This problem disproportionately affects workers living in the South, young people, and people of color.
Direct-care workers need access to preventive care and timely health care intervention to live healthier lives. Healthy workers are better able to provide high-quality care to the people they serve.
Policymakers, advocates, and employers all have a responsibility to address this inequity.
Protect and Improve the ACA
To ensure that millions of people, including direct-care workers, can retain their coverage, the Affordable Care Act must be protected from attacks that chip away at essential aspects of the law, such as the recent challenge of the legislation's federal subsidies. Additionally, the ACA should be monitored, assessed, and improved to ensure that each provision is resulting in equitable access to high-quality care.
Expand Medicaid in Every State
State governments should expand Medicaid in every state, reaping benefits for their residents and their state economies. For example, to improve the political feasibility of Medicaid expansion, seven states have asked the Centers for Medicare and Medicaid Services (CMS) to waive certain Medicaid requirements, through 1115 waiver programs. Though these waivers have limitations, they nevertheless allow for enhanced Medicaid enrollment in places where it would be otherwise politically unfeasible.
Additionally, states that have expanded Medicaid eligibility could choose to further expand eligibility, as three states have done for parents or childless adults, or take up the “Basic Health Program”—an option offered in the ACA to make care more affordable and ease churning for individuals with incomes up to 200 percent FPL.
Employer-Sponsored Health Coverage
Providers such as nursing facilities and home care agencies could elect to make employer-sponsored coverage more accessible, particularly if states would create the incentives for providers to do so.
Differential reimbursement rates. To support providers in covering the costs associated with increased wages and benefits for direct-care workers, a handful of states have increased their Medicaid reimbursement rates. Higher rates make it more feasible for providers to offer health coverage to employees. In light of the employer mandate, all states should consider similarly increasing rates to ensure providers can afford to offer quality employer-sponsored health care coverage at affordable rates.
Small-employer pools. Small direct-care providers for whom providing employer-sponsored insurance is particularly challenging could join with other small providers as a pool to negotiate better rates with insurance plans, and in turn help provide coverage to their workers.
Stable work schedules. Direct-care workers are often faced with unpredictable schedules, and most work part-time hours, which makes them ineligible for employer-sponsored insurance even where it is offered. Providers could offer more predictable schedules and guarantee a minimum number of work hours to direct-care workers, helping stabilize their incomes and their eligibility for Medicaid, health care subsidies, or employer-sponsored insurance.
Direct-care Workers in States that Have Not Expanded Medicaid Eligibility Under the Affordable Care Act
|State||Total||Uninsured||Under 138% FPL||Under 100% FPL|
|Percentages drawn from American Community Survey 2009-2013 ACS 5-year PUMS. These were applied to counts of direct-care workers from the Bureau of Labor Statistics, Occupational Employment Statistics program, May 2014 estimates.|
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