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: The long-term-care system is broken. How can we fix it?

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If you’re reading this column, odds are you’re aware the U.S. population is aging and older Americans are living longer, on average. Still, the numbers are striking. For instance, average life expectancy for men at age 65 in 1950 was 13.1 years and for women 16.2 years, according to the Social Security Administration. The current figures are 18.09 years and 20.7 years, respectively.

“Aging is actually living, and that longevity is a good thing,” said Ai-jen Poo, president of National Domestic Workers Alliance and executive director of Caring Across Generations during a recent panel discussion at Columbia University’s 2022 Age Boom Academy entitled Caregiving and Our Longer Lives. “Aging means longer to learn and to connect and to love and to teach.”

Aging also means the risk that older people will eventually need some kind of long-term care and services (LTSS) remains significant. LTSS is shorthand for people getting assistance with basic activities, such as bathing, dressing, and preparing meals. Not everyone ages well and even the healthiest elders eventually deal with some physical and mental limitations, or worse.

“Our results show that 70% of adults who survive to age 65 develop severe LTSS needs before they die and 48% receive some paid care over their lifetime,” writes Urban Institute economist Richard Johnson in “What Is The Lifetime Risk of Needing and Receiving Long-Term Support and Services.”

Problem is, America’s approach to long-term care is profoundly inadequate, a patchwork of underfunded programs and services. Medicare typically doesn’t pay for long-term care costs. Medicaid does, but to qualify household assets must be depleted. Premiums in the private long-term-care insurance market are too high for many families. Unpaid family members take on many responsibilities caring for frail elders. There were nearly 42 million family members caring for someone 50 years and older in 2020, up from 34 million in 2015, calculates the National Alliance for Caregiving and AARP.

“With the boomer generation aging and people living longer we have essentially added an entire generation to our lifespan without actually adapting our policies to support quality of life as we live longer,” said Poo.

The need for reform has been long obvious. Yet progress has been maddingly slow. While there is no simple policy wand that could easily create an equitable, affordable and universal high-quality long-term care system, perhaps the policy lever with the most promise at unleashing broader reforms is dramatically improving the compensation and professional status of the low-wage low-status direct care workforce.

“Today America’s elderly and disabled citizens are cared for by a low-wage and poorly trained workforce,” writes MIT economist Paul Osterman in Who Will Care for Us? “Continuing in this way is in no one’s interest, and the case is compelling to transform the jobs of direct care workers.”

Direct care workers support people in need, usually in the home but also in institutional settings like nursing homes and assisted living centers. (Direct care workers help children and younger adults with disabilities and special needs, but for this column the focus is on older adults.) The current median wage of these frontline workers is around $15 an hour. The job typically comes without benefits and nearly half rely on some form of public assistance, such as Medicaid. The workforce is primarily women, people of color, and immigrants.

Direct care workers lack status within the healthcare industry. The job is wrongly looked down upon as unskilled labor.

“Direct care is skilled work,” said Robert Espinoza, executive vice president of policy at PHI, an advocacy and research organization on home health issues. “We need to move away from thinking it’s unskilled. It isn’t.”

Just ask Susie Rivera. The thoughtfulness required to be a professional caregiver is obvious listening to her discuss her work. (You can listen to a podcast interview with Rivera here.) She has been a caregiver since 1986. She’s worked in a variety of care positions during her career. Like many professional caregivers, she’s also been an informal family caregiver. She makes slightly more than $15 an hour and puts in at least 72 hours a week to make ends meet. Rivera is passionate about the work.

“It’s a calling. It’s so rewarding,” she says. “I’ve always said this, wherever I go and take care of somebody, I said the calvary is here. Don’t worry, we’ll take care of you.”

There are about 4.6 million direct care workers. From 2019 to 2029 a total of 7.4 million job openings will need to be filled, estimates PHI. The increase reflects rising demand for workers and the need to find additional workers as caregivers exit the profession (many can earn more at fast-food restaurants and even dog walking). Attracting and keeping workers will require higher pay, better benefits and, perhaps most important, training and a clear path to career advancement.

“We can all appreciate we need to value the caregiver more, but we haven’t paid the dollars into the system and held the providers accountable to really get the dollars to the workforce,” said David Grabowski, professor of healthcare policy, department of healthcare policy at Harvard Medical School at the Age Boom Academy.

Time for policy impatience. The report Making Care Work Pay by four experts (published in 2020) suggests paying a living wage, an improvement they predict would boost employment and reduce turnover. MIT’s Osterman recommends federal and state authorities use their purchasing power to enhance working conditions and compensation. A higher federal minimum wage and more generous earned-income tax credit would also help. Although it didn’t pass, President Biden proposed spend $400 billion on home- and community-based care and the plan offered numerous ideas for improving compensation, including federally provided paid sick leave.

Where could the funding come from? Most families already find professional caregivers expensive, so the funds will have to come from somewhere else. The main source of funds for paying direct care workers is Medicaid. Funding could be increased, reimbursement rates substantially hiked, and rules established that build a living wage into the program. More ambitiously, the U.S. should establish a universal social insurance system to finance long-term care. There’s no shortage of thoughtful reform blueprints.

The question is how to push reform forward. The transformation could begin with policies that turn direct care work into quality jobs.  

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