by, Renee Wood
In June of 2021, when the pandemic had quelled somewhat, all businesses were struggling to fill vital positions which are necessary to keep their businesses open and operating smoothly. More often than not, these positions are hands-on that can’t be done remotely from the comfort of one’s home. Positions such as waiters/waitresses, cooks, retail clerks, janitors, and those who care for the daily needs of the elderly and those with disabilities are going unfilled. Not having enough workers to serve you your hamburg in a timely fashion is just a mere inconvenience, but not having enough workers to get you out of bed, clean your butt and feed you, truly is a “crisis!” If Burger King closes due to lack of a workforce, you can go to Taco Bell, or throw a hamburger on the grill at home. If someone doesn’t come to assist with daily care, in many cases that person can get sick, end up in a hospital or even die. Make no mistake, this is happening in institutional care just as much as in-home care. Only difference, institutions can cover it up better. So if my non-disabled readers think institutions are the obvious “back-up” plan for caring for people in a workforce crisis, they need to understand institutions have a workforce crisis too. Besides, we’ve seen what COVID did in nursing homes and other institutions where the vulnerable reside – they are not safe places to be for the most part.
Historically, the category of the jobs mentioned above, are known as “low level or entry positions”, also recently known as “front-line workers” because society now realizes these are the people necessary to keep society going through all kinds of events. However, the respect and pay these workers receive, reflects how society still views these types of hands-on positions. Hands-on positions are considered low-level jobs just because they don’t require a college degree, but in many cases they do take hours of specialized on-the-job training. One doesn’t just walk into Burger King and start flipping burgers! They have to learn health protocols, how to work all the equipment including cash register etc. The same is true for home and institutional care workers. It takes some training to know how to properly care for someone’s personal needs.
Businesses can’t survive with just filling higher paying upper management positions alone, they need boots on the ground, and hands in the dish water! Some claim that these jobs in fast food and retail were meant for high schoolers, or young people starting out in the job market. However, there is not enough young people to cover all these fast food and retail jobs, and young people don’t want these types of jobs anyway (the reason is a topic for another blog). This means that these jobs are being done by working class people who have family’s to support. On NPR I heard 93% of single individuals working a minimum wage job (7.25 US minimum wage, but some States have a higher minimum wage. Ohio is moderately better at $8.80.) can’t afford a one bedroom apartment on even a $10 per hour job! This is calculated by reasoning that people shouldn’t be spending more than 30% of their income on shelter, so they are also able to afford food, healthcare, transportation to get to their job, utilities and other necessities.
Many of our workers who care for older people and those with disabilities (commonly known as Direct Care Workers DCW, or Direct Support Professionals DSPs – here I’ll refer to them as DCW) are on rental assistance and foodstamps because even at $12 an hour (many make much less $9 – $10 per hour if working through an agency) a single parent with 2 children can’t afford food and rent even working 50 hours a week at $12 an hour. Hell, even a single person would struggle at that rate! Then throw in the pandemic on top of it, with kids out of school – there’s no way they can afford a babysitter 9 hours a day, or even daycare if they can find one open with room for another child, they have to stay home with their kids. Their managers and owners of the agencies DCWs work for, make much more, with the luxury of working from home, where there’s a lower risk of infection, not to mention – they don’t wipe butts (although during the pandemic, many in management positions were also doing direct care for their clients because there wasn’t enough workers to even take care of the basic needs of the clients they contracted to care for)! Ask yourself if you would be willing to be on government assistance and working 50 hours a week, caring for another person’s family member? We need fair wages, healthcare insurance and retirement plans for those workers who support and care for the most vulnerable among us.
These DCWs do not get the respect and recognition for what it means to take good care of someone. Maybe because society as a whole, really does not respect or value the lives of frail elderly or people with disabilities, so the people who have these jobs to care for your loved one, are seen, treated and paid as working in “inferior jobs” that any person can do. But the truth is, it’s hard physically, and psychologically stressful to care for someone, especially if it’s not one’s own family member. Then throw-in substandard pay, horrendous amounts of red tape and regulations, with little respect from society – and these workers are throwing in the towel by the droves, and going to work for Taco Bell for $3 more an hour than if one worked for a care agency. Besides higher pay, working at places like Taco Bell has less regulations, red tape and knowing when one will get a paycheck. If an individual is paid directly through Medicaid as an Independent Provider (IP) for caregiving, they never know how long it will be before receiving a payment. Plus IPs being paid through Medicaid are 1099’d as a contract worker, so the State can avoid offering a pension, healthcare benefits or sick-pay. If this worker works over 32 hours a week to care for particular individual(s), being labeled as a “contract worker” is probably as illegal as hell. Problem is, in Ohio, many people who need care, perfer the services of the IPs because they are more reliable and consistent, than many agencies. Since IPs are paid directly through Medicaid, their pay rate is much higher than DCW working for agency providers. These low pay rates is one reason agencies are losing workers, like I said above.
Who suffers the most?
Those who absolutely need hands-on daily care in order to continue their existence here are the victims of this economic game. People are being left in urine soaked beds for a couple days, with only the food and water left on their bedside table. People are being left up all night in their wheelchair because the worker failed to show, and the agency either fails to answer the phone, or doesn’t have anyone to send. People with disabilities are afraid to say too much or make a public fuss about their lack of care for fear the authorities will find out, and place them in an institution. Institutions are struggling with the same issues of finding workers, so one fears they might be placed in an institutional setting, with little care, for a high cost, and no voice in what is happening because they are isolated. At least the caveat in receiving care in one’s home, is one doesn’t sign their timesheet if the provider doesn’t provide the care for that time period, and then the agency doesn’t get paid by Medicaid. It’s more intolerable to know an institution gets paid the same whether they provide the individual’s prescribed care for the day, or not. When one receives care at home, they can call family and friends to come to witness what is going on and feel as if they have some control over the situation. Being in an institution, especially during the time of COVID, where visitation is either limited or non-existent, leaves one vulnerable to what integrity an institution may, or may not, have. Not to mention the high risk of dying of COVID!
Many of us feel, if we’re going to risk death from lack of care, we rather risk it in our own home, where it will be harder to cover-up our lack of care. Also, it would be at least be perceived as “fair” by individuals needing care, if they knew that the institution was not being paid to let people linger in a life-threatening situation of neglect. I’m not meaning to slam for-profit institutions as if they don’t care, because most do, or as if these institutions are knowingly committing Medicaid fraud, because the vast majority don’t. However, from a business aspect, it would take time to bill Medicaid according to who received the proper amount of care that day, and who might not have received the care that they required. Time is precious when under staffed, so from a business standpoint, if the individual is in the building and still alive, just bill the daily allowable for that individual without regards to what care they received that day (especially if they have a hard time communicating, or feel threatened somehow which would make it difficult for the individual to rely to an outside person the care that they are, or are not, receiving), so no Medicaid authority will be the wiser for it. On the other hand, from the standpoint of an individual who needs care, knowing an institution can be paid for not doing your prescribed care, pisses you off beyond belief!
Who Else Suffers From This Crisis?
Direct Care Workers who are truly devoted to those they support, especially workers providing care in institutions, or who work for home care/provider agencies, suffer the effects of this crisis too. Especially the devoted ones, if it were any other job, they would probably leave, due to lack of adequate pay, lack of benefits, such as; affordable healthcare and a decent retirement pension (Social Security will be very minimal since they were paid so little throughout life-long work) are suffering poverty for genuinely caring for others – maybe these workers are caring for your own family member, do you think they should make adequate pay for caring for your loved one? But their hearts are in it to make life better for others. These DCW sacrifice a decent living, to care for someone they didn’t know at first. Although, on a daily basis, individuals and families show appreciation for individual workers who care for them or their loved one, society has yet to step-up to understand what an important job it is to support people to live and contribute to society to their fullest potential, by ensuring these workers who support and care for those who are frail or disabled have a decent career that doesn’t leave them in poverty.
How To Fix It
To better understand the solution, one has to understand how the free market works, and the difference between for-profit agencies and non-profit organizations.
Non-profit Care Providers vs For-profit Care Providers
The way the system is currently set-up, for-profit care agencies, including institutional care settings, are not sustainable under Medicaid reimbursements. This is because these are profit driven entities, rather than true mission driven organizations such as non-profits. No matter what the Medicaid reimbursement rate is, low direct care worker wages increase profit for the business (owners/upper management). There are no current regulations that says if Medicaid pays this rate for a particular individual’s needs, then the agency is required to pay its direct care workers this amount to care/support that individual. Even if Medicaid, or State Departments who dole out Medicaid funds to provide care for eligible individuals, there’s no requirement for that hired care agency, or institution, to pass a certain percentage to DCW. Even when there was an increase primarily intended for DCW working for agencies, there was no requirement that says, if agencies accept the increase, that the care agencies would guarantee that a certain portion of the that increase would be passed on to the DCW. It is possible that a for-profit agency could absorb the entire increase passing nothing directly into the pocket of the DCW. Truthfully, some have pass some down to the DCW, these amounts very from agency to agency, but there’s not even a requirement for agencies to at least report to Medicaid what percentage of the increase they passed onto the DCW. For-profit businesses are sacrosanct in American society and besides mandating minimum wage laws, there’s little else the government is willing to do to ensure taxpayer dollars are going to its intended target – the DCW.
Also Medicaid pays all care agencies the same rate. There may be a little variation for people who have high needs, but even that extra $1 and change is not guarantee to the actual workers who serves the needs of that individual. Again, the agencies are solely responsible for the discretion of passing a portion onto the DCW. If it’s truly imperative to keep the current system of how Medicaid reimburses, where all providers are reimbursed at the same rate, for same services provided, then we need to look into non-profit care agencies. Like health insurance, it’s difficult for direct care agencies to make a profit without cutting expensive people, or keeping wages low. Remember, the free market relies on price setting, and other forms of competition, to regulate the industry, and make a profit. Whereas non-profits want to break even, and rely more on best practices and customer service to draw their customers to them. Therefore, breaking even for non-profits relies on good customer service to attract people to receive services from them, and in return, draw down reimbursement from Medicaid per person.
However, if service agencies were truly market driven, agencies would set its own prices for care, rather than Medicaid setting the price they will pay an agency, and consumers would decide what they are willing to pay out of a budget allocated for that person’s assessed care needs. The the person, or their family, shops for an agency, considers each agency’s price, and the care they would receive for that price. When the free market is allowed to work, it naturally tends to drive out underperforming agencies out of the market, or overpriced businesses (currently they are not, unless they have severely committed Medicaid violations). If the market were allowed to set their price for care, good service organizations would rise to the top. Since currently, high performing agencies get the same pay rate as those who under perform, or with moderate performance, there’s little incentive for low performing agencies to improve to get more profit. Whereas high performing agencies may wane, since their efforts are compensated the same as lower performing agencies. If care agencies could set their own rates for service, then consumers of the service could judge the cost/benefit of paying the rate that particular agency asks. The consumer of the service may even choose an agency with a lower cost because they judge it’s about the same quality of service, but they get more for the budget allotment assessed for their level of need/care. Care agencies setting their own prices may consider higher wages, and benefits to their full-time DCWs factored into their asking price.
The market solution above, is the truest form of self-direction individuals with disabilities yearn for, and in turn, will bring back and sustain the direct care workforce with true market driven competition. If the same reimbursement is given to all direct care providers, with no leeway for for-profit business to set its own prices, then there will be no competition to do better for what you would charge for the service. Therefore, profits can only come from keeping direct care worker’s wages low, while only striving for minimum performance to satisfy Medicaid requirements. No one benefits, except maybe some business owners who are only concerned with the profit line.
For more in-depth details of how the care industry has commoditized individuals with disabilities, read my blog:
Renee's Ramblings 