|
TRENDSThe Personal Assistance Workforce: Trends In Supply And Demand
The workforce providing noninstitutional personal assistance and home health services tripled between 1989 and 2004, according to U.S. survey data, growing at a much faster rate than the population needing such services. During the same period, Medicaid spending for such services increased dramatically, while both workforce size and spending for similar services in institutional settings remained relatively stable. Low wage levels for personal assistance workers, which have fallen behind those of comparable occupations; scarce health benefits; and high job turnover rates highlight the need for greater attention to ensuring a stable and well-trained workforce to meet growing demand.
MANY PEOPLE WITH disabilities need help from other people in performing daily activities, help that enables them to participate more fully in society, maintain their health and functioning, and avoid institutionalization. When provided at home or in the community, such help is often termed personal assistance services, which include help with activities of daily living (ADLs), such as bathing, dressing, or eating, and with instrumental activities of daily living (IADLs), such as shopping, preparing meals, or managing finances.1 The aging of the U.S. population is expected to bring about increased demand for personal assistance services over the coming decades. Projections indicate that the number of people needing these services will more than double, from thirteen million in 2000 to twenty-seven million in 2050. Satisfying the increased need for personal assistance services is expected to pose a serious challenge.2 The vast majority of these services are provided by unpaid caregivers, often family members: Only 16 percent of total hours are provided by paid helpers, often referred to as attendants or home care workers. Of the 13.2 million U.S. adults receiving some form of personal assistance services in the mid-1990s, only 3.2 million got help from one or more paid attendants. People who live alone or who have high levels of assistance needs are the most likely to receive paid help.3 One study found substantial unmet need for personal assistance services, with lack of adequate services leading to adverse consequences such as poor nutrition, discomfort, secondary health conditions, and increased isolation.4 Eligible Americans can obtain paid help through public programs such as Medicaid or, in limited circumstances, Medicare. Un-met need can result from limitations in eligibility for such services (for example, only people with very low incomes, having very severe disabilities, or recovering from a recent hospitalization), from public program waiting lists or caps on the amount of care provided, or from the scarcity of skilled workers.5 Few studies have examined the workforce providing personal care outside of institutions. Those that have done so found low wages, scarce health benefits, and irregular work schedules.6 These factors make it problematic to attract and retain qualified workers. In this paper we use data from two federal surveys of the U.S. population to assess both the size of the workforce providing paid personal assistance services and the relative growth of that workforce compared with the population needing such services. We are aware of no prior studies that address work-force growth over time, including both agency and independent personal assistance providers, and compare that growth to the demand for services. We also confirm earlier findings of low wage levels, adding to the literature a comparison of wage growth compared with that in similar occupations, and we assess other job factors likely to limit the future growth of the personal assistance workforce.
Data sources. The Current Population Survey (CPS) is a nationally representative survey of approximately 60,000 U.S. households each month, focusing on labor-force issues.7 We obtained occupational, industry, and wage data from the monthly CPS for 1989–2004. Additional information was obtained from periodic supplements: health insurance coverage data from the 1992–2004 Annual Demographic Survey, conducted in March of each year, and information on job tenure from a supplement conducted in January or February of even-numbered years from 1996 to 2004. The National Health Interview Survey (NHIS) is a nationally representative survey of approximately 45,000 households per year.8 We used the NHIS data to obtain estimates of the population needing assistance with daily activities for the period 1989–2004. Measures. To identify personal assistance workers, we used data on the respondent’s current (or most recent) primary job as self-reported by labor-force participants, and we required both the stated occupation and industry to fall within appropriate categories. Thus, both agency- and self-employed workers, including those providing paid help to another family member, are counted if this is their main occupation and is reported as such.9 For 2003 and 2004, people are considered personal assistance workers if they are classified in (1) the occupational categories "nursing, psychiatric, and home health aides" or "personal and home care aides" and (2) the industry categories "home health care services," "other health care services," "individual and family services," or "private households."10 Prior to 2003, the CPS used an earlier occupation and industry classification. For 1989–2002, we considered people to be personal assistance workers if they were classified in (1) the occupational categories "health aides, except nursing" or "nursing aides, orderlies, and attendants" (there are no categories for home health, personal, or home care aides) and (2) the industry categories "health services, not elsewhere classified," "social services, not elsewhere classified," or "private households."11 We used a trend fit to the monthly workforce estimate to determine the extent to which the classification change affects the number of workers identified; in the analysis, the 2003–04 estimates were corrected by a small amount (7.0 percent) to account for this change.12 For comparison, we also examined trends in the number of aides working in nursing homes and residential care facilities. For this purpose, we used CPS data with the same occupational categories (except that the category "medical assistants and other health care support occupations" is also included for 2003–04) but different industries. For 2003–04, the industry must be either "nursing care facilities" or "residential care facilities, without nursing." Prior to 2003, a single industry classification was used: "nursing and personal care facilities." A trend fit indicates that the change in classification scheme did not significantly affect the number of nursing home and residential care aides identified.13 We used NHIS data from 1989–2004 to identify people needing assistance in ADLs ("personal care needs, such as eating, bathing, dressing, or getting around inside this home") and IADLs ("handling routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes").
Workforce trends. Monthly estimates of the personal assistance workforce for 1989–2004, seasonally adjusted and corrected for a 2003 change in occupational and industry classifications, are shown in Exhibit 1  , along with a trend fit. A pronounced upward trend is apparent, with the number of workers more than tripling during the period—from 264,000 in January 1989 to 894,000 in December 2004.
In contrast to the rapid growth in the personal assistance workforce, comparable occupations in institutional settings show no similar growth pattern (seasonally adjusted data shown in Exhibit 2 ), nor do the data suggest that the growth in the personal assistance workforce was the result of nursing home and residential care aides shifting to noninstitutional work.
Trends in Medicaid spending. Data on Medicaid long-term care spending show similar patterns to the workforce trend data.14 Noninstitutional spending, consisting of personal assistance services provided under state personal care plans, home and community-based services waivers, and the home health services benefit, shows a steady increase over the period (Exhibit 3 ).15 This spending more than tripled between 1989 and 2004, even after inflation in health care costs is adjusted for; it rose from $3.3 billion to $14.7 billion (1989 dollars).16 In contrast, Medicaid institutional long-term care spending (nursing homes and intermediate care facilities for people with intellectual disabilities) increased only 19.7 percent over the period, from $22.3 billion to $26.7 billion (1989 dollars).
There is a clear relationship between expansion of Medicaid personal assistance programs and the growth in this workforce, especially during the decade of rapid growth in home and community-based programs from 1994 to 2004. When states are ranked in terms of their relative increases in such spending and divided into three tiers, the greatest workforce growth is found in the top tier (136.6 percent), and the least amount of growth, in the bottom tier (31.4 percent). Workforce growth relative to demand. Mitch LaPlante and colleagues found that people with an ADL level of need tend to receive far more paid help than do those needing help only in IADLs.17 Based on their estimates, we calculated that people needing ADL help, despite constituting only a minority of personal assistance service users, receive more than three-quarters of the total hours of paid help provided. We therefore used the number of people reported as needing ADL help as a preferred indicator of the demand for paid personal assistance. Data from the NHIS indicate that the community-resident population needing ADL help grew from 2.6 million in 1989 to 4.1 million in 2004, a 54.2 percent increase. Thus, although the demand for personal assistance rose greatly over the period, it grew much more slowly than the personal assistance workforce.
Exhibit 4
Earnings, job tenure, and benefits. Earnings data from the CPS show that median hourly wages for personal assistance workers climbed from $5.41 in 1989 to $8.40 in 2004 (Exhibit 5 ), an increase of 55.3 percent, approximately keeping pace with inflation (52.3 percent).19 This level of increase compares unfavorably with that for nursing home aides, who saw a 78.9 percent increase in hourly wages over the period and whose earnings overtook those of personal assistance workers beginning in 2001. An even less favorable comparison can be made to people working in entry-level positions at food counters, cafeterias, and other such establishments, whose hourly wages increased 85.5 percent over the period and who earned only about $1.50 less per hour in 2004 than personal assistance workers earned, for much less demanding work.
In 2004, 49.9 percent of personal assistance workers had "worked continuously for their current employer" for two and a half years or less; the comparable figure for the labor force as a whole is only 35.1 percent. Some 30.0 percent of personal assistance workers had been on the job for one year or less (compared with 21.8 percent for the labor force as a whole). No trend in these rates is apparent over the period during which CPS job tenure supplements have been conducted, 1996–2004. Data from the CPS also indicate that few personal assistance workers receive health benefits. In 2004, only 29.4 percent of such workers were covered under their own employment-based coverage. Receipt of health benefits has hovered at roughly one-third of employed personal assistance workers since 1992. One reason for this is that many such workers have part-time or irregular work schedules (44.5 percent reported either variable hours or fewer than thirty-five work hours per week in 2004); only 16.9 percent of them have employment-based coverage.
Data from the CPS show a large and steady increase in the number of workers providing personal assistance or home health services to people living in the community, with the size of this workforce tripling between 1989 and 2004. In contrast, the number of workers performing similar functions in institutional settings grew only 35.6 percent during the same period. The growth of the personal assistance workforce parallels the expansion of Medicaid programs providing home health and personal assistance services at home and in the community, with states whose Medicaid personal assistance programs increased most rapidly also showing the largest workforce increases. With Medicaid expansion a driving force in building the personal assistance workforce, however, current pressures to reduce Medicaid spending could result in reduced availability of such services in the community.20 The population needing personal assistance services grew during the same time period, according to NHIS data. The number of people needing assistance in ADLs increased by more than half between 1989 and 2004. This increase, however, pales in comparison with the growth rate in the personal assistance work-force. When measured in terms of number of workers divided by the population needing help, the size of the workforce shows a 94 percent increase over the period—from a little more than one worker per ten people needing ADL help to a little more than one for every five. But when the denominator includes people needing any type of assistance (ADL or IADL, or both), even the most recent data indicate only one worker per ten potential consumers, which suggests that substantial competition for workers remains despite the rapid workforce growth. Although these data cannot be used to assess the extent of unmet demand for formal personal assistance services (a critical indicator not routinely measured in national surveys), the increased availability of paid workers is likely to have narrowed the substantial gap in needed services that was documented in data from the mid-1990s.21 This improved access to paid help has probably allowed many people with personal care needs to remain in the community, rather than moving to nursing homes, and to avoid the deleterious effects of insufficient care on health and activities. Although improvements in access to formal personal assistance services are undoubtedly a positive development for the population with disabilities, the future is by no means certain. If Medicaid personal assistance programs are curtailed—for example, by limiting eligibility to people living in poverty as opposed to the less restrictive programs now offered in many states—many low- to moderate-income people with disabilities will lose ready access to these services. Given the current instability of the personal assistance workforce, with workers typically changing jobs every 2.5 years, many workers might move on to more remunerative occupations if Medicaid reductions result in fewer work hours available. Demand for personal assistance workers is expected to increase. As states implement so-called Olmstead plans, in response to a Supreme Court decision ruling that people with disabilities must receive services in noninstitutional settings when possible, a higher proportion of people needing personal assistance will remain in the community and require services at home. Furthermore, as the baby boomers age, with more of the population needing help and fewer able to provide it informally or formally, the ratio of workers to people needing help may return to low levels not seen for many years. Attracting and retaining skilled workers could become increasingly difficult if job conditions do not improve. Our analysis confirms prior findings of low wage levels and scarce health benefits for this workforce.22 Trend data indicate that personal assistance workers have fallen behind similar occupations in earnings levels. These factors may increasingly relegate this type of work to new immigrants and others lacking more saleable job skills and training. An unstable workforce can compromise both access to services and the quality of services received. A shift in the economy, a reduction in the scope of government programs, or competition from other occupations could result in precipitous declines in the personal assistance work-force. We feel that this occupation must be upgraded to offer a living wage, stable work hours, health benefits, and job security. State certification requirements might also ensure that workers possess adequate training and job skills. More federal and state initiatives should be directed toward recruiting new groups of workers, training, and retaining workers by improving job quality. For example, a California initiative targeted previously un- or underemployed workers for recruitment and training.23 Other states have piloted programs to raise public awareness of the importance of this work, improve workers’ training, increase wages, or offer health benefits.24 CONTINUED GROWTH in the personal services workforce will be necessary to meet the expected increase in demand. Workforce policies must change to make personal assistance a more desirable occupation, one in which workers receive wages and benefits commensurate with the critical importance of the work they perform to the lives of people with disabilities.
Steve Kaye (steve.kaye{at}ucsf.edu) is an associate adjunct professor in the Institute for Health and Aging, University of California, San Francisco (UCSF). Susan Chapman is an assistant adjunct professor in the UCSF Center for the Health Professions. Robert Newcomer and Charlene Harrington are professors in the Department of Social and Behavioral Sciences, UCSF. This research was conducted at the Center for Personal Assistance Services with funding from the National Institute on Disability and Rehabilitation Research (Grant no. H133B031102).
This article has been cited by other articles:
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Top
Study Data And Methods
Study Findings
