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• Posted April 26, 2023

In an Aging America, a Looming Shortage of Home Health Care Workers

Over the last decade, an aging American population has increasingly turned away from nursing homes in favor of trained caregivers who can provide critical help in the home with basic daily tasks.

But a new investigation warns the need for at-home care has vastly outpaced a much smaller growth in the pool of home care workers.

The result: between 2013 and 2019, the number of available home care workers for every 100 patients in need has fallen by nearly 12%.

The resulting caregiver gap is putting vulnerable patients in a very precarious position, the researchers said.

"We know that the number of people who want to receive long-term care at home has been growing over time, which is in part because the U.S. population is getting older,"explained study lead author Amanda Kreider. She is a postdoctoral researcher with the Leonard Davis Institute of Health Economics at the University of Pennsylvania, in Philadelphia.

"Additionally, older adults and people with disabilities are increasingly accessing long-term care at home instead of nursing homes,"Kreider added.

Much of that shift stems from expanded low- or no-cost coverage for home and community-based services (HCBS) steadily put in place by Medicaid, the main insurer for long-term care, she noted.

In theory the shift is a "positive trend,"Kreider said, given that "people with long-term care needs tend to prefer to live at home when possible."

But Kreider and study co-author Rachel Werner wanted to know if caregiver availability is actually meeting the moment.

To find out, the duo pored over data collected by two sources.

The first was the Census Bureau's American Community Surveys conducted between 2008 and 2020. The annual survey gathers information on the characteristics of 3.5 million American households, and by inference indicated the number of health care professionals who had been working in a home setting each year.

The second was survey information collected by KFF, a non-profit health policy organization. KFF's data tracked the number of Medicaid participants seeking home care in each state between 1999 and 2020.

Kreider and Werner determined that the home care workforce had, in fact, grown between 2008 and 2019, from 840,000 to more than 1.4 million. However, they also noted that the pace of that growth slowed after 2013.

At the same time, the number of Medicaid-covered patients seeking home care rocketed upwards, rising from just over 2 million in 2008 to more than 3.2 million by 2019.

The result: an 11.6% drop in the availability of home care workers for every 100 patients seeking their help.

The size of the need gap may very well have grown further since 2020, said Kreider, "but we are interpreting that data point cautiously due to the COVID-19 pandemic."

As to why the home care industry isn't growing faster, she pointed to a number of job downsides.

"These jobs are not attractive,"said Kreider. "They're very demanding, and offer low pay and benefits. Many care workers live in poverty, and more than half rely on public benefits like Medicaid and SNAP. Agencies report a really difficult time attracting workers, and anecdotally, they lose workers to the fast-food industry, which often pays higher wages. It's possible that this has gotten worse due to COVID burnout."

That points to practical ways to fix the problem, with the most central issue being pay.

"Agencies commonly say that they can't pay workers more," Kreider noted, "because Medicaid payment rates for these services are too low. Since Medicaid is the nation's primary insurer for long-term home-based care, it's possible that reimbursement rates will have to rise in order for wages to increase."

The field also needs better "opportunities for training, growth and career advancement, predictable scheduling, and improved culture and worker agency,"she added.

The findings were published in the May issue of Health Affairs.

Alice Burns is KFF's associate director of the Program on Medicaid and the Uninsured.

She said that while the size of the patient-home caregiver gap may be a matter of debate, the noted job downsides "are part of the story."

"The one factor I would add to your list is that there is an overall shortage of [all] workers who provide caregiving in the U.S.,"said Burns, with a similar shortfall seen when looking at institutional settings such as nursing homes.

"A recent study of health employment by sector shows that employment in nursing care facilities is [about] 13% lower than prior to the pandemic,"she noted.

And with both home care jobs and institutional setting jobs pulling from the same workforce pool, "a big component of the shortage of home and community-based service workers is an overall shortage of low-skilled people in the caregiving field,"Burns said.

More information

There's more on the post-pandemic home care landscape at KFF.

SOURCES: Amanda Kreider, PhD, postdoctoral researcher, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia; Alice Burns, PhD, associate director, Program on Medicaid and the Uninsured, KFF, Washington, D.C.; Health Affairs, May 2023