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TRENDS

The Personal Assistance Workforce: Trends In Supply And Demand

Abstract

 
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.

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.

Study Data And Methods

Top Study Data And Methods Study Findings Discussion NOTES

 
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").

Study Findings

Top Study Data And Methods Study Findings Discussion NOTES

 
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.

View larger version (11K): [in this window] [in a new window] EXHIBIT 1 Number Of Personal Assistance Service Workers, Seasonally Adjusted And Adjusted For 2003 Survey Change, And Trend Fit, 1989–2004

View larger version (10K): [in this window] [in a new window] EXHIBIT 2 Number Of Nursing Home And Residential Care Aides, Seasonally Adjusted, And Trend Fit, 1989–2004

View larger version (13K): [in this window] [in a new window] EXHIBIT 3 Medicaid Long-Term Care Spending In Institutional And Noninstitutional Settings, Adjusted For Inflation In Medical Care Costs, Fiscal Years 1989–2004

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 shows the trend in workforce size per 1,000 population needing ADL assistance. In 1989 there were 110.2 personal assistance workers per 1,000 needing ADL help; by 2004 that figure had grown to 214.0 workers (94.2 percent). Exhibit 4 also shows the ratio of personal assistance workers to the entire population needing personal assistance with either ADLs or IADLs. The dashed line section reflects a change in the NHIS in 1997, which reduced capture of people needing help in IADLs only (the change did not affect capture of those with ADL needs).¹⁸ Despite the survey change, a clear increase is apparent in the ratio of workers to people needing any type of personal assistance.

View larger version (15K): [in this window] [in a new window] EXHIBIT 4 Number Of Personal Assistance Services Workers Per 1,000 People Needing Personal Assistance, By Level Of Assistance Needed, 1989–2004

View larger version (11K): [in this window] [in a new window] EXHIBIT 5 Median Hourly Wage For Personal Assistance Workers, Nursing Home Aides, And Food Counter Workers, 1989-2004

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.

Discussion

Top Study Data And Methods Study Findings Discussion NOTES

 
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.

Editor's Notes

 
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).

NOTES

Top Study Data And Methods Study Findings Discussion NOTES

 

1. A.I. Batavia, G. DeJong, and L.B. McKnew, "Toward a National Personal Assistance Program: The Independent Living Model of Long-Term Care for Persons with Disabilities," Journal of Health Politics, Policy and Law 16, no. 3 (1991): 523–545.[Web of Science][Medline]
2. U.S. Department of Health and Human Services, The Future Supply of Long-Term Care Workers in Relation to the Aging Baby Boom Generation: Report to Congress (Washington: DHHS, 2003).
3. M.P. LaPlante, C. Harrington, and T. Kang, "Estimating Paid and Unpaid Hours of Personal Assistance Services in Activities of Daily Living Provided to Adults Living at Home," Health Services Research 37, no. 2 (2002): 397–415.[CrossRef][Web of Science][Medline]
4. M.P. LaPlante et al., "Unmet Need for Personal Assistance Services: Estimating the Shortfall in Hours of Help and Adverse Consequences," Journals of Gerontology, Series B: Psychological Sciences and Social Sciences 59, no. 2 (2004): S98–S108.
5. M. Kitchener, T. Ng, and C. Harrington, "Medicaid 1915(C) Home and Community-based Services Waivers: A National Survey of Eligibility Criteria, Caps, and Waiting Lists," Home Health Care Services Quarterly 23, no. 2 (2004): 55–69.[CrossRef][Medline]
6. Y. Yamada, "Profile of Home Care Aides, Nursing Home Aides, and Hospital Aides: Historical Changes and Data Recommendations," Gerontologist 42, no. 2 (2002): 199–206[Abstract/Free Full Text]; and R.J. Montgomery et al., "A Profile of Home Care Workers from the 2000 Census: How It Changes What We Know," Gerontologist 45, no. 5 (2005): 593–600.[Abstract/Free Full Text]
7. U.S. Census Bureau and Bureau of Labor Statistics, "Current Population Survey: Design and Methodology," Technical Paper no. 63RV (Washington: Department of Commerce, 2002).
8. S.L. Botman et al., Design and Estimation for the National Health Interview Survey, 1995–2004, Vital and Health Statistics Series 2, no. 130, 2000, http://www.cdc.gov/nchs/data/series/sr_02/sr02_130.pdf (accessed 9 May 2006).
9. The extent of paid family caregiving cannot be determined from this survey.
10. This method of classifying personal assistance workers is identical to that used in a prior study (Montgomery et al., "A Profile of Home Care Workers"), except that we included the miscellaneous category "other health care services," referring to venues other than a health care provider’s office, outpatient care center, hospital, nursing facility, or residential care facility.
11. Health care venues other than providers’ offices, clinics, hospitals, nursing facilities, or personal care facilities. Social service venues other than job training, vocational rehabilitation, child care, or residential care facilities.
12. A fourth-order polynomial, along with terms measuring seasonal workforce fluctuation [A.M. Stolwijk, H. Straatman, and G.A. Zielhuis, "Studying Seasonality by Using Sine and Cosine Functions in Regression Analysis," Journal of Epidemiology and Community Health 53, no. 4 (1999): 235–238] and a step to allow the level to shift with the change in classification, was fitted to the logarithm of the monthly personal assistance workforce population estimate. Significant seasonal variation was detected along with a statistically significant step; monthly data shown in Exhibit 1 were seasonally adjusted based on the results of this model, and data for 2003–04 were also corrected for the change in classification.[Abstract]
13. In this instance, a fifth-order polynomial was required to adequately describe the workforce trend; the step was found not statistically significant and was dropped.
14. B. Burwell, K. Sredl, and S. Eiken, "Medicaid Long Term Care Expenditures in FY 2004" (Cambridge, Mass.: Medstat, 2005).
15. Spending under home and community-based services waivers may include other services provided to personal assistance recipients.
16. U.S. Bureau of Labor Statistics, "Consumer Price Index—All Urban Consumers: U.S. Medical Care Services," 15 June 2005, http://data.bls.gov/cgi-bin/surveymost?cu (accessed 1 July 2005).
17. LaPlante et al., "Estimating Paid and Unpaid Hours."
18. H.S. Kaye, "Activity Limitation in the National Health Interview Survey: Effect of the 1997 Revision on Measuring Disability," Disability Statistics Working Paper no. 0201 (San Francisco: University of California, San Francisco, 2002).
19. BLS, "Consumer Price Index—All Urban Consumers: U.S. All Items," 15 September 2005, http://data.bls.gov/cgi-bin/surveymost?cu (accessed 6 October 2005).
20. U.S. Government Accountability Office, Long-Term Care Financing: Growing Demand and Cost of Services Are Straining Federal and State Budgets, Pub. no. GAO-05-564T (Washington: GAO, 2005).
21. LaPlante et al., "Unmet Need."
22. Yamada, "Profile"; and Montgomery et al.,, "A Profile of Home Care Workers."
23. R. Matthias et al., Caregiver Training Initiative: Final Process and Outcome Evaluation Report (Sacramento: California Employment Development Department, 2003).
24. National Clearinghouse on the Direct Care Workforce, Results of the 2005 National Survey of State Initiatives on the Long-Term Care Direct-Care Workforce (Bronx, N.Y.: National Clearinghouse, 2005).

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