In 2015, nearly 33 million people in the U.S. reported that they had difficulty completing some of the tasks necessary for daily, independent living. Fourteen million of those people are currently over 65, but that number is expected to balloon to 22 million as the baby boomer population ages.
Many people who need help with daily living — and don’t live in a nursing home — have some sort of help at home. While unpaid family and friends typically shoulder the brunt of this work, there are millions of home care aids and certified nursing assistants who also help. They are typically low-paid and limited in what they can do for their clients. In some states, they cannot even administer eye drops.
MIT Sloan professor Paul Osterman examines the problems facing the home care workforce in his new book, “Who Will Care for Us: Long-term Care and the Long-Term Workforce.” He argues that reforms like better training to manage health issues at home and increased compensation for home care workers could not only improve outcomes for clients, it could save the system money. One study concludes that better transitional care and management for chronic conditions could save billions.
You're a labor economist — what motivated you to look at the state of long-term care? I first I became interested in this because a lot of my work had to do with low-wage jobs and how to improve the quality of those jobs. And health care workers represent a large number of very low-wage workers, so I wanted to understand their situation and how to potentially improve it.Once I started doing that, I came to understand that to make any progress I really needed to understand the industry itself — which I think can be seen as a model for thinking about how to improve low-wage jobs in general. And as I learned about the industry, I also became interested in the more general problem of long-term care, and the challenges we'll face in providing that care as baby boomers age.
What is providing long-term care like for the workers? Home health aides engage in everything from simple companionship to help with what are called “activities of daily living,” such as shopping, bathing, toileting, those kinds of functions. The work is typically isolated — they're alone in people's homes. It can be both physically and emotionally very challenging.Paul Osterman
One of the key points of the book, though, is how disrespected these folks are. They're not treated with respect by the remainder of the medical members of the health care team nor by insurance companies. Policymakers both at the federal and the state level don't really understand them. A lot of this disrespect is due to the status of the job and the hierarchical nature of medicine. But it's hard to overlook the fact that these are overwhelmingly women, and they're disproportionately people of color and immigrants — groups that are typically not well treated in the labor market. A key issue here is the attitudes towards these folks and how that constrains what they could potentially do.
A central argument of the book is that training home care workers better and paying them more would address a number of issues. What would it achieve? These folks are very constrained by state level scope of practice rules that limit what they can do. They can't perform anything that even looks like a medical task. If they were trained to do a little bit more, it would lead to both better outcomes for clients and it would save the system money in a variety of ways.First off, some work could be shifted from higher paid occupations such as nurses to these people, which would result in cost savings. With better training and the ability to do a little more, we'd save on unnecessary calls to 911 and emergency room visits. We'd have better transitions out of acute care episodes at hospitals. Today, too many transitions end up in nursing homes, which are very expensive.
More generally, we'd reduce the use of nursing homes. We'd also have better care of long-term chronic conditions, since home health aides could be health coaches. For instance, they could advise and help diabetic clients with exercise and diet. They could act as physical therapy assistants. They could help administer prepackaged medications.
What are some of the barriers to reform? There are multiple barriers to reform. One is the attitudinal barrier that comes with the demographic of the people in these jobs, and I don't think you should underestimate that.The second barrier has to do with the politics of occupational competition. Health care is full of examples of one occupation trying to keep a set of tasks to itself, which is true here too. Nurses could be opposed to expanding the scope of practice of aides, and it's been a challenge to overcome that.
Another barrier has to do with some elements of the younger, cognitively capable disability community opposing training requirements for aides. They are concerned that training standards will undermine their autonomy and control. That could be a barrier politically in getting this to happen at a state level.
Of course, another obstacle is just the general knowledge and interest of payers. Medicaid and insurance companies need to understand what is possible.
You also are somewhat optimistic. Why is that? There are two sources of optimism. One is that as the baby boomers age, and as the supply of unpaid family caregivers decline, the lack of home health aides is going to become a huge issue. There will be a constituency of baby boomers pressing for reform, and since it is also in the interest of the work force, there is the potential for a consumer-worker alliance here. This will provide an opportunity for our political leadership to pick up on this and do something.Secondly, the institutions that have money in the system and who pay — the insurance companies, Medicaid — will have a self-interest in doing this too, and they have power.