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U.S. Elder Care Is in a Fragile State
Elder care in the United
States is in critical condition. Over the last few years, nursing homes
have become plagued with bankruptcies and stressed by understaffing, and
the direct-care workers that these institutions and home-care agencies
depend on have been going on strike or quitting in droves. With baby
boomers approaching retirement age, the implications of this breakdown are
sobering. During the last three
years, three of the nation's four largest for-profit nursing-home chains
entered Chapter 11 bankruptcy. According to Steven Dawson, president of
the Paraprofessional Healthcare Institute, this situation stems from the
homes' inability to cope with changes in reimbursements from federally
financed Medicare, which subsidizes long-term care. "They are
beginning to climb back out of that crisis," Dawson said, "but
it's not over yet." Few elderly citizens can
expect Medicare or private insurance to cover the costs of their care, so
it is not surprising that two out of three nursing-home residents rely on
Medicaid to do the job. As a result, Medicaid, which was designed only as
a safety-net program for the poor, is being stretched to the limit. In addition to
relying on Medicare and Medicaid, long-term care relies on health
paraprofessionals — the direct-care workers — who typically earn
poverty-level wages.
These people are the eyes and ears (and often the hands and legs) of
elderly patients, the workers who quite literally do the heavy lifting to
enable frail and often disoriented patients to get through each day. Across the country, 2.1
million of these workers are employed in institutional care settings and
through home-care agencies. As the baby-boom generation ages, the need for
these workers, who now account for 38 percent of nursing-home employees
and 50 percent of employees in home health care, will continue to expand.
The U.S. Bureau of Labor Statistics recently projected a 58 percent rise
in demand for home-care aides from 1998 to 2008.
In the past, finding
low-skilled, female workers to fill these jobs (86 percent of the
positions today are filled by women) was easy. But the aging of baby
boomers has also meant that the ratio of workers (women of prime working
age, 25 to 54) to older people needing care has fallen; over the next 30
years it is projected to be cut in half. The opening up of less stressful
low-wage work options during the recent "full employment
economy," coupled with that aging trend, has made direct-care workers
much harder to find and even harder to keep. Providers have begun pleading
with state authorities to raise the Medicaid reimbursement levels so that
they can more easily raise the wages they pay. Nursing homes' financial
and personnel difficulties have hurt the quality of care. The vast
majority of nursing homes are certified by the Health Care Financing
Administration (HCFA — now renamed the Centers for Medicare &
Medicaid Services) so that they can qualify for Medicaid reimbursements.
Among homes that are certified, each year for the past seven years up to
60 percent failed to pass the agency's minimum health and safety
standards. Labor groups and regulatory agencies alike attribute a large
part of the poor quality to understaffing. Labor Shortage or Labor Flight? Because direct-care jobs
are still generally filled by younger (under 45) women, it would seem a
natural solution to recruit new workers from the ranks of post-welfare
mothers. But, HCFA's own bare-bones requirement of two weeks of
pre-employment training for direct-care aides runs afoul of Congress' 1996
welfare reform measures, whose "work first" provisions
discourage pre-employment training for welfare leavers. Moreover, the current
staffing shortages, which are prevalent in professional nursing as well,
outpace anything that can be explained by demographic trends alone. At
nursing homes, average annual turnover of direct-care workers is very
high, estimated from 40 percent to as high as 100 percent. Besides being
bad news for quality care — bad for continuity, training, and morale —
this instability is also expensive for providers. Why are these employees
quitting? In addition to wages that are only slightly higher than the
average for fast-food workers, the General Accounting Office reports that
roughly a third of all direct-care employees — whether in nursing homes
or in home care — have no health coverage. These women also endure one
of the highest rates of on-the-job injury in the country, one and a half
times higher than that for construction workers. Steven Dawson points to
disrespectful treatment as a significant cause as well. "Focus groups
among these workers all show the same thing," he said. "They
complain that they're treated as if they were invisible, at best, by nurse
supervisors and other managers." The last few years have not
brought entirely bad news for direct-care workers. Pressure from consumer
and labor groups, as well as industry lobbying, has so far led 19 states
to pass legislation upgrading direct-care wages through "pass-throughs"
that earmark Medicaid funds for this purpose. For their part, direct-care
workers and nurses alike have begun organizing in ever-larger numbers,
leading a new wave of union growth and bargaining victories. Last spring, a dramatic
month-long walkout by nursing-home workers throughout Connecticut
demonstrated their willingness to risk their jobs for improved state
policies, although in the end it did not produce long-term changes. Also last spring,
approximately 22,000 home-care workers in Los Angeles County who work at
least 112 hours per month were declared eligible to receive health and
dental benefits under the county's community health plan. This radical
improvement in their status came after more than 10 years of labor
negotiations. With a recession now
official, according to the National Bureau of Economic Research, it is
uncertain whether that kind of success can be replicated across the
country, whether by labor action or state initiative. Equally unclear is
how soon federal lawmakers will be willing to enact more comprehensive
changes. But it is certain that the current problems will not go away of
their own accord.
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