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By 2020, the direct-care workforce — nursing assistants, home health aides, and personal care aides — is projected to be the nation’s largest workforce at 5 million workers, according to a new PHI analysis available in PHI FACTS 3: America’s Direct-Care Workforce (pdf).

Home care jobs — both home health aide and personal care aide positions — are the nation’s fastest-growing jobs, projected to increase over the decade 2010-2020 at an astounding 69 and 71 percent, respectively. Nursing aide, orderly, and attendant positions are expected to increase by 20 percent. Together these jobs will add an additional 1.6 million jobs to the economy.

Comprising nearly a third (30.6 percent) of the entire U.S. health care workforce, direct-care workers far outnumber other health care practitioners, including physicians, nurses, and therapists. These workers also outnumber all those employed in allied health occupations, such as medical and dental assistants, and physical therapy assistants and aides, by nearly three to one.

Shift Toward Home and Community-Based Settings

The analysis found that there were at least 4 million direct-care workers in 2011, with the majority employed in home and community-based settings. The workers employed in these settings are expected to outnumber facility workers by more than two to one by 2020.

PHI researchers estimate that there are at least 800,000 independent providers who provide personal care services for consumers who are enrolled in public programs. These workers, who are employed directly by consumers and their families in home and community-based settings, are not tracked by the U.S. Bureau of Labor Statistics and have been heavily undercounted in government surveys, the researchers explain.

Wages and Benefits Worsen

The PHI analysis also found that the wages and benefits of direct-care workers continue to worsen.

The median wage of $10.59 in 2011 for all direct-care workers is far below $16.57, the median wage for all U.S. workers that year. Moreover, adjusted for inflation, wages for all direct-care workers have declined over the last decade.

In addition, more than one third of aides employed by home care agencies and one quarter of nursing home aides lacked health care coverage.

Poverty Increases

With wages and benefits declining, an increasing number of direct-care workers live in poor households. Since 2008, direct-care workers living in households with incomes below 200 percent of the federal poverty line have increased from 44 percent to 47 percent.

At this income level, many of these workers are eligible for — and rely on — public benefits such as Medicaid and food stamps to support their families.

To learn more about the direct-care workforce, download PHI FACTS 3: America’s Direct-Care Workforce (pdf).

– by Deane Beebe

President Obama announcing his support for federal minimum wage and overtime for home care workers on December 15, 2011.

A New York Times editorial published on April 15 explains that the proposed rule to extend home care workers minimum wage and overtime protections is still just a proposal and will take “Obama’s engaged leadership to ensure that the long-overdue new rules” are actually implemented.

The editorial, “Keeping a Promise to Home Care Aides,” tracks failed efforts to extend home care workers fair pay in the past, and highlights the hurdles that still lay ahead.

The Times warns that while most of the thousands of public comments on the proposal are supportive, “The problem is that the new rules have yet to be finalized, and could still be derailed or watered down.”

The editorial references for-profit home care franchisees’ ongoing opposition to extending home care workers fair pay and praises the advocates’ efforts.

“This time the around, proponents for change have been better organized and armed with research to rebut such claims,” it says, linking to two PHI reports and NELP testimony at a recent House hearing.

This editorial marks the sixth time that The New York Times published an editorial in support of extending home care workers fair pay.

– by Deane Beebe

At nearly 88,000 strong, direct-care workers comprise Wisconsin’s largest workforce — yet many earn wages low enough to qualify for public benefit programs, according to a fact sheet released by PHI this month.

The median hourly wage for home health aides, for example, is just $10.35, while personal care aides earn $9.62 an hour. Both wage levels are lower than 200% of the federal poverty level ($10.42).

Due to those low wages — as well as the fact that many direct-care workers can only find part-time employment — more than 40 percent of Wisconsin’s direct-care workers qualify for state and federal assistance programs, such as food stamps or Medicaid.

The estimated cost of these public benefits is more than $180 million — the equivalent of a $1 to $2 public subsidy for every hour worked by a Wisconsin direct-care worker, the PHI fact sheet reports.

Other Findings

Wisconsin’s direct-care workforce is its single largest occupational grouping, at 87,797. (Retail salespersons are next, at 76,180.)

Included within those 87,797 direct-care workers are:

• 37,630 nursing aides, orderlies, and attendants;
• 22,080 home health aides;
• 19,630 agency-employed personal care aides; and
• 8,457 independent providers in public programs.

According to the fact sheet, direct-care workers comprise nearly one-third (32 percent) of Wisconsin’s overall health care workforce.

PHI’s analysis also shows that direct-care workers’ wages are declining. In 2000, for example, personal care aides earned an inflation-adjusted median wage of $10.69 an hour — more than a full dollar higher than in 2010.

Fact Sheets Support Advocacy Efforts

The Wisconsin fact sheet is one in an ongoing series of PHI fact sheets providing overviews of the direct-care workforce in select states.

It was funded by a Health Care Workforce Development Grant from the state of Wisconsin.

Stakeholders in Wisconsin say that the fact sheet will be used to educate state legislators about Wisconsin’s direct-care workforce.

For information on direct-care workers in each of the 50 states, visit the PHI State Data Center.

– by Matthew Ozga

Three brief stories on direct care:

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CMS Proposes Guidelines for State Balancing Incentive Payments Program

The Centers for Medicare & Medicaid Services issued a “State Medicaid Directors Letter” (pdf) on September 12 to provide guidance for establishing the State Balancing Incentive Payments Program, a provision of the Affordable Care Act.

The new program, created to serve more people in home- and community-based settings, will assist states in “transforming their long-term care systems” by:

• improving systems performance and efficiency;
• creating tools to facilitate person-centered assessment and care-planning; and
• enhancing quality measurement and oversight.

The Balancing Incentive Program offers a targeted increase in the Federal Medical Assistance Percentages (FMAP) for non-institutional long-term services and supports (LTSS) to states that undertake structural reforms to increase access to home- and community-based LTSS.

On October 7, the Friday Morning Collaborative, a coalition of national aging and disability organizations, is hosting a webinar on the Balancing Incentive Payments Program. Registration is free, but space for the webinar is limited.

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State Direct-Care Worker Associations to Hold Annual Meetings

The Arizona Direct Care Worker Association (ADCWA) is holding its 4th Annual Conference and Celebration in Tucson on October 5 to honor and educate certified nursing assistants, home care workers, and professional caregivers in the state. To learn more about the event and register, visit the ADCWA website.

The Florida Professional Association of Care Givers is sponsoring its 16th Annual Caregivers Convention entitled, “Building a Quality Direct Care Workforce for Tomorrow’s Demands!” The all-day educational meeting will take place in Altamonte Springs on October 20. A registration form and more information is available at the association’s website.

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Des Moines Register Editorializes on Better Rewards for Caregivers

The Des Moines Register published an editorial in late August arguing that to ensure an adequate supply of direct-care workers to care for aging Iowans, those workers must have better wages, health coverage, education and training, and be valued in the medical field for the critical work they perform.

The editorial also explains that worker turnover is costly to employers, Medicaid, and consumers.

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PHI Newsletter Survey

If you have not done so already, please take a moment to give us your feedback on the PHI Quality Care, Quality Jobs newsletter by completing this anonymous survey. Thank you to all of the subscribers who already responded.

Senator Tom Harkin (D-IA), the chair of the U.S. Senate Committee on Health, Education, Labor and Pensions (HELP), and Senator Robert Casey, Jr., a fellow HELP Committee member, are calling for an end to the “companionship exemption,” which excludes home care workers from federal wage and overtime protections that most workers enjoy.

In a September 12 letter (pdf) to Department of Labor (DOL) Secretary Hilda Solis and Office of Management and Budget (OMB) Director Jacob Lew, the senators write that the DOL’s broad interpretation of the companionship exemption in the Fair Labor Standards Act (FLSA) is a “longstanding injustice that must be corrected.”

Harkin and Casey explain that when Congress expanded FLSA in 1974 to include most domestic workers, it included a “narrow exemption” for companionship services “to address concerns that the FLSA would be extended to teenagers, neighbors, and friends who provided occasional or informal services, such as babysitters.”

“A professional caretaker is not the type of informal and casual relationship that Congress sought to exempt,” the letter states.

Low Pay and Inadequate Benefits

The senators write that millions of home care workers “provide physically and emotionally demanding and often life-sustaining care.” Despite performing a “critical job,” these workers “receive low pay [and] minimal to low benefits.”

Noting that “a shortage of qualified home care workers and high turnover endanger our ability to meet our nation’s long-term needs,” the senators advise that “one way to ensure that we meet these challenges is to provide home care workers the critical protections under FLSA.”

The senators urge Solis and Lew to “complete the notice of proposed rulemaking on companionship services regulations,” adding that they “hope that the ensuing comment period and final regulation will be completed within a reasonable time period.”

DOL hosted two listening sessions on the companionship exemption earlier this summer and is expected to issue revised regulations this fall.

For more information on the companionship exemption and how to contact Secretary Solis, visit the PHI Campaign for Fair Pay.

In a letter (pdf) to President Obama, PHI President Steven Dawson explains why investment in quality direct-care jobs presents a strong opportunity to put thousands of people back to work.

The already-great demand for eldercare/disability services and will only grow as the Baby Boomer generation advances to retirement age. Because of that surging demand, “direct-care jobs are uniquely positioned to help repair and stabilize our faltering economy,” Dawson writes.

The September 8 letter coincided with the unveiling of the Obama administration’s jobs plan during a joint session of Congress.

In the PHI letter, Dawson tells Obama that direct-care jobs must pay family-sustaining wages and provide adequate health benefits.

“We urge you to invest in improving the quality of these jobs by requiring a wage floor for positions created by the investment and by offering health insurance coverage” through Medicaid, Dawson writes.

Investment in quality direct-care jobs has huge positive implications beyond the workers themselves. A strong direct-care workforce supports working family caregivers throughout the country.

When family caregivers know their loved ones are safe and secure under the skillful care of well-trained direct care workers, they can focus on producing maximum value for their employers — and, thus, the nation’s economy.

“In short,” Dawson writes, “the caregiving infrastructure created by the direct-care workforce is as essential to a well-functioning economy — and as worthy of investment — as roads and bridges.”

More information on the eldercare/disability service industry’s untapped potential for job creation can be found in PHI FACTS 2 (pdf).

– by Matthew Ozga