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The White House is Building Momentum to Tackle the Direct Care Workforce Crisis

By Jake McDonald (he/him) | April 9, 2024

Since taking office, the Biden-Harris Administration has taken significant and historic steps toward recognizing the value of the direct care workforce (including home health aides, nursing assistants, and personal care aides). This recognition comes amid a growing care crisis caused by poor direct care job quality. Nursing homes, home care agencies, individuals, and families across the country are struggling to find and keep the workers they need to provide essential services. While far from complete, the Administration’s policies are pointing toward the transformational change our country needs to make.

The COVID-19 pandemic created a sea change in how Americans see essential workers, including those in direct care. That attention has combined with a rapidly aging population and strained family caregivers to create a growing movement dedicated to strengthening the direct care workforce. Despite this, there has been limited traction in this Congress to pass meaningful legislation for direct care workers.

In this context, the Biden-Harris Administration has used regulatory and executive actions to highlight the vital role direct care workers play in our care system and the larger economy. They are discussing the tremendous challenges facing that workforce, particularly poor job quality. And, they are acknowledging our country is struggling to recruit and retain the workforce it needs because direct care workers are not getting enough compensation, support, respect, or recognition.

The throughline connecting this Administration’s work is a realization that addressing the care crisis will require improving job quality for direct care workers. Through this lens, the Administration has taken important—though incremental—steps in turning the corner on these issues. One year from President Biden declaring April to be National Care Workers Recognition Month, we’re looking back at this past year’s highlights, continuing our project to document the direct care workforce movement’s progress.

A Historic Executive Order

On April 18, 2023, President Biden signed an Executive Order that included more than 50 executive actions designed to enhance care for hard-working families and bolster support for direct care workers and family caregivers. These directives, aimed at almost every cabinet-level agency, seek to broaden access to affordable, high-quality care, in part, by improving the quality of direct care jobs.

In response to the Executive Order, PHI produced a five-part fact sheet series examining the executive order relevant to the direct care workforce and focusing specifically on compensation, job quality, training, equity, and data collection. This series highlights the distinct opportunities within this executive order to strengthen the direct care workforce and recommends additional steps federal agencies can do to improve direct care jobs.

Following the Executive Order, the Centers for Medicare & Medicaid Services (CMS) has taken action to highlight the value of direct care workers and the challenges they face.

Raising worker compensation so people can access Medicaid home and community-based services.

First, in April 2023, CMS proposed a rule designed to improve access to Medicaid services for millions of people around the country. A key part would require 80% of all Medicaid funding for home and community-based services to go directly toward workers’ wages and benefits.

Expected to be finalized soon, the proposed rule addresses the heart of job quality issues for direct care workers: compensation. Direct care wages, including those for home health aides, are not competitive with other jobs with similar, or even lower, entry requirements. In other words, workers can often make more at fast food chains or department stores without facing the difficult and dangerous job of caring for someone with complex needs.

As we wrote in our comments, when low wages are combined with minimal benefits and, often, part-time, piecemeal schedules, total compensation for these jobs falls below what is needed to attract and recruit the workers required to fill the gap. Workers struggle financially, live below the poverty line, and leave the workforce in droves, which means those who need access to direct care services cannot always find someone to do the job. This proposed rule starts to address this issue by ensuring a higher proportion of Medicaid payments go directly to workers.

Rethinking job quality for Medicare home health aides.

Next, in July 2023, CMS used a Request for Information to highlight the overlooked work of Medicare home health aides. Contrary to what many believe, Medicare does not provide robust coverage for home care. And even when care is covered, Medicare beneficiaries often face barriers to accessing it. Here, CMS found there was a steep and significant decline in the use of Medicare home health aides despite a growing need for their services.

Such issues are rooted in society’s failure to recognize, respect, and support the vital role home health aides play in the lives of those they support. For example, Medicare treats aides as unskilled workers, has policies that inappropriately deny home care services, and fails to ensure home health aides have the job quality needed to ensure an adequate, trained workforce is available.

As we wrote in our comments, it is vital that CMS recognizes the barriers Medicare beneficiaries face in accessing home health aide services and looks for ways to address them, particularly through improving job quality. CMS has considerable leverage as a payor, a creator of the structure for Medicare home health aide services, and an educator of home health agencies. Through these pathways, CMS can increase direct care recruitment and retention which will ensure a high quality of care.

Underscoring how important direct care workers are to nursing homes.

Then, in September 2023, CMS released a proposed rule on minimum staffing levels in nursing homes. The proposed requirements would improve job quality for nursing assistants in nursing homes by increasing supervision, reducing workloads in currently understaffed facilities, and shed light on how facilities are compensating workers. CMS also used the proposed rule to establish two important things:

  1. Direct care workers are poorly compensated, which is a leading cause of the workforce issues that limit access to long-term care facilities and reduce the quality of care that residents receive.
  2. Increasing direct care workers’ compensation is vital to creating a stable workforce with well-qualified staff, lower turnover, and safe, high-quality care.

As we stressed in our comments, CMS demonstrated here that improving the quality of care at nursing homes and meeting every community’s long-term care needs is contingent upon improving the quality of direct care jobs. And, this means addressing limited training and advancement opportunities, a general lack of support and recognition, and, especially, inadequate compensation. Once again, CMS is recognizing and incrementally moving towards addressing the fact that we must improve direct care job quality to stabilize our care system and ensure we all have access to high-quality care.

We need to build on this momentum.

Across the nation, individuals are grappling with a critical shortage in the direct care workforce, a situation that not only deprives many of the essential care they require but also relegates direct care workers to positions that fail to reflect the significant value of their contributions. This crisis is further exacerbated by the fact that many of these roles are poverty-level jobs, starkly underscoring the profound disconnect between the importance of their work and the quality of their employment conditions.

Acknowledging this, the Biden-Harris Administration is demonstrating a commitment to taking incremental steps that better value direct care work and address the workforce’s challenges. Moving forward, we urge the Administration to double-down on their commitments and use this momentum to truly transform direct care jobs and ensure access to high-quality care for all Americans.

Jake McDonald (he/him)
About The Author

Jake McDonald (he/him)

Senior State Policy Advocacy Specialist
As the Senior State Policy Advocacy Specialist, Jake McDonald improves job quality for direct care workers by deepening and expanding PHI’s state-based advocacy approach.

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