The size of the home- and community-based services workforce has not kept pace with expanding numbers of Medicaid program participants, according to a new study whose authors contend that better pay and working conditions may help.
In a study published online Wednesday by Health Affairs, University of Pennsylvania researchers looked at HCBS trends. The majority of long-term services and supports used to be provided in institutional settings such as nursing homes, but today most are delivered through Medicaid HCBS programs, including by assisted living providers who participate in waiver programs — and 13% to 32% of Medicaid recipients rely on direct care workers, the researchers wrote.
Although the study excluded workers who work primarily in residential care facilities, including assisted living communities, study co-author Amanda Kreider, PhD, a postdoctoral fellow at the Leonard David Institute of Health Economics at Penn, told McKnight’s Senior Living that the findings still are important for assisted living community operators.
The study found that Medicaid HCBS participation increased continuously between 1999 and 2020, with some acceleration between 2013 and 2020. Growth in the workforce, however, has not kept pace with growth in Medicaid HCBS participation.
Although the home care workforce also increased between 2008 and 2019, it slowed after 2013; the number of home care workers per 100 Medicaid HCBS participants declined by 11.6% between 2008 and 2019, with evidence of further decline in 2020 attributed to the COVID-19 pandemic.
“To the extent that people in assisted living facilities seek out paid help with personal care, these trends are an indicator that the workforce to supply this care may not have kept up with demand over the last decade,” Kreider said.
A workforce shortage, the researchers said, could result in unmet care needs with serious adverse consequences for older adults, as well as extended stays in nursing homes when home care is unavailable.
The authors also noted that funding made available to states through the American Rescue Plan to improve workforce recruitment must be used by March 2025, and the proposed $400 billion in HCBS funding as part of the Build Back Better initiative in 2021 eventually was pared back to $150 billion, but it stalled in the Senate later that year.
“There is reason to believe these worker shortages may worsen over time, as the COVID-19 pandemic has increased the desire of older adults and people with disabilities to receive care at home,” the authors wrote. “Given these findings, and the increasing importance of HCBS in long-term services and supports, it is important that states and the federal government expend effort to support and expand the home care workforce.”
Medicaid HCBS reliant on workforce investments
The researchers noted that although greater insurance coverage for HCBS through Medicaid is an “encouraging development” for individuals who need care, that coverage should be coupled with workforce investments to meet rising demand.
Future investments, they added, should be directed toward improving wages and benefits to sustain the HCBS workforce, but the researchers acknowledged that low Medicaid reimbursement rates may limit the ability to pay and attract those workers.
“To attract more workers into this industry, we believe that pay and benefits will need to improve,” Kreider said, adding that many direct care workers live under the federal poverty level, and more than half rely on public benefits. “Since low Medicaid reimbursement rates are a commonly cited reason for low wages in the home care industry, improved working conditions will likely require increased investment from states and the federal government.”
In addition, Kreider said that the research told them that other aspects of workforce culture may need to improve to attract more workers, including opportunities for training, growth, and career advancement (career ladders), predictable scheduling and improved culture and worker agency.
