In February 2018, Virginia Olthoff, 87, died of dehydration in a 5-star-rated Iowa nursing home after going several days without water. In response, her senator, Chuck Grassley, held another in a long line of hearings on “protecting Americans from abuse and neglect in nursing homes.”
In reading over testimony from the hearing, I was struck by how little attention was paid to a point raised by Olthoff’s daughter, the lead witness. It was echoed by almost every other speaker, but only in passing. Grassley made no mention of it in his opening remarks.
“I want to thank the CNAs, nurses and others who work in care facilities and do their jobs right,” said Patricia Olthoff-Blank after noting several certified nursing assistants raised alarms but had been ignored by their superiors. “The facilities are often understaffed and these people work for much less money than they should be paid.”
“Understaffed” and “much less money” don’t begin to describe the abysmal working conditions at America’s skilled-nursing facilities and home health agencies. According to the most recent Bureau of Labor Statistics data, the average pay for CNAs in 2017 was about $13 an hour. Home-care workers earned about $11 an hour.
While wages have inched up in the past few years, the purchasing power of take-home pay for those on the lower rungs of the healthcare workforce is no different today than it was a decade ago. Moreover, a substantial share of the 4.4 million jobs in the sector are part-time, forcing workers to take on multiple engagements to make ends meet. Turnover in the sector is over 60%.
Let’s be frank about who takes these jobs. They are disproportionately people of color. Nearly 30% of the home health workforce are immigrants, some of whom are undocumented.
This is the workforce that healthcare leaders and federal and state officials hope to engage in moving care closer to home and in coordinating care that will keep the frail elderly and disabled out of the hospital. But rather than promoting legislation that would bolster pay, improve training and create career ladders, we get another hearing on the tragedies that inevitably occur in a dysfunctional system.
Representatives of the trade associations representing the nation’s 12,000 home health agencies and 15,000 nursing facilities rightfully point to woeful reimbursement by state Medicaid agencies across the country. Medicaid is primarily responsible for the long-term support of the frail elderly and disabled without long-term-care insurance or savings, i.e., nearly two-thirds of the population in need of those services.
Medicare, which does not provide long-term care, ignores the issue. The Medicare Payment Advisory Commission argues that high SNF margins (over 10% for nearly two decades) for post-acute medical services justifies lower reimbursement. It ignores overall margins that are below 1%, a reflection of the -2.4% margin on non-Medicare services paid by Medicaid and private payers.
MedPAC has also called for a 5% cut in reimbursement for post-acute home health services. If put into effect, this would drive wages for home health workers even lower since Medicare cross-subsidizes low payments under Medicaid.
If Congress wants to take on the issues that underlie all-too-frequent nursing home tragedies, it should raise reimbursement rates in a way that ensures new money flows to the people who take care of our parents, grandparents and disabled family members. It should pass legislation that provides training and job ladders for these workers.
It should bolster state efforts to improve oversight of neglect and abuse, of course, although more background checks will never solve the problems of chronic understaffing, turnover, poor training and lousy morale.
Care is moving closer to home. That’s a good thing. But to make it safer, more effective and more patient-friendly, we need to do more for the CNAs and home health aides delivering that care.