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A May 2011 report by Families USA says that the proposed federal cuts to Medicaid would put the health of older adults and people living with disabilities at risk by eroding the health care safety net that Medicaid was established to provide.

Cutting Medicaid: Harming Seniors and People with Disabilities Who Need Long-Term Care also discusses how slashing the Medicaid program would hinder the nation’s ability to build the direct-care workforce to meet the increasing demand for long-term services and supports.

Families reports on the projected shortage of direct-care workers and cites PHI data on the workforce growth needed in each state by 2016 (pdf). The organization expects that payments to long-term care providers will be reduced should the proposed Medicaid cuts be enacted, and says such measures will “hamper efforts to build up the direct-care workforce.”

A reduction in Medicaid provider payments will lower compensation for direct-care workers and further exacerbate the workforce shortage. Ultimately, everyone will suffer — even individuals whose long-term care is not covered by Medicaid — because a workforce shortage will lower the quality and availability of care for everyone, the report explains.

Key Findings

Families reports that many older adults and people with disabilities depend on Medicaid for health care and long-term services and supports:

• More than 16 million older adults (6.3 million) and people with disabilities (9.8 million) depend on Medicaid — in other words, more than one in four people who are over 65 or living with a disability rely on Medicaid.
• Medicaid is a critical source of coverage for people who need nursing home care; it is the primary payer for an estimated 63.6 percent of all nursing home residents.
• Medicaid services help older adults (3 million) and people with disabilities (2.8 million) to remain living in the community.

A series of State Fact Sheets that provide details on how the federal cuts to Medicaid would affect each state accompanies the Families USA report.

Bill Passed to Allow States to Reduce Medicaid Enrollment

There are several proposals in Congress on different measures to cut Medicaid:

• convert Medicaid to a block grant with much less federal funding
• cap federal spending
• allow states to significantly reduce Medicaid eligibility and enrollment

Under the Affordable Care Act (ACA), states are prohibited from making large reductions in Medicaid eligibility or changing the eligibility criteria to make it more difficult to enroll in the program.

Families explains that this ACA protection, known as the “maintenance of effort” (MOE) requirement, was included in the law to ensure that important health coverage remains in place until the new law is fully implemented in 2014. It reports that the effort to repeal this provision is likely to be taken up in Congress “very soon.”

In fact, CQ Weekly reports that on May 12, the Republican-led House Energy and Commerce Subcommittee on Health approved a bill (H.R. 1683) that would permit states to reduce Medicaid enrollment. The journal says that the bill is expected to be passed by the Energy and Commerce Committee but a date for the vote has not yet been set.

For more information on Medicaid block grants, read the PHI publication Medicaid Matters…for Long-Term Services and Supports.

– by Deane Beebe

The Affordable Care Act (ACA) contains numerous provisions that will help the U.S. meet the rising demand for eldercare-focused health care workers, according to a brief by the Alliance for Health Reform.

The brief points out several ACA provisions that are specifically designed to strengthen the direct-care workforce.

Causes of Rising Demand

The ACA itself will raise the demand for health care workers — physicians, nurses, and direct-care workers — by expanding coverage to approximately 32 million additional legal U.S. residents.

Additionally, demand will increase dramatically as the “baby boomer” generation ages into Medicare eligibility.

According to the brief, 78 million baby boomers will reach age 65 by 2030. That’s an average of 10,000 baby boomers turning 65 each day, according to the Pew Research Center.

These elders will increasingly rely on health care workers who specialize in caring for older individuals, the brief notes.

Direct-Care Workforce Provisions

“The ACA recognizes the value of direct-care workers to health care delivery and contains a number of initiatives that address current issues and future challenges,” the brief states.

These initiatives include:

• Grants and other financial incentives aimed at encouraging providers to enhance training, recruitment, and retention of direct-care staff.
• Grants to Geriatric Education Centers requiring that the centers offer courses on geriatrics, chronic care management, and long-term care.
• The Personal and Home Care Aide State Training (PHCAST) program, in which six states received grants to develop core competencies and certification programs for personal and home care aides.
• The establishment of a Personal Care Attendants Workforce Advisory Panel, which will advise the Department of Health and Human Services (HHS) and Congress on matters relating to the personal care attendant workforce.

Other ACA provisions that focus on the development of the direct-care workforce can be found in PHI Health Reform Facts 1: Workforce Development and Training Opportunities for Direct-Care Workers (pdf).

The Alliance for Health Reform brief was produced with funding from the Robert Wood Johnson Foundation.

– by Matthew Ozga

Iowa’s direct-care workforce is among the lowest-paid employment groups in the state, according to a survey published by the Iowa CareGivers Association.

The average direct-care worker in Iowa makes just $11.50 an hour, according to the 1,276 survey respondents, a group that included certified nursing assistants, home health aides, and personal care assistants.

By contrast, Iowa’s median hourly wage for all workers is $14.40.

Nearly half (49.9 percent) of Iowa’s direct-care workers live in households earning under 200 percent of the federal poverty level.

Iowa’s direct-care workers also struggle to obtain health insurance, the survey found: nearly one-forth (23 percent) of respondents said they were not insured. Overall, 12.4 percent of Iowa’s adults lack health coverage.

Additionally, only 43 percent of direct-care workers in Iowa are offered paid sick leave.

Low Pay Discouraging to Workers

According to the survey, this lack of adequate wages and benefits is driving many Iowans away from direct care. More than 20 percent of direct-care workers surveyed said that they are actively seeking to leave the field entirely in order to find better-paying jobs.

“Workers are leaving direct care at exactly the wrong time,” said John Hale, a public policy consultant for the Iowa CareGivers Association. He notes that, of the ten jobs expected to be most in demand over the next decade, three are in the field of direct care.

“We cannot meet the future demand for workers who will enter and stay in the profession unless we make these jobs better by improving their pay and benefits,” Hale continued.

Recommendations for Future

The report offers several ways that Iowa can address the issue of low pay and benefits for direct-care workers.

For example, the report says that Iowa could insure more workers by expanding Medicaid eligibility to 133 percent of the federal poverty level. The Affordable Care Act will require all states to do that beginning in 2014, but states have the option of expanding Medicaid eligibility (pdf) at any point before then.

The report further recommends that Iowa expand eligibility levels for its subsidized child care program, as well as increase the size of its Earned Income Tax Credits.

– by Matthew Ozga

The New York Times published a letter to the editor by PHI President Steven Dawson on February 11, regarding the article “As Germany Booms, It Faces a Shortage of Workers.”

Dawson reminds readers the U.S. will soon face the same problems as Germany in attracting sufficient numbers of workers to care for the growing numbers of elders.

The U.S. will need more than 1.1 million additional direct-care workers between 2008 and 2018, he explains. Yet the entire labor supply of women between the ages of 24 to 54 — the people who typically fill these positions — falls well short of that total.

Poor pay and the “low status” of Germany’s direct-care workers impede long-term care providers’ ability to attract workers, the article reports. Lifting restrictions on immigration to bolster the labor supply will not be much of a help either, it explains.

Dawson writes that similarly increased immigration will not be a solution to the U.S. “care gap.” He advises that the U.S. must make direct-care jobs far more attractive — providing better wages, benefits, training, and opportunities for advancement, which will not only improve elder care but strengthen economies — particularly in low-income communities.

– by Deane Beebe

Iowa’s direct-care workers still lack adequate wages and benefits, according to an Iowa CareGivers Association survey that is set to be released in the coming days.

The survey, conducted by the Child & Family Policy Center, is the third — and so far, most comprehensive — overview of Iowa’s direct-care workforce published over the past decade. The last survey was released in 2004.

Like the rest of the country, Iowa is facing a shortage of direct-care workers just when the demand for their services is peaking. The aging of the baby-boomer generation will create a need for an additional 10,000 new direct-care workers in Iowa alone over the next 10 years.

In that context, the need for high-quality direct-care jobs is more urgent than ever.

“The needs of persons with disabilities and aging Iowans will go unmet if we continue to ignore and undervalue this incredibly important workforce,” said Di Findley, the executive director of the Iowa CareGivers Association.

“We can no longer, as a society, get by thinking that we can compensate people poorly simply because they are nice, caring people,” she continued.

Specific Survey Findings

Among the findings in the 2010 Iowa survey:

• Iowa’s direct-care workers are among the lowest-paid in the state, earning an average of $11.50 an hour, compared with the median hourly wage of $14.40 for all Iowa workers.
• A majority of direct-care workers in Iowa work full-time hours — but nearly half (49.9%) report household incomes that fall below 200% of the federal poverty level. Nearly one out of five direct-care workers in Iowa (18.2%) are below the federal poverty line entirely. Many rely on public benefit programs such as food stamps and child care assistance to make ends meet.
• Across the board, direct-care workers are less likely to be covered by health insurance than non-elderly workers throughout Iowa.
• More than one-fifth of all direct-care workers in Iowa say they are actively trying to leave the field, mostly due to low pay and poor benefits.

The survey suggests that some of the financial difficulties faced by Iowa’s hard-working direct-care workers could be offset by expanding public services, such as Medicaid eligibility and earned income tax credits, to more Iowans.

It also recommends that the Iowa government use its position of as a primary purchaser of direct-care services (under Medicaid) to raise wages and provide more benefits.

– by Matthew Ozga

The current issue of the National Academy on an Aging Society‘s Public Policy & Aging Report is dedicated to the Community Living Assistance Services and Supports (CLASS) program.

In the introduction to the issue, entitled “Bringing CLASS to Long-Term Care through the Affordable Care Act,” Editor Robert B. Hudson writes that the long-term care provisions, including the CLASS Act, in the recently passed national health care legislation are an “enormously important yet widely unrecognized development.”

For the first time, with the CLASS Act, a “publicly administered social insurance program” has been introduced into long-term care, Hudson explains. People who enroll in the program will no longer have to be “demonstrably poor or spend themselves into penury to receive long-term care protection.”

The report covers how the CLASS act became a provision in the Patient Protection and Affordable Care Act (ACA). It also presents analyses of key long-term care provisions in the legislation, and explains hurdles that are expected during the legislation’s implementation.

Workforce Issues Featured

Two of the articles discuss direct-care workforce issues.

Lisa R. Shugarman writes that “an integrated system cannot exist without a workforce (pdf) to care for the population in need” and “in particular, there is a clear demand for a labor force that is trained appropriately to address the concerns of older adults.”

Joshua M. Wiener describes the multiple long-term care provisions in the health reform legislation, and how the ACA addresses the 800,000 direct-care workers who do not have health insurance, citing PHI research (pdf).

“I am delighted that Josh Wiener cited the expanded coverage for direct-care workers as the most overlooked aspect of long-term care under the ACA,” said PHI Government Relations Director Carol Regan.

“The number of uninsured is closing in on a million workers, and the trends toward home- and community-based services and part-time work will only exacerbate problems with the availability and affordability of employer-sponsored insurance for these women. The new law is a huge benefit for direct-care workers,” Regan said.

“Bringing Class to Long-Term Care through the Affordable Care Act” was made possible with funding from the SCAN Foundation.

– by Deane Beebe