As health care shifts to homes, need for home health aides grows

September 14, 2015

PHILADELPHIA — Yes, James Guyton is tethered to an oxygen line half as long as his rowhouse in North Philadelphia’s Olney neighborhood. And yes, he’s a little unsteady on his feet. But nobody knows how to mop better than Guyton, 69, now suffering from chronic obstructive pulmonary disease.

"He wants to outdo me in cleaning," said home health aide Antwanette Hill, 28, laughing. Hill visits Guyton every day to help him bathe and make sure he eats.

"I told you he was stubborn," she said affectionately, as the bucket toppled, sending a puddle of cleaning solution onto the floor.

"Love at first sight" is how Hill describes her relationship with Guyton. It has to be love, because what the agency pays her isn’t much — $10.50 an hour. She works 39 hours a week, over seven days, for two clients, struggling to earn enough to raise her two children, 10 and 4.

Baby boomers, as they grow older and more infirm, will need more people like Hill — home health aides, and personal care aides — jobs that overlap, the latter often doing more housekeeping. The U.S. Bureau of Labor Statistics says both categories will be among the fastest growing in the next seven years, adding just over a million jobs.

Aging baby boomers are driving the demand for more health services, but how that care is delivered is not just about demographics. It’s also about who can do it more cheaply, said labor economist Paul Harrington, director of Drexel University’s Center for Labor Markets and Policy.

Already, he said, the trend is moving from care provided in expensive facilities such as hospitals and nursing homes to less-costly places — outpatient clinics and rowhouses in cities and towns nationwide.

Responsibilities also are shifting from expensive professionals, such as doctors, to nurses and ultimately to caregivers such as Hill.

Nearly 3.1 million people may be employed in these fields by 2022, so it’s not surprising that their pay, prospects and working conditions are stirring concern and controversy.

That’s in part because of the complex way these workers are paid.

Agencies typically hire the workers, assign them to case, and pay them; but the underlying funds often come from the government, with Medicaid being a major payer. Other aides are employed directly by the people they help if those clients do not qualify for a government program.

Until recently, home health aides in most states were not entitled to overtime.

When the U.S. Labor Department set out new rules allowing overtime as of Jan. 1, industry groups, including the Home Care Association of America, sued successfully to block their implementation.

On Aug. 21, a federal appeals court overturned the block. The association said it plans to appeal to the U.S. Supreme Court, but the appellate decision now clears the way for home health workers in New Jersey to get paid for overtime. Pennsylvania law had already required overtime pay.

"We’d be willing to provide the pay," said David Totaro, chief government affairs officer for Bayada Home Health Care, and an association board member. "However, reimbursements have not kept up with increased costs."

In New Jersey, where Bayada is based, hourly compensation from Medicaid rose on July 1 to $18 an hour, from $15.50, he said. In Pennsylvania, it’s $19.19. Delaware pays $26.52. North Carolina, at $13.88 an hour, hasn’t had an increase since 2008.

"Agencies have 1 to 2 percent profit," Totaro said, "after all the expenses: wages, taxes, training, overhead."

Each state has its issues, Totaro said.

In New Jersey, as of July 1, managed-care providers gained contracts to oversee Medicaid reimbursements, and they take a slice of the $18 an hour.

That slice actually drives hourly reimbursements below what they were before the July 1 increase, he said.

In Pennsylvania, the issue is the specter of unionism. On Feb. 27, Gov. Tom Wolf issued an executive order setting up an advisory council on home health care, which was not controversial.

What was controversial was his proposal for home care workers to elect an organization to represent them before state officials and create a "memorandum of understanding" about wages and conditions.

"It sounds like collective bargaining," said Harrisburg lawyer Jim Kutz, whose agency clients quickly gained an injunction preventing Wolf from drawing up any "memorandum of understanding." The case is pending.

Meanwhile, home care workers have elected a representative, United Home Care Workers of Pennsylvania, a partnership of the SEIU and AFSCME unions.

State law bars unions for these workers when they work directly for their clients in their homes. Agency workers can unionize. Hill, employed by Liberty Resources Inc., is a union member.

On the industry side, with turnover running above 40 percent a year, recruitment is always a challenge, as the work is hard and wages are low.

"Great economy, bad economy, it’s still hard to find people," said Kevin Campbell, a director at Bayada.

On a recent Monday, when Bayada’s Philadelphia home care director, Megan Miller, got to work, she found 40 new applicants awaiting review on Bayada’s online system.

At least 25, lacking qualifications, were eliminated on the spot. Of the 15 contacted, only seven returned calls. If two pass the interviews and reference checks, that’s a good week, she said.

"This a really frustrating system on multiple levels," agreed Martha Ross, an analyst who studies these workers for the Brookings Institution.

"The educational requirements for these jobs are very low," Ross said, "so that’s good, because there’s a low barrier to entry. But in order to move up to positions with a higher earning potential, you need a significant amount of higher education."

Three years ago, Antwanette Hill landed a scholarship to pursue a two-year degree to become a registered nurse, which would have more than doubled her annual income of $21,300, lifting her out of near-poverty.

The scholarship would have paid half her tuition. But she had to turn it down because the balance was beyond what she could afford, considering that her children get medical assistance and she qualifies for food stamps.

"I’m still hoping to better myself," she said. "Only quitters will say it’s impossible."



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