In most cases, Medicare does not pay for home care for basic services. “One of the biggest misconceptions people have is that there will be a safety net to catch them. And there isn’t,” says Robert Espinoza, vice president of policy at PHI, a direct care workforce advocacy group, which includes home health aides.
Long-term care insurance policies were once seen as a solution, but insurers found they had underestimated the amount they would have to pay in claims and miscalculated returns on investment due to low interest rate. This prompted many companies to stop selling the policies. Today, policies are still available, but they are not very popular. Only some 49,000 new policies were sold in 2020, according to the American Association for Long-Term Care Insurance. Cost could be one reason. A 55-year-old single man will pay $950 per year for a premium with an initial amount of $165,000. A 55-year-old single woman will pay $1,500 for the same policy.
“It’s a product that doesn’t come cheap,” says Jesse Slome, director of the American Association for Long-Term Care Insurance. “And there’s no sense of immediacy that you have to buy it – unlike other insurance. You can’t buy a house and have a mortgage without home insurance. He adds, “There’s a certain type of person who buys it. They can afford it and they plan. Not everyone is a planner. And most importantly, you have to be in good health when you buy this coverage. We have a nation that is not not particularly healthy.
Financial relief may be on the horizon: The Caregiving Credit Act, introduced in Congress in May 2021. The AARP-backed bipartisan bill would provide up to $5,000 in federal tax credits to eligible family caregivers. Eligible expenses include respite care, home modifications and the hiring of home health aides, as well as assistive technology and transportation.
Another option can be found in some Medicare Advantage plans that offer coverage for more services, including home health aides to help with caregiving. In 2018, the Centers for Medicare & Medicaid Services (CMS) expanded the scope of “primarily health-related” supplemental benefits for these private plans. Now, some plans can offer gym memberships, transportation to doctor’s appointments, healthier food options and grab bars in bathrooms, and can even cover the cost for a person with chronic asthma to have their carpets deep cleaned to help control the condition.
Challenge #4: Shortage of well-trained and reliable caregivers to hire
Paul McCartney wondered if anyone would feed him at the age of 64. This question, for many older Americans, has become a very legitimate concern. As the number of older adults increases, the demand for home and personal care workers is expected to increase by 33% from 2020 to 2030, according to the United States Bureau of Labor Statistics. This rate of increase is much higher than the average for all occupations.
“We’ve been warning about a labor shortage for years,” says Espinoza. According to the Bureau of Labor Statistics, in 2021 the average hourly wage for health care aides and home health aides was $14.07 and the average annual wage was $29,260.
In every state and the District of Columbia, the median salary of direct care workers is lower than the median salary of other occupations that have similar entry-level requirements, according to a 2020 PHI report. This includes janitors, retail clerks and customer service representatives. “In many states, McDonald’s and Macy’s will capture these applicants with easier entry points and training,” Espinoza says. “We need to understand the compensation piece.”
Some states are finding creative ways to boost recruitment and retention of the paid caregiver workforce.
In Wisconsin, the WisCaregiver Careers program was launched in 2018 as a public-private partnership between the state Department of Health and nursing home provider associations, attracting the interest of 9,000 recruits to 3,000 home care positions through marketing, free training and a $500 retention bonus. . “We were competing with the big box stores and coffee shops, so it was really rewarding to get so much interest,” says Kevin Coughlin, policy initiatives adviser for the Wisconsin Department of Health. A new iteration of the program about to start will expand it to include jobs as home healthcare workers, not just positions in nursing homes.
In New Mexico, the Encuentro Home Health Aide (HHA) program focuses on creating career paths for Spanish-speaking immigrants to enter elder care to meet the needs of Spanish-speaking communities. Emphasis is placed on HHAs to be independent contractors, not signed with an agency, allowing the caregiver to earn a higher salary. In 2021, part-time and full-time Encuentro graduates “earned an average of $17.50 an hour,” says Mayte Lopez, Home Aide Training Specialist for Encuentro. “These agency HHAs earned an average of $11.50.”
Challenge #5: Lack of transportation options
One of the biggest logistical headaches for the caregiver and care recipient is transporting loved ones to a destination – to the store, to medical appointments, to treatment centers, to visit friends . According to a 2018 National Aging and Disability Transportation Center survey, about 40% of caregivers spend at least five hours a week providing or arranging transportation. What if a trip cannot be arranged? An older study published in the Transportation Research File: Journal of the Transportation Research Council found that approximately 3.6 million people in the United States in a given year did not receive medical care due to transportation problems. Not being able to go out also adds to a sense of isolation, which has been linked to an increased risk of serious health problems.
Community transportation programs are available; one such program is Dial-A-Ride, usually funded by a local government and made available to riders 65 and older or those who qualify under the Americans With Disabilities Act. Volunteer transportation programs, such as Shepherd’s Centers of America, are available; Shepherd’s sends volunteer drivers from more than 55 affiliate centers across the country every day.
Medicare will generally only cover emergency medical trips, such as those requiring an ambulance, except in certain chronic and debilitating cases, so relying on Medicare is not the answer. But due to changes that went into effect a few years ago, more Medicare Advantage plans began offering transportation benefits; 2020 saw a 25% increase over the previous year, according to the Medical Transportation Access Coalition.
Denver Health was one of the first hospitals to partner with a ride booking company. In 2017, after an elderly patient waited several hours for a transport that never came, hospital administrators knew something had to be done. A partnership with Lyft made the difference, says Amy Friedman, director of experience at Denver Health.
“We use them every day,” Friedman says, adding that the hospital provided 5,800 rides — “almost 16 a day” — in 2021. She notes the program is funded by the Denver Health Foundation, a separate philanthropic organization , and that it is reserved for patients who have no other choice. “It must be a last resort.”
San Antonio-based SafeRide Health has a partnership with Lyft. SafeRide is creating software that will make organizing such rides even easier. “We want to make sure that we can make transportation as accessible as possible with the click of a button,” says Andy Auerbach, chief revenue officer at SafeRide Health, saying that when a patient makes an appointment, the next question should be: ” Do you need a walk? Great. One button.
Challenge 6: Inequalities exist within the system, causing disparities in the world of care
Think family caregiving is hard? It’s especially difficult in communities of color, where there’s less access to health care, more people work in hourly jobs, people often don’t trust government officials who may try to providing assistance and housing may be substandard. “These issues are really built into the system,” says Edem Hado, policy and research manager at the AARP Public Policy Institute.
A 2021 analysis by the Commonwealth Fund, a private foundation dedicated to health issues, found that every state’s health care systems are “failing” many people of color. Even in states deemed “high performing,” many people of color received “significantly worse” health care than whites.
The National Institute of Aging has established a “Strategic orientations for research, 2020-2025” plan; one of its goals is to “understand health disparities associated with aging and develop strategies to improve the health status of older adults in diverse populations.”
“Politicians will say, ‘Show me the data,’” says Hado. “If we don’t collect it in a way that reflects different groups, where is the support there?”
But Jan Mutchler, director of the Institute of Gerontology at the University of Massachusetts Boston, says the issue needs to be approached from an even broader perspective: Creating vulnerable communities in general will also improve care delivery. “Policies tracing back through the life course to maternal care, child care, early childhood education – anything that shapes the accumulation of health and human capital are relevant to thinking about what needs to happen to establish a fairer old age.”
Ann Oldenburg, a former USA today journalist, is associate director of the journalism program at Georgetown University. She holds a master’s degree from Georgetown’s Aging & Health program and spent several years as a full-time caregiver to her mother.