ISSUES
A Preventable Labor Crisis, Part II: The Potential for a Solution
by PHI
The research is already in1 about what is needed to improve the quality of long-term care in this country: a more stable, experienced and trained paraprofessional healthcare workforce. Furthermore, since the long-term care services delivered by these paraprofessionals are largely paid for by public dollars, the government enjoys significant leverage to effect the changes necessary to improve this workforce.
Public Policy Actions Needed:
Investigate how our tax dollars are being spent. The government pays the private sector billions of dollars every year to deliver long-term care services. Yet the government does not require that these private agencies report on how many of those dollars actually get down to the frontlines of long-term care delivery: i.e., to the training, compensation or support of the direct-care workers who provide 80-90% of those publicly funded long-term care services. The government should collect data from all its providers on workforce turnover, training, and wages and benefits to establish greater accountability and to establish a baseline from which the government might assess how to improve more broadly the delivery of these hands-on services.
Require and support better training. The government has set some standards for paraprofessional certification within nursing homes and Medicare home health, but these have proven largely inadequate - and there are entire segments of the direct-care workforce, particularly under Medicaid, for which no training standards exist at all. The government needs to create better and more uniform training standards across a range of comparable direct-care positions. In addition, while the healthcare delivery system has taken responsibility for training its professionals (doctors, nurses, etc.), it has largely left the training of low-income paraprofessionals to public workforce development programs (JTPA/WIA, welfare-to-work, etc.) - a system that in recent years has begun to turn away from supporting pre-employment HHA/CNA training for many low-income job-seekers. The government should convene an interagency working group among agencies responsible for health care, labor, and welfare to focus on these gaps in our country's healthcare workforce development system.
Target reimbursements to the frontlines of care. Several state Medicaid programs have used mechanisms like "wage pass-throughs" to ensure that a certain portion of the public dollars paid to private long-term care agencies is passed on directly to the frontline workers who are delivering those services. Such initiatives have multiplied in response to current labor shortages. States should look at how they can direct more of their Medicaid dollars down to the frontlines of care, so that too many of those resources are not lost to agency overhead and profit.
Ensure health insurance for healthcare workers. Through CHIP and other initiatives, the Federal government has created vehicles to ensure health coverage for greater numbers of low-income Americans. In addition, some states have expanded coverage for adults below or near the poverty line-including workers within particular industries that rarely offer employer-paid health insurance (e.g., Massachusetts' fishing industry or Rhode Island's childcare workers). The government could likewise address the tragic irony of healthcare workers without healthcare coverage through an industry-specific "healthcare for healthcare workers" initiative, thereby significantly reducing turnover and instability within this vital American workforce.
Who would gain from such initiatives.
The Elderly and People Living with Disabilities - They would be cared for by the paraprofessional workforce that they need and deserve.
Women- They are the primary consumers of long-term care, and they are the primary deliverers of that care - whether they are paraprofessional workers or family members who need assistance with the care of their loved ones.
Providers - They would be able to count on a stable, competent, and well-trained workforce that was capable of meeting the increasing demand from consumers.
People of Color - Within our urban centers and the rural South, direct-care workers are primarily a workforce of color - composed largely of low-income African-American and Latina women caring for their neighbors.
Low-Income Workers and Their Advocates - Unionization of this workforce is less than 10-12% nationally. These "working poor" would benefit greatly from national leadership calling attention to their situation. And unions that have prioritized the future organization of this workforce would likewise enjoy the support of a national call for an improved and better supported direct-care workforce.
Welfare Recipients- Low-income women on welfare are being "set up to fail" if we continue to direct them toward paraprofessional jobs with turnover rates of up to 100% a year. Individual agencies - like those in PHI's Cooperative Healthcare Network - have shown that direct-care jobs can become long-term vehicles of employment and advancement for women on public assistance. A national strategy to expand on those lessons could mean stable and enriching employment for hundreds of thousands of TANF recipients.
[1] For an overview of that research, see American Association of Retired Persons' 1998 conference paper: "Paraprofessionals on the Front Lines: Improving Their Jobs, Improving the Quality of Long-Term Care."
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