Who will care?
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Who will care?

Our elderly population—vulnerable, often invisible and growing rapidly—faces a healthcare system that’s overwhelmed with critical labor shortages and massive funding gaps, potentially exposing millions to insufficient care.

Based on an article by Matt Schur from the AMT Pulse, Spring 2022.

An alarm is about to sound. Every day, from now until 2030, an average of 10,000 baby boomers will turn 65. By 2030, roughly 25% of the United States’ population will be 65 or older.

This forthcoming wave has been likened to a disaster, with doom-evoking names such as the “silver tsunami.” Such worry is warranted; more than half of the American population will need some long-term care, with roughly 15% of people having medical bills that exceed $250,000. Yet nearly half of U.S. households headed by someone who is 55 or older have no retirement savings, according to the U.S. Government Accountability Office.

“We find that a large number of people in the United States will lack the resources to receive the full amount of care they will need,” says Patrick Hubbard, research associate, Center for Retirement Research at Boston College, Boston.

Population numbers and inadequate funding represent only part of the problem. Direct care workers—a huge portion of the elder care workforce, totaling roughly 4.5 million employees—earned a median salary of $20,200 in 2020, according to PHI (Paraprofessional Healthcare Institute). Low pay, in combination with limited career mobility and poor training, drives huge turnover—hovering around 67% and as much as 80% annually in recent years.

“One part of the looming crisis is that the workforce is so underpaid and so undervalued that we can’t recruit and retain enough workers to meet the current demand, let alone the oncoming demand from the aging population and from the need for childcare,” says Josie Kalipeni, Executive Director, Family Values @ Work, Washington, D.C.

As people continue to live longer, the demands on the system will only increase—a reminder that this isn’t a problem exclusive to today’s elderly; the wave is coming for us all.

A Fundamental Gap

The impending crisis is not new. Congress has been holding hearings on these issues since the early 1970s. Alarms have already gone off for other nations that have addressed the issue to some degree, whether through paid family leave policies, publicly funded long-term care insurance or other benefits. The U.S. remains one of the few countries in the world without mandated paid family leave.

“This is not a problem that’s going to solve itself,” Kalipeni says. “This is also not a problem that families can earn and save enough for. Except, and even in some cases of disability care needs are often unpredictable—there’s no way to meaningfully anticipate what the costs are going to be.”

Medicaid, which was established in 1965, is the primary funder of long-term care, accounting for $182.8 billion in spending in 2019, or 42.9% of total long-term spending. Medicare accounted for 20.5%, with additional spending coming from: other public funding (6%), out-of-pocket (14.9%), private insurance (9.0%) and other private funding, such as philanthropic support (6.6%).

While 96% of seniors have Medicare coverage, it doesn’t fund long-term care, only acute and post-acute care. Medicaid, meanwhile, comes with eligibility requirements that can be particularly limiting for age (you typically must be 65 or older) or income. A patchwork of varying state eligibility requirements adds to the confusion.

“People think Medicaid and Medicare are going to step in right when they need it,” Kalipeni says. “The reality is many people don’t qualify for Medicaid, which puts people in a predicament to have to spend down all of their life savings and assets to qualify for meaningful services and supports. That’s people’s hard work. To spend all of that down to qualify for Medicaid is devastating for many, many families and cuts off the opportunity to pass on generational wealth.”

While noting that we need better funding options, Dr. Clark-Shirley says, “Medicare is starting to incorporate payments for services like a nutritionist or transportation, which is a good indicator of where this  conversation is going. It recognizes that we can’t provide good acute care if we can’t keep people out of the hospital because they’re living in dangerous or unhealthy situations.”

Care Climate

Much of the work in caring for seniors is done for free. About 34 million Americans provide unpaid care to an older adult, often a family member. While money isn’t necessarily being spent, these jobs carry real costs. A person who looks after a family member often loses the chance to have another job and earn money; they may lose the ability to spend time elsewhere, such as looking after their own children. The job can be exceedingly stressful, too. As our population has fewer kids, we have fewer people to maintain this unpaid labor.

“Family caregivers are, and probably forever will be, the backbone of long-term care,” Dr. Clark-Shirley says. “We have to get serious about paid family leave. I think that’s the beginning of this conversation.”

Caring for elderly populations is also one of the biggest job sectors in the country, with growth skyrocketing. The direct care workforce, which includes personal care aides, home health aides and nursing assistants, is projected to add 1.3 million new jobs from 2019 to 2029, with a total of 7.4 million job openings, according to PHI.

These factors are “driving people into an industry that has job opportunities, but not family-sustaining job opportunities,” Kalipeni says. “It’s almost an invitation into poverty.” After all, more than half of direct care workers rely on food stamps, Medicaid or other public assistance.

“What’s needed is a competitive wage, not just a living wage, and we’re nowhere near that—most of these wages are poverty-level wages,” Espinoza says. One of the reasons turnover is so high is that direct care workers can find jobs in other sectors, such as in retail or fast food, where pay can be $15 an hour, and schedules are consistent. “Direct care work is often wrongly described as low-skilled or unskilled—that’s a rhetorical trick to keep low-paying jobs low paying,” Espinoza says.

But these jobs are far from unskilled—the National Academy of Medicine says workers should be receiving at least 120 hours of training. “These jobs require an incredible amount of skill,training, emotional labor and problem solving,” Espinoza says. “I think people are always surprised to realize direct care often requires a lot more than making a meal or lifting someone out of bed.”

Dr. Clark-Shirley echoes this idea: “We have such a limited view of what we think people on the front lines are doing and the effect they have. Taking care of people is such an expression of humanity and who we are. I don’t think any other profession can even touch it.”

In addition to better wages, the industry and organizations should try to position the work as a profession, not just a job, says Robyn Stone, DrPh, Senior Vice President of Research, LeadingAge, Washington, D.C. “How do we show people meaningful career pathways? You are caring for people and delivering essential services that require a lot of highly valued competencies. We have an opportunity to highlight these occupations as real professions for people who want to be in them, and to provide career advancement opportunities for  aides to go into jobs such as phlebotomists, med techs, dementia specialists, human resources specialists or technology specialists.”

A Different Lens

Part of the work of changing this country’s trajectory is a matter of narrative, Dr. Clark-Shirley says. “I think at a very high level, it’s really important to me that people see this not as a senior-care issue for some other  group, but really that this is a conversation about all of us.”

After all, ability is fragile. “Whether you think you’re going to be surfing at age 70 or not, there is no way to predict what can happen to us tomorrow,” Kalipeni says. “The more we’re invested in building a better care infrastructure, the better off we’ll all be in both the predictable and unpredictable moments.”

If the aging conversation does shift from something that happens to some nebulous other group to something that will happen to all of us, then that automatically shifts the perspective, Dr. Clark- Shirley says. It changes the questions to: What do I want? Where do I want my life to happen? “The infrastructure, funding, supports, programs and resources that we make available today are going to be available to all of us in the future as our society continues to age,” Dr. Clark-Shirley says. “It’s all of our privilege to get old.”

A Vision of Care

Florida might be too much of a haven for retirees, but with that climate comes some perks, Alice Macomber says half-jokingly. Before retiring, Macomber, RN, RMA (AMT), RPT (AMT), AHI (AMT), was a Unit Department Chair and Medical Assisting Instructor at Keiser University, Port St. Lucie, Florida. Given the demographics, the care climate is built differently in the state—something Macomber experienced firsthand when she had to go to the ER following knee surgery.

While there, she was in a unit dedicated to people over 65. So many small details impressed her: Signage was printed in big letters, and the clinic had spare readers for items in smaller type; the beds were mechanical and low, preventing any climbing pain or mishaps; the waiting room had plenty of chairs for family members. Without such specialized care, “patients might not feel wanted or that they can ask important follow-up questions,” Macomber says, all of which can lead to worse health outcomes.

Whether it’s designated hospital wings, geriatricians or a clinic just being thoughtful, such attention to detail is critical to providing great elderly care, she says. Macomber wishes more providers had dedicated services for elderly care as they do for, say, infants. According to the American Geriatrics Society, 30% of people 65 and older will need care from a geriatrician. There are currently only around 7,000 geriatricians—half of whom practice full time. By 2025, 33,200 geriatricians will be needed.

However, individual practitioners can still make a major difference, Macomber says. “Something I’ve found is that this population really looks forward to the appointment,” she says. It’s not just a medical visit—it’s often a social one, too. “And you can really help that person so much.”

Healthcare workers shouldn’t look to solve every problem a geriatric patient faces, though. Macomber learned through her years that providing resources, such as pamphlets or agency phone numbers, can better serve this population. “When I worked, I had all of these different agencies and their numbers—American Heart Association or American Lung Association—I let people know how they can get that information.”

For more insight on geriatric care, check out the AMT course “Needs of the Geriatric Patient,” which Alice Macomber helped develop.

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