Minnesota's home health care industry and the growing labor shortage

CATHY WURZER: Now, you know that Minnesota is facing a labor shortage. Now, the whole country is. And there are few places where that's more apparent than the home health care industry. Since January of 2020, 400,000 nursing home and assisted living staff have quit, citing pandemic exhaustion as well as low pay and lack of advancement opportunities typical of the field, a field that's among the fastest growing industries in the nation. And why is that?

About 10,000 people a day turn 65 years old. The percentage of people over the age of 85, the group that most needs care, is predicted to double to 14 million by 2040, leading many to ask, who will take care of this country's elderly? Here to talk more is Dr. Joseph Gaugler. He's a Professor and the Robert L. Kane Endowed Chair in Long Term Care and Aging at the School of Public Health at the University of Minnesota. Doctor, welcome back.

JOSEPH GAUGLER: Thank you so much. So great to talk to you again.

CATHY WURZER: Professor Kane, a noted researcher, was still alive. And, gosh, he talked at length about this problem to anybody who'd listen. And the problem is here now. What are the factors that have led to this shortage of workers?

JOSEPH GAUGLER: Well, Ms. Miller, time is short. Quite frankly, there's a litany of them. Some would argue the reasons for the shortage overwhelm potential solutions. But really when one considers the landscape of the home health workforce shortage, it comes down to several different factors. First are recruitment challenges.

Generally, those who provide home health care are more or less labeled as low wage workers and assigned a low value. There's a certain stigmatization that many in society-- policymakers, providers-- accord to these individuals. And that kind of clouds this whole discussion. And certainly in trying to seek out solutions, I think that's a critical factor.

You've already alluded to, and I think we all know about, inadequate compensation. Pre-pandemic, the median hourly wage for at least a home health care provider that was a personal care aide was only around $11.30. That may have come up a little bit since the statistic I have access to. But that being said, roughly half of home care worker households are dependent on some form of public assistance. And so, again, it clearly makes it very challenging to recruit individuals when this is the pay level.

CATHY WURZER: Let me ask you a little bit more about the pay here, because I've had the opportunity to be involved in home care with a parent. And we were paying $35, $40 an hour, really. It was expensive, but the worker didn't get much of that at all. So where's this money going?

JOSEPH GAUGLER: That's a great question. One would assume it is going into the various administrative costs associated with managing home health care workers. Now, I think for those of us that have a more critical eye to this arrangement, that is by no means sufficient. Are there ways to cut into the administrative overhead costs of this type of service so that, in fact, these home health care workers can get paid more?

And one thing that was interesting I think, Ms. Miller, when considering the pandemic, and the huge stress test it placed on the long-term care service and support system-- and it was certainly a significant crisis-- was it did also offer the ability to flexibly deliver some types of home health services. For example, the use of telehealth services-- now, one certainly probably would not argue that delivering a visit over telehealth for home health is not sufficient when trying to complete various types of personal care tasks.

But many home health agencies were using telehealth services, for example, to obtain consent and reduce some of the other administrative burden of delivering these services. And so when we think about potential solutions, that is one-- how do we flexibly administer home health services to cut down on costs so people can get paid more and get paid what they deserve?

CATHY WURZER: I'm wondering, when home health care is not available, folks have to make some tough decisions, right-- and sometimes having unpaid family members fill the gaps. So let's talk about that. Do we see that happening more and more? And what's the long-term economic effect to that?

JOSEPH GAUGLER: Certainly, at the very least anecdotally-- and again, I'm using COVID-19 as a reference point-- we have heard many stories of families having to shoulder significant burdens throughout the pandemic and now endemic of COVID-19, where available, accessible, affordable, community based long-term services and supports were in short supply, or, in some cases, families simply couldn't use them because they were shut down. I'm thinking, for example, adult day services. The long-term effects of this are significant.

There's a large, large scientific literature, and I think many people who are involved in family care, such as yourself, know that the long-term implications on one's health, one's need for services themselves goes up considerably when one is providing ongoing, long-term support to a relative that often has complex chronic care needs. So certainly, it is no solution to continually rely on family members to serve as the core long-term care support system in the US.

That's what we've always done traditionally. There is certainly pretty compelling data to suggest that there won't be as many unpaid family members available in the future to provide this help. So how are we going to offset what I and others have called this family care gap for older people in the future?

CATHY WURZER: What's the best thinking about what's the answer? Because as I mentioned in the introduction, baby boomers are getting older. And it sounds like we are going to be in a big problem down here down the road.

JOSEPH GAUGLER: I think what you're pretty much doing to me now is if you had to pin me down and try to identify the one solution, ideally, this would be a solution coming from the federal level. I'm not certain that that's going to be happening. But when we look at some states who have been at the cutting edge of innovation of how they approach long-term services and supports in a variety of different ways, I look at the state of Washington, in particular how they chose-- I believe this was right before the pandemic in the fall of 2019-- to basically enact a law to refinance community based long-term services and supports for their state citizens.

It received broad support by the electorate in the state of Washington, which basically allows residents to accumulate a voucher of sorts-- basically up to $36,000, I believe-- to purchase community based long-term services and supports. And so why is this helpful? It's either $36,000 or $56,000. I don't remember off the top of my head.

But in any event, what that allows people to do, families to do is to have resources available to purchase important services like home health, like adult day services, maybe home modifications, et cetera to allow older people to live at home as long as possible, which, by and large, they wish to do, and also to offset some of the stresses and challenges to this very large and vast unpaid long-term care support system.

I really have wished and hoped that the state of Minnesota would be pivoting in this direction. And my hope continues that will happen to our state as well, which is known also as an incubator of innovation in long-term services and support.

CATHY WURZER: So in a sense, it's like an HSA for long-term care.

JOSEPH GAUGLER: I think that's the best way to think about it. And we all know, even $56,000 is not a lot of money when we're talking about residential long-term care. I mean, assisted living or nursing home often costs in five figures per month. But when we're talking about an adult day program, using an adult day program several times a week, which roughly costs, I'd say, around $75 out of pocket or so for a full day-- those funds can be very helpful for at least several years when an older person could utilize these services and maximize them the most.

So I think that's a step in the right direction. Again, I do see this type of policy innovation as one that has the potential for bipartisan appeal. And one would hope that other states would adopt similar types of approaches.

CATHY WURZER: Interesting. It's an interesting situation. It's a scary situation, especially if you've got older parents. I appreciate your time. Thank you so much.

JOSEPH GAUGLER: Thank you so much for having me.

CATHY WURZER: Dr. Gaugler, Joseph Gaugler, is a Professor and the Robert L. Kane Endowed Chair in Long Term Care and Aging at the School of Public Health at the University of Minnesota.