The demographics of a growing demand for elder care in America is raising alarms. The number of adults 65 and over requiring long-term care could rise by more than 70 percent over the next quarter century, estimates MIT Sloan School of Management professor Paul Osterman, author of the new book, Who Will Care for Us?: Long-Term Care and the Long-Term Workforce. But the supply of home care workers is likely to fall short of demand. Perhaps a novel program from the AARP Foundation and Capital Impact Partners, a Community Development Financial Institution based in Arlington, Va.,will help solve this problem.
Home Care Workers: The Rodney Dangerfields of Health Care
The nation’s 2.2 million home care workers (also known as personal aides) are on the front line of everyday caregiving. They let some of the disabled elderly age in place by providing light housekeeping, companionship and personal care, such as bathing, dressing and medication reminders. Problem is, home care workers are the Rodney Dangerfields of health care: They get little to no respect.
The home care workforce, which is 90 percent female and 56 percent minority, occupy the lowest rung of America’s vast health care system. Median hourly wage: about $10; median annual wage: roughly $22,000. Wages have fallen 5 percent over the past decade. Two thirds of home care workers do it part-time; most do so for private agencies and don’t receive benefits.
Little wonder that the profession’s annual turnover rate is about 60 percent.
A Workforce With a History of Discrimination and Exploitation
“Home care has a long history of being undervalued—a glorified babysitter. For decades it has been seen as companionship and not as a complex profession with a wide range of skills,” says Robert Espinoza, vice president of policy at PHI, a nonprofit that looks to improve elder care and disability services. “The other factor is the demographics of this workforce — women, women of color and a large proportion of immigrants —with a long history of discrimination and exploitation.”
A joint program funded with $200,000 the AARP Foundation and managed by Capital Impact Partners aims to create quality home care jobs for women 50 and older through what are called home care cooperatives. The grant money pays for the cost of program participants who are 50+ to become state-certified home care aides.
Where the Home Care Co-Ops Are
Currently, there are just 10 home care co-ops in operation, with another five in the formation stage. The co-ops are, or will be, located in California, Colorado, Hawaii, Maine, New Mexico, New York, North Carolina, Pennsylvania, Texas, Vermont, Virginia, Washington and Wisconsin. The largest and oldest is Cooperative Home Care Associates in Bronx, N.Y. Established in 1985, it has a staff of some 2,000.
In sharp contrast to traditional for-profit agencies that hire home care workers, co-ops are worker-owned and worker-controlled. They provide members more training opportunities, steadier hours and benefits. Any profits are distributed as dividends to members annually.
The emphasis on mutual commitment and support may be particularly attractive to older caregivers.
Caregiving as a Second Career
Part of the AARP/Capital Impact Partners experiment is to see if the co-op model might offer older workers a second career option in caregiving.
Also, with the passage of time, the co-op members might get the chance to stay employed there when the physical demands of caregiving become too much. “Maybe the older caregiver can transition to training and bookkeeping,” muses Candice Baldwin, director of Aging in Community at Capital Impact.
“I think the cooperative is the only model for home care,” says Kippi Waters, founder of the Peninsula Homecare Co-op in Port Townsend, Wash. This co-op, started
in 2016, recently raised its hourly wage to $15 an hour — up from $13. “We’re trying to change the perception that home care isn’t a good job,” says Waters. “Caregiving has a bad rep in our culture. It should have the best rep.”
A Tale of Two Co-Op Caregivers
Vibeke Danborg, 59, recently joined Peninsula Homecare as a member of the co-op. Born and raised in Denmark, she came to the U.S. in her 20s and has been a long-time caregiver in the Seattle area, Boston and now Port Townsend, which is a two-hour ferry ride from Seattle.
“The difference between an agency and membership is big,” Danborg says. “Members have input into the day-to-day running of the coop. I am a team player. I have a voice. It’s very fulfilling.”
Grace Rosen, who will celebrate her 66th birthday this month, echoes her sentiments. Rosen moved to Port Townsend last year from Portland, Maine — where she ran a therapy business and also became a Peninsula home care worker. She has several customers, including a 96-year-old former member of the Coast Guard and an 88-year-old former elementary school teacher.
“The job has been one of the more challenging things I have done in my life,” Rosen says. “To change careers at age 65 seems bizarre. But I love it.”
The National Potential of Home Care Co-Ops
One goal of the AARP Foundation/Capital Impact Partners venture is to test the national potential of home care cooperatives.
“We want to support innovation,” says Baldwin. “If we understand the cooperative business model better, then we can finance it.”
The Cooperative Development Foundation (CDF), whose mission is to promote community, economic and social development through co-ops, will analyze the results of the initiative. Resources on home care co-op development, membership, operations and replication are on the CDF site.
Reforming the Home Care Worker Profession Is Daunting
You can see why the cooperative home care model is enticing. The reality of reform is daunting, however.
Coops currently account for a mere sliver of the home care market. So they have a long way to go before filling the gap between the demand for caregiving services and the supply of home care workers.
There is also no way to broadly improve working conditions of the home care profession without Medicaid reform.
Medicaid pays for two-thirds of long-term care in the U.S. and generally requires impoverishment to qualify for benefits. But its reimbursement rates for home care workers are low and inflexible. Consequently, most home care co-ops must focus on clients who are not on Medicaid and who pay for services through savings, private insurance, family resources or some combination.
At the moment, politicians in Washington D.C. show little interest in tackling long-term care reform, including improving Medicaid payouts for the home care workforce.
“Long-term care is absolutely the stepchild of health care on multiple dimensions,” says Osterman in an interview.
Holding Out Hope
Still, don’t give up on prospects for reform.
Remember what the Queen told Alice in Lewis Carroll’s Through the Looking-Glass, and What Alice Found There:
Alice laughed: “There’s no use trying,” she said, “one can’t believe impossible things.”
“I daresay you haven’t had much practice,” said the Queen. “When I was younger, I always did it for half an hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”
The combination of an aging population and the growing need for qualified home care workers just may eventually put pressure on Washington and states to come together, redesign the long-term care system and make home care the profession it deserves to be.
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