Here’s the latest in PHI’s Long-Term Care Expert Interview Series spotlighting issues and trends affecting direct-care workers.

When Josh Wiener talks, people listen. So it’s good news for everyone who’s working to improve direct-care jobs that Wiener talks a lot about the looming shortage of direct-care workers. The growing care gap, he says, is ”the elephant in the room” whenever people are talking about providing or reforming long-term care in the U.S.

Wiener, who got his bachelor’s degree from the University of Chicago and his masters and doctorate degrees at Harvard, all in sociology, has worked for the Health Care Financing Administration, the Urban Institute, and the Brookings Institution, among other influential institutions. He is currently a senior fellow and the program director for aging, disability and long-term care at RTI International. The author of eight books and more than 100 articles about long-term care, Medicaid, health reform, and related topics, he often advises state and federal policymakers on issues concerning aging, disability, and long-term care. In a recent interview with PHI, he explained why he has been warning those policymakers that they need to pay more heed to the growing care gap and how to close it.

The problem

”It seems to me that a lot of the discussions about improving the quality of care or changing the delivery system start with the assumption that we will have workers who can provide services, and I think the long-range demographics are such that that’s not clear at all,” he says. ”In 2005 there will be close to 35 people aged 25 to 64 for every person aged 85 and older, but by 2050 that ratio falls to about 15. So we’re going to have to get a much higher proportion of the overall workforce into long-term care than we are now, and given the pay, the benefits, and the overall structure of the job, we’re not very likely to be able to do that.

”That raises a lot of questions. Are we not going to provide the services? Are we going to put the old people on the ice floe and send them off? Are we going to find some kind of technological substitute? While I’m not quite as skeptical about the future of technology in this area as I was in the past, long-term care is basically a hands-on, person-to-person kind of job, and it’s not clear how technology is going to significantly substitute for people.”

The solution

Wiener believes there ”a number of common-sense things” that could be done to improve direct-care jobs in order to find and keep the growing number of workers needed.

”The troika is basically wages and benefits, trying to change the organizational culture, and providing additional training and job redesign — making it more into a career ladder. The career ladder, in my view, is really sustainable in the long run only if it ties into wages and benefits. And in nursing homes, there is a threshold issue of staffing. The study Abt Associates did in 2000 and 2001 suggested that about 90 percent of nursing homes were understaffed. Raising the staffing levels would make the work experience there better, because people there would feel better about the work that they’re doing.”

Wiener doubts that employing more immigrants is the solution to the direct-care worker shortage, though it is sometimes touted as such. ”This will require us to have a very different discussion about immigration than the one we just had, where people were largely up in arms about the number of people coming in and trying to restrict the number of low-income immigrants,” he says. ”And it raises significant questions about exploiting this population. Are we going to have them coming in with a level of pay and benefits such that we can’t get Americans to do the job?” Employing people who are from other cultures than the people they are assisting, especially if they speak a different language, also raises questions about how well caregivers can communicate with and about the consumers they assist.

The lack of political will

The barrier to solving the problem of high turnover and vacancy rates among direct-care workers is not a lack of solutions. ”The core issue has been the political will to do those things,” Wiener says. ”That will be the test of this society now and in the future.

”We in the policy scene are not really spending very much time and effort trying to address those workforce issues,” he adds. ”We certainly don’t have a conscious strategy either at the national or the state level. We’re not thinking strategically about this.”

Wiener thinks that failure to act is due to two factors. The first is a ‘’strong aversion to the expansion of public health programs” since the collapse of the comprehensive health care reform effort in 1994. Since state and federal governments are the main payers for long-term care, improving direct-care jobs would mean spending more on wages, health care coverage, training, or other benefits — and that’s a hard sell for policymakers and elected officials. ”Raising wages for direct-care workers doesn’t provide you much politically, because you’re basically paying more to provide the same services for the same set of people,” Wiener points out.

The second factor is the relatively low priority that has historically been given to long-term care in policy discussions. ”When the baby boomers turn 85, long-term care will be on the cover of Time magazine 26 weeks a year and Newsweek the other 26 weeks, but that’s a long time away,” Wiener says. To prepare for that time, we need to focus on the challenges and make changes now, but at the rate things are going, he fears, ”we may not be able to make the changes fast enough to solve things in a very satisfactory way.”

The elephant in the room

When he talks to policymakers about the need to address the workforce, Wiener says, ”Much of the reaction I get is: ‘Yes, this is going to be a big problem, and no, I don’t want to deal with it right now, thank you.’ That’s why I’ve called it the elephant in the room: Everyone knows it’s there; everyone knows it’s going to have a huge impact, but few policymakers are willing to take on what it would need to address this in a systematic fashion.”

But that awareness, and the increasing focus on the problem by researchers and funders, is progress in itself. Except for a bit of ‘’sporadic attention” paid to a worker shortage in the early 1990s, when low unemployment rates made it more difficult for long-term care employers to compete for employees, there was ”almost nothing” published about direct-care workers in the research literature until about 1997, Wiener says. ”It’s only been in the last eight or nine years that it’s gotten some increasing attention.” The shortage of the early ’90s also ”jump-started the interest of the Robert Wood Johnson and Atlantic foundations and of HHS, especially ASPE.”

For the last 20 years, Wiener has given speeches that ended by predicting that the baby boomers were going to put long-term care on the political agenda soon. As they began caring for their aging parents and learning about the weaknesses of the current system, they were sure to demand better. ”So far I’ve been proven wrong,” he adds with a laugh. ”But we’re not through that demographic yet.’