the U.S. workforce: transforming long-term care into a higher-quality, better-paid job that could support the middle class of the future.
It can be done. In his new book, “Who Will Care For Us?,” to be published next month by the Russell Sage Foundation, Osterman suggests that improving these jobs could actually improve the quality and efficiency of the entire health care system. “It could save the system money,” he told me.
There are a few reasons long-term care is such a bad job. “Most people see it as glorified baby-sitting,” said Robert Espinoza, vice president for policy at PHI, an advocacy group for personal care workers that also develops advanced training curriculums to improve the quality of the workforce.
The fact that most workers are immigrant women does not help the occupation’s status. Occupational rules that reserve even simple tasks for nurses, like delivering an insulin shot or even putting drops into a patient’s eye, also act as a barrier against providing care workers with better training.
But perhaps the most important barrier is the government’s budget: Medicaid — funded by federal and state governments — picks up more than half the tab for the $300 billion or so spent every year on long-term care.
States spend about $200 billion of their own funds on Medicaid. It is the second-biggest item on their budget, after education. To raise reimbursement rates for long-term care agencies, they would have to find the money elsewhere.
Still, Osterman points out that shortchanging long-term care is shortsighted. Home health aides trained to do more — to spot patients’ health problems, to keep track of their pills and doctors’ appointments and to offer advice on healthy living — could wring billions of dollars in savings from the health care system.
Better-trained aides could help patients manage chronic conditions like obesity and diabetes. They could also help manage the transition out of a hospital, ensuring that patients took their medication and followed up with the doctor, to prevent them from having a relapse or ending up in a nursing home.
One assessment of the academic literature concluded that there are $250 billion in savings to be had from better managing chronic conditions and reducing hospital and emergency room admissions and readmissions.
And there are other jobs for personal care aides to do. For instance, community health workers doing home visits can help bridge the gap between patients and doctors — improving rates of immunization, helping manage conditions like high blood pressure and otherwise encouraging healthy behaviors.
Marisol Rivera offers a glimpse at how this could be done. After 16 years as an aide for Cooperative Home Care Associates, she was promoted to senior aide, assisting less-experienced aides in the field. She reminds them how to use the Hoyer lift to get patients out of bed and into their wheelchair. She keeps tabs on hospital discharge papers to make sure patients — which the firm calls members — make their next doctor’s appointment. “Most of time the reason members go back to hospital is because they don’t check back with the doctor,” Rivera said.
Rivera offers some hope for the profession. Her hourly wage went from $11 to more than $15. Still, her situation is rare. Worker-owned Cooperative Home Care Associates has only two senior aides like her. What’s more, she says, “I still live week by week.”
Changing the system of long-term care to give more responsibilities to better-trained, higher-paid aides will not be easy. For starters, there is the awkward question of the distribution of costs and benefits. Medicaid pays for most long-term care, but Medicare would reap most of the potential cost savings from things like fewer hospital readmissions.
Cash-short states have resisted efforts to raise aides’ pay. Worried that overtime rules would break their budget, some opposed the Obama administration’s effort to cover home-care aides under the Fair Labor Standards Act, from which they had been excluded based on the outdated argument that they were little more than baby sitters.
Then there are the powerful nursing unions, ready to fight tooth and nail to keep aides from encroaching on their turf. Carol Raphael, former chief executive of the Visiting Nurse Service of New York, the largest home health agency in the United States, told Osterman that when the association tried to expand the role of home-care aides, the “nurses went bonkers.”
Even advocates for older Americans have lobbied against tighter rules covering things like training for long-term care workers. Many of them also opposed covering aides under the Fair Labor Standards Act, as states facing overtime payments might cap the workweek for aides at 40 hours. If a relative were caring for you and the government said that she could work for only 40 hours, how would you get more hours if you needed them?
Still, overhauling long-term care seems within reach. Penalties for excessive readmissions are already encouraging hospitals to rethink the role of home-care aides. And Obamacare is changing the health care industry in ways that would support a better-trained, better-paid home-care workforce, pushing providers to manage the overall health of patients rather than offer health services for a fee.
“There is a light bulb that is sort of going off,” Powell said. “Shouldn’t we figure out how to leverage this workforce and invest in this workforce to reduce hospitalization, to reduce ER visits, to manage chronic diseases that are so expensive?”
This is encouraging the formation of health teams, in which long-term-care aides — who are cheaper than doctors or nurses — could have a larger role in managing patients’ well-being.
You might think of it in terms of demographics. By 2040, there will be more than 50 million disabled people in the United States needing some form of long-term care, 12 million more than there are today. Most will be cared for by family members, but the demand for care workers will explode.
It makes sense for these workers to be better trained and empowered to offer better care. If nothing is done to improve the quality of their jobs, many will go unfilled — losing the competition for workers with McDonald’s.
In the end, the issue is not just who will care for you when you are old and frail. The broader issue is what American society will look like then. Because these are the jobs of America’s future. And America will look much better if they can sustain a middle class.