Should the aides who provide home care for frail elders and younger people with disabilities receive a living wage and decent benefits? If they do, how can families, who often are unable to afford care today, be expected to pay those higher wages and benefits? Should the market be allowed to set these prices, or should government intervene through minimum wage and mandatory overtime laws? Should cash-strapped Medicaid programs be required to pay more for these services? And which home care workers should be eligible for pay raises and Medicaid reimbursement?
These questions have set off an enormous, but largely unnoticed, political firestorm. In some cases, they have pit states against the federal government, people receiving care against their aides, and large home care agencies against independent direct care workers.
Last week, I got a taste of this heated controversy when I participated in a panel discussion at the New America Foundation. A presentation by author and advocate Ai-Jen Poo was disrupted by a disability group angered by her support of new rules that would boost wages for direct care workers.
Why would self-styled advocates for people with disabilities oppose better pay for those who provide them with personal assistance? You’d think people would want aides who are well-paid and well-trained.
Instead, they fear that if Medicaid pays workers more, it will reduce other homecare benefits, such as hours of assistance, to offset the cost. And the result, they insist, is that people with disabilities will end up in nursing homes.
In fairness, the protestors represented only a small number of people with disabilities. Many others strongly support higher pay and benefits for aides.
And it is hard to dispute their case.
People who need long term services and supports overwhelmingly want to live at home. While family members are the bedrock of home-based care, many frail elders or younger people with disabilities also need help from paid, direct-care workers. They cannot live at home without them.
Yet, on average, these workers are paid about $10 per hour for extremely difficult work. They suffer more on-the-job injuries coal miners. They often work extra hours for little or no pay and get few benefits the rest of us take for granted such as sick days, health insurance, vacation pay, or retirement.
In sum, we entrust the care of our most vulnerable loved ones to people who are often paid less than fast-food workers. By paying veterinary technicians more than home health aides, we are saying we value the care of our cats more than the care of our parents.
This controversy has been boiling since the Supreme Court ruled in 2007 that homecare workers had no right to overtime pay under federal labor law. A number of bills were introduced in Congress to overturn that decision but have gone nowhere. In 2013, the Obama Administration proposed regulations to allow overtime pay for some home care workers but those regs were blocked by another federal court.
Meanwhile the dispute over how much Medicaid should pay aides is heating up in several states including California and Ohio, where lawmakers also are looking to bar Medicaid payments to workers who are not affiliated with approved home care agencies.
But keep in mind the battle over paying some of the lowest compensated workers in the country is really a proxy war over a much bigger issue: There is not enough money in the long-term care system to finance the care people need.
Instead of squabbling among themselves governors, advocates for care workers and care recipients, and federal officials should sit down together to figure out how to better fund long-term supports and services. The solution could include both public and private elements, such as a rethinking long-term care insurance; a better targeted but more flexible Medicaid safety net; a well- integrated, more efficient system of medical and personal care; and improved ways for families to tap home equity and private savings.
But the bottom line is that somehow, from somewhere, we will need more money to pay for this personal assistance, especially as 77 million Baby Boomers move into old age. Fighting over a shrinking pie is not going to solve the problem. Neither is putting the burden of the shortfall on the backs of direct care workers or those they help.