Building the Nation’s Eldercare Direct-Care Workforce: Policy Implications: Page 2 of 2

August 16, 2012

Policy Future

And now to the subject of policy future. Who knows, right? Will 2013 find us with a new president, a new Congress, and an entirely new budget? Will the U.S. Supreme Court uphold the constitutionality of the ACA?a

One thing we will predict: the battle ground for where policy will be shaped will shift—indeed is already shifting—away from the federal and state governments and into the hands of managed-care payers. Even as you read this, deals are being struck in states across the country. Pressures to reduce costs and integrate services are pushing the states to contract with managed-care plans for their Medicaid populations—particularly for high-need, high-cost individuals—and it will then be up to these plans to determine how services will be delivered. For example, if you are interested in care coordination for low-income elders receiving long-term care services, over the next 5 years, no matter who is president, it will increasingly be the managed-care organizations (MCOs) that will determine the design of care coordination teams, not the federal or state governments. While government policymakers will work to regulate care outcomes—and we support aggressive attempts to do so—the design of service delivery inputs (which have the greatest impact on eldercare workers) will be left primarily to managed-care plans within broadly capitated reimbursement frameworks.

It is fascinating that, in this age of “transparency,” we are entrusting our service delivery system design to an exceedingly opaque structure. And we are not against MCOs in principle—the PHI sponsors Independence Care System, a Medicaid-managed long- term care plan in New York City. It is just that each MCO is a bit of a black box, and the values that you pour into that box determine what pours out. Therefore, we support policy efforts to ensure consumer engagement and more explicit state contracting standards and reporting requirements, but we also call for direct engagement in building MCOs that model best practices in service delivery design.

The PHI and the AGS, in our fieldwork with homecare agencies and nursing homes, teach direct-care workers, supervisors, and administrators that you can’t really control other people, but can only control yourself. So in that spirit, we would like to argue that we have the greatest chance of shaping future policy if we don’t focus so much on what others are or are not doing—but rather that we take a hard look at ourselves.

And here is where we’re sure we will get into serious trouble. But we believe it is worth taking some risks, for when looking to the future, we are genuinely concerned that those who care about the quality and availability of eldercare services remain unnecessarily divided, and those divisions in turn diminish our effective advocacy.

(1)       First, it is our experience that the aging community remains quite separate from the disability community—to the detriment of both. From the aging perspective, we would simply submit that the disability community has accomplished enormous policy change in how all of us now think and talk. After all, the core concepts of “consumer direction” and “person-
centered care,” and even the language of “long-term services and supports,” all originated from the disability community—even though the disability community has 1/100th of the resources (no Administration on Disability, no equivalent of the John A. Hartford Foundation). We have much to learn from the assertiveness and courage of the disability community.

(2)       Second, family caregiver advocates and paid caregiver advocates still need to coordinate more closely, to make sure that we are not pitted against one another. There has been significant progress in this area over the past 5 years, due to relationship-building across organizations, but we still have a long way to go. We simply shouldn’t compete against one another to determine who is the more worthy of attention and
resources—we must combine forces more explicitly.

(3)       Third, there remains enormous distrust between organized labor and much of the rest of the eldercare community. We acknowledge that there is a whole lot of history there, but any hope that the field can make systemic progress on workforce issues—particularly direct-care workforce issues—without thoughtful cooperation between organized labor and other advocates seems fruitless. This will take more than serving on a few coalitions together. This will take genuine communication, trust-building, and, ultimately, change—across all parties.

(4)       Fourth and finally, gaps remain between professionals and paraprofessionals within eldercare services. Again, there is progress here—notably the Institute of Medicine’s report on the eldercare workforce dedicated an entire chapter to the direct-care workforce—yet we still have a long way to go. Technically, this divide will be played out along questions of where and how to draw the line on scope of practice issues—50 different lines drawn within 50 different states. But more systemic and more hidden are our own biases. There is often a class and race divide here, between the professionals and the paraprofessionals, and it limits all of us in solving the challenges we face. Just one example: in a funding proposal that we recently reviewed, two roles were described, one for a professional, the other for a paraprofessional. In a brief description of each, the proposal noted that the paraprofessionals would be drug-tested, but curiously, no mention of drug testing was in the professional’s description. We are blind to our own prejudices, and they, in turn, blind us.

So, now that we may have succeeded in annoying almost everyone, let us simply restate the plea for policy future: that we can and must fight against budgets and all other forces that attempt to constrict resources for elders. We have the greatest chance of succeeding, particularly in the long run, if we focus on ourselves and work to determine how we can build more trust and confidence in one another. The EWA is a very good example of that—we’ve bridged many a divide around that table—and we have only just begun. If you are not yet part of the EWA, we urge you to join us. Find more information at

Our thanks!