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

“Aging is living, and that longevity is a good thing,” said Ai-jen Poo, president of the National Domestic Workers Alliance and executive director of Caring Across Generations during a recent panel discussion at the 2022 Age Boom. Academy of Columbia University titled Caregiving and our longer lives. “To grow old is to learn longer, to connect, to love and to teach.”

Aging also means that the risk of older people eventually needing some kind of long-term care and service (LTCS) remains high. LTSS is a shortcut for people who receive help with basic activities, such as bathing, dressing and preparing meals. Not everyone ages well, and even the healthiest seniors eventually face some physical and mental limitations, or worse.

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

The problem is that the American approach to long-term care is deeply inadequate, a patchwork of underfunded programs and services. Medicare generally does not pay long-term care costs. Medicaid does, but to qualify, household assets must be exhausted. Premiums in the private long-term care insurance market are too high for many families. Unpaid family members take on many responsibilities in caring for frail elders. There were nearly 42 million family members caring for someone 50 and older in 2020, up from 34 million in 2015, the National Alliance for Caregiving and AARP calculate.

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

The need for reform has long been evident. Yet progress has been extremely slow. While there is no single policy wand that could easily create an equitable, affordable and universal high-quality long-term care system, perhaps the most promising policy lever to trigger broader reforms is the dramatic improvement in the earnings and employment status of low-income people. wages of lower status direct care workers.

“Today, elderly and disabled American citizens are supported by a poorly paid and poorly trained workforce,” writes MIT economist Paul Osterman in Who will take care of us? “Continuing in this way is in no one’s interest, and the case is compelling for transforming the jobs of direct care workers.”

Direct social workers support those in need, usually at home, but also in settings such as nursing homes and assisted living centers. (Direct care workers assist children and young adults with disabilities and special needs, but for this column the focus is on seniors.) The current median salary for these frontline workers is approximately $15 per hour. The job is generally without benefits and nearly half rely on some form of public assistance, such as Medicaid. The workforce is primarily made up of women, people of color, and immigrants.

Direct care workers have no status within the healthcare industry. Labor is mistakenly considered unskilled labour.

“Direct care is skilled work,” said Robert Espinoza, executive vice president of policy at PHI, a home health advocacy and research organization. “We have to stop thinking it’s unqualified. This is not the case.

Ask Susie Rivera. The thought required to be a professional carer is evident in listening to her discuss her work. (You can listen to a podcast interview with Rivera here.) She has been a caregiver since 1986. She has held a variety of nursing positions over the course of her career. Like many professional caregivers, she has also been an informal family caregiver. She earns just over $15 an hour and puts in at least 72 hours a week to make ends meet. Rivera is passionate about work.

“It’s a calling. It’s so rewarding,” she says. “I always said this, wherever I went to take care of someone, I said the ordeal is here. Don’t worry, we’ll take care of you.

There are approximately 4.6 million direct care workers. From 2019 to 2029, a total of 7.4 million vacancies will need to be filled, estimates PHI. The increase reflects growing demand for workers and the need to find additional workers as caregivers leave the profession (many can earn more at fast food restaurants and even walking their dogs). Attracting and keeping workers will require higher wages, better benefits and, perhaps most importantly, training and a clear path to career advancement.

“We can all understand that we need to value the caregiver more, but we haven’t poured the money into the system and held the providers accountable to really get the money to the workforce,” said David Grabowski , Professor of Health Policy, Department of Health Policy at Harvard Medical School Age Boom Academy.

It’s time for political impatience. The report Making care work pay by Four Experts (published in 2020) suggests paying a living wage, an improvement they claim would boost employment and reduce turnover. MIT’s Osterman recommends that federal and state authorities use their purchasing power to improve working conditions and compensation. A higher federal minimum wage and a more generous earned income tax credit would also help. Although it did not pass, President Biden proposed spending $400 billion on home and community care and the plan offered many ideas for improving compensation, including paid sick leave. the federal government.

Where could the funding come from? Most families already find professional caregivers expensive, so funds will have to come from elsewhere. Medicaid is the main source of funds to pay direct care workers. Funding could be increased, reimbursement rates dramatically increased, and rules established to build a living wage into the program. More ambitiously, the United States should set up a universal system of social insurance to finance long-term care. Thoughtful reform plans abound.

The question is how to move the reform forward. Transformation could start with policies that transform direct care work into quality jobs.