Putting “Number Six” First

For those not familiar with the day-to-day demands of direct care jobs, I recommend a recent article in Vox.  The piece provides a first-person perspective on the realities of the profession.  The work is physically and emotionally difficult, does not provide a living wage, typically comes with no benefits, offers few opportunities for advancement and little respect, acknowledgement or empowerment from supervisors, or at times even from clients.  In short, it has few to none of the hallmarks most of us would say characterize a desirable job.  It’s not at all surprising to me that recruiting and retaining people to do this work is no easy task.  I’ve heard many critical comments over the years about individuals who leave direct care work for jobs in retail or food service.  It is particularly unfortunate when these are people with a strong desire to care for others and a gift for doing this kind of work.  But frankly, if you compare the relative demands and compensation for these very different types of work, it’s more surprising that anyone stays in caregiving.  We all owe those that do a tremendous debt of gratitude.

Impacting this issue will require a deep look at how we as a society value this kind of work and the people who do it.  And it’s high time we went there.

Maine’s newly-established Commission to Study Long Term Care Workforce Issues met for the first time on September 11, focusing state leaders’ attention on this critical issue for our future.  Last month, the Washington Post  published a timely precursor to their discussions, exploring the rapidly-growing gulf between the availability of professional caregivers for older people in Maine and the demand for these workers.  The heartbreaking stories of older Mainers struggling to meet their needs for support captured attention in a way that statistics and data alone rarely can.  They illuminated the relevance of this issue to each and every one of us.

I am pleased that the Commission has begun their work and hope that constructive and promising solutions will emerge. Though I find it concerning that among the seven directives articulated in their enabling legislation, we have to get all the way to Number Six before we see, “Developing strategies to improve the quality of long term care jobs.”  I recognize that these directives are not explicitly prioritized, but numbers one through five reflect the themes that have dominated these sorts of discussions for years: assessing demand, developing a campaign to promote direct care jobs, supporting career ladders, identifying and meeting education needs, and identifying barriers to hiring and methods to overcome them.  All are certainly worthwhile and good things.  But unless we deal with “Number Six” – the proverbial elephant in the room – all the campaigns and education in the world will not achieve the desired outcomes.

Direct care workforce experts PHI National publish annual reports analyzing data on direct care workers in home care and nursing home settings. Their 2019 reports show that U.S. home care workers earn an average of $11.52 an hour or $16,200 per year, and one in six of these workers lives in poverty.  Wages and earnings are modestly higher for nursing assistants working in nursing homes at $13.38 and $22,200, respectively. Thirteen percent of these workers live below the federal poverty line.  Nationally, 53% of home care workers and 36% of nursing assistants rely on some form of public assistance given their low income levels.

Why, then – when we know that our care worker shortage is reaching crisis proportions – is it so tough to get to the heart of the matter?  I fear that a key underlying factor in the persistence of this challenge lies in another aspect of the PHI data – the demographics of this workforce.  About 9 in 10 home care workers and nursing assistants are women; more than half (62% and 57%, respectively) are people of color; and 31% and 21%, respectively, are immigrants.

Often, new immigrants are identified as a key solution to our caregiving crisis.  The unstated implication is that since these are poverty-wage, poor quality jobs, expanding the immigrant labor force is the best solution.  To put it bluntly, the troubling take-away message is that we need to find more people like the ones doing this work now that can be exploited to grow this workforce.  It is simply too challenging and uncomfortable to examine why we allow the jobs themselves to persist in being so undervalued, and to address the underlying factors that stem from disparities in power, privilege and resource allocation.

I appeal to the Commission to finally help elevate “Number Six.” It’s time to put our collective creativity to work with a focus on systemic issues and root causes, and to have the difficult conversations this will require.  I am hoping we as a state will commit to meaningfully transforming direct care jobs, including ensuring a livable wage, essential benefits and opportunities for a career path. This will create the conditions to attract the new people we need in the numbers we need them into this noble field – including new immigrants, as well as others.  As the oldest state in the nation, the time is now to engage in the effort to find the lasting solutions that will ensure there is someone there to support each of us as we age.