Bill promises ‘generational investment’ in senior living and care workforce

by Kimberly Bonvissuto

Proposed federal legislation would make a “generational investment” in the senior living and care workforce at a time when the aging population is growing exponentially and an increasing number of older adults are living with chronic conditions and disabilities, according to its sponsors.

The Long-Term Care Workforce Support Act, introduced by Democrats, was met with mixed reviews from senior living industry advocates on Tuesday, however.

US Sen. Bob Casey (D-PA), chairman of the Senate Special Committee on Aging, called direct care workers the “backbone” for long-term services and supports and said they are “irreplaceable” and “essential” during a Tuesday committee hearing focused on long-term care workforce shortages.

“Here is the bottom line — if we claim that their work as caregivers is essential, we should accord them the status of a professional,” Casey said in introducing the bill, S 4120, co-sponsored by Sens. Tim Kaine (D-VA) and Tammy Baldwin (D-WI). “By professionalizing and supporting the long-term care workforce, we can better recruit and retain professionals in this vital field.”

Casey said the bill would ensure that caregiving can be a sustainable, lifelong career by providing “substantial” new funding to support workers in every part of the long-term care industry, from assisted living communities to nursing homes to home care. Specifically, he said, the bill would provide pathways to enter the care workforce, improve wages and benefits, ensure a respectful and safe working environment, and introduce best practices on recruitment as well as training strategies to promote retention.

Pointing to a PHI report, Casey noted that caregivers earn a median wage of $15.43 per hour, resulting in almost 70% of assisted living communities and 92% of nursing homes reporting significant or severe workforce shortages. 

US Rep. Debbie Dingell (D-MI) introduced companion legislation in the House of Representatives, HR 7994, calling caregiving the “foundation of our economy” that allows for all other work to be possible.

“No care workers should have to live below the poverty line to do this work that millions of Americans depend on,” Dingell said in a statement. “This legislation will make much-needed investments in our care infrastructure and workforce, including family caregivers, to ensure they have the support they need, are paid a living wage, and are able to continue doing their critical jobs.”

‘Time is of the essence’

Provider advocates had varying responses to the bill.

Argentum said it appreciated recognition of the workforce shortages and potential resources to address it but added that “time is of the essence,” with the need to create more than 3 million new jobs in senior living by 2040 to care for a rapidly aging population.

Argentum Senior Vice President of Public Policy Maggie Elehwany said that workforce issues have been one of the few areas of bipartisan agreement in the 118th Congress, with multiple congressional hearings and calls from both sides of the aisle to “stem the exodus of healthcare workers.” 

The association, she added, continues to champion public policy efforts to bolster the senior living workforce, including support for the Safeguarding Elderly Needs for Infrastructure and Occupational Resources (SENIOR) Act, which targets assisted living workforce development, and the Care Across Generations Act, which addresses twin senior and childcare workforce shortages.

The American Seniors Housing Association told McKnight’s Senior LIving that the act prioritizes the need for workforce development programs as the industry and nation face the “real risk of not having enough available and willing workers to keep pace with the growing demand for their services.”

“This important legislation makes a significant investment in workforce development and training grant programs to be offered at the state level, offering a wide range of worker supports, skills training, demonstration projects, technical assistance, as well as worker protections,” ASHA Vice President of Government Affairs Jeanne McGlynn Delgado said. “These are all worthy goals, and if enacted and successful in creating a pipeline of trained long-term care workers, the industry will be well served.”

But Delgado said the legislation is only a partial solution, adding that immigration reform is a necessary component to addressing the sector’s workforce shortage challenges. ASHA said that Congress must take action to advance “one of the many reforms” already proposed, including creating a new visa category for caregivers, accelerating the timeframe an asylee can seek work authorization, and granting green card status to essential workers who worked during the COVID-19 pandemic.

“Congress will have to address the broken immigration system, and the sooner it does, the better for our seniors,” Delgado said. 

The Center for Excellence in Assisted Living, CEAL@UNC, which formally endorsed the legislation, said the act calls out “discriminatory” immigration actions, but “unsurprisingly” doesn’t go so far as to address the “third rail” of immigration.

“CEAL@UNC encourages supportive immigration policies to build the pipeline of new workers into assisted living and other long-term care settings,” Sheryl Zimmerman, MSW, PhD, executive director of CEAL@UNC, told McKnight’s Senior Living.

Zimmerman also said that although the federal government calls for recognizing the importance of the long-term care workforce, CEAL@UNC suggests going one step further and formally recognizing all of those providing direct care.

“The Center for Excellence in Assisted Living appreciates the federal government’s recognition of the essential nature of the direct care workforce, the fact that’s it’s important to virtually every family at some point in their lives, the evidence tying its sufficiency and competency to the well-being of older adults, and that the Long-Term Care Workforce Support Act expressly references the importance of the workforce in assisted living,” Zimmerman said.

Workforce bill ‘misses the mark’

Some senior living and long-term care industry advocacy organizations, however, said the proposed bill “misses the mark” and wouldn’t produce its intended effects.

“The entire long-term care continuum, no matter the type, faces a growing caregiver shortage that impacts access to care for our nation’s seniors and individuals with disabilities,” Clif Porter, senior vice president of government relations for the American Health Care Association / National Center for Assisted Living, told McKnight’s Senior Living. “This legislation ignores a wide swath of the profession and fails to address the elephant in the room — Medicaid frequently doesn’t cover the cost of care, making it difficult for providers to offer higher paying, competitive jobs.”

Porter added in a statement that it’s important for policymakers to recognize that assisted living communities and nursing homes “do everything possible to hire more caregivers.” 

“We must focus on meaningful and comprehensive policies that will actually help long-term care facilities recruit and retain workers, as well as build a strong pipeline of caregivers,” Porter said in a statement. “We hope to continue working with Congress and the administration to find more supportive ways to ensure our nation’s seniors have continued access to care.”

AHCA / NCAL said it supports several bipartisan bills to address workforce challenges facing providers, including the Healthcare Workforce Resilience Act and the Train More Nurses Act as well as three pieces of legislation that apply specifically to nursing homes: the Protecting Rural Seniors’ Access to Care Act, the Building America’s Health Care Workforce Act and the Ensuring Seniors’ Access to Quality Care Act. 

LeadingAge, which also pledged its support to the above-mentioned bills, similarly said that the “devil is truly in the details.”

President and CEO Katie Smith Sloan, in written comments submitted to the committee, urged policymakers to pay attention to “necessary refinements” on funding for the education and training initiatives needed to build and sustain the workforce and investment in coordinated state and federal infrastructures to ensure programs achieve desired goals.

Among LeadingAge’s recommendations was passage of the Expanding Veterans’ Options for Long Term Care Act, the Home and Community-Based Services Relief Act, the Better Care Better Jobs Act and the Expanding Service Coordinators Act to address “inadequate” reimbursement mechanisms. 

In addition, LeadingAge called on Congress to pass legislative proposals addressing gaps in the US immigration system and to develop and streamline federal training requirements for direct care professionals, including exploring how licensed vocational / practical nurses and experienced direct care professionals can assume increased training responsibilities for professional caregivers. 

“This should be done with a focus on developing stackable certifications and opening pathways for aging services staff to engage in a lifetime of career development and learning,” Sloan wrote in her comments. 

Addressing the newly introduced Long-Term Care Workforce Support Act, Sloan suggested dedicating a specific fund to clear HCBS waiting lists, including long-term care providers in both the rate-setting process and the formation of any passthrough threshold for which they would be held accountable by their states, combining grant funds under one roof, and including home health and hospice in the definition of long-term care. 

Senate Aging Committee Ranking Member Sen. Mike Braun (R-IN) cautioned against a federal “one-size-fits-all” approach, suggesting that innovation at the state and local levels is needed to meet the increased demand for direct care professionals. 

“Giving more power to the federal government usually means printing more money and forcing top-down solutions. These solutions are partisan and will not get us anywhere,” Braun said. “To grow the long-term care workforce, the federal government should make it easier for people to enter by removing barriers.”

Elehwany said that Argentum agrees with Braun’s stance on partisan solutions and the need to “work together to pass bipartisan solutions that offer flexibility.”

‘Historic’ legislation addresses job quality

PHI called the bill “historic” and said that it “enthusiastically endorses” the legislation designed to systematically improve direct care job quality and address the sector’s workforce crisis. The organization said the bill enshrines many of PHI’s long-standing policy priorities related to compensation, training, employment conditions and evaluation.

Specifically, the organization noted that the bill authorizes the Department of Health and Human Services to award grants to support workforce recruitment, training, compensation and retention. This authorization includes a $10 million investment in pilot projects on education, training and career advancement across settings, as well as $10 million to support a national technical assistance center to support states’ workforce efforts. 

PHI also supports the bill’s proposal to create a National Direct Care Professional Training Standards Commission to develop national training standards for the direct care workforce, as well as an advisory council to develop a national direct care compensation strategy. 

Issues are ‘multi-dimensional’

Jasmine Travers, PhD, RN, an assistant professor at New York University Rory Meyers College of Nursing, testified during the hearing that the issues affecting the recruitment, retention and morale of the direct care workforce are “multi-dimensional and compounded by an external environment that devalues this work.”

She said the realities that make direct care work unsustainable include low wages and limited benefits, inequities, chronic under evaluation and a demanding work environment, insufficient training and limited growth opportunities.

Travers called for a multi-pronged approach involving federal and state governments, managed care organizations, aging organizations, payers, providers, advocates, care recipients and direct care workers to create solutions for a stronger direct care workforce. 

Financially, she called for competitive wages and benefits, and spending minimums for staffing for Medicaid-funded facilities. She also called for enhanced training programs and opportunities for career advancement, fostering a positive work environment through culture change, focusing on recruitment and retention and sharing best practices. 

“To improve access to and quality of long-term care, we must ensure that all direct care workers receive a living wage, a safe, respectful work environment; opportunities for advancement; adequate training; and accessible benefits to maintain their health and well-being,” Travers testified. “Only when we recognize that these workers are critically important, hardworking professionals, can we begin to improve equity and health outcomes for staff and patients alike.”

Brooke Vogleman, a licensed practice nurse with senior living and care operator TLC Management of Marion, IN, said that staffing should be about training, education and retention.

“We need workforce development programs that help us grow the care force, incentivize caregivers to choose a career in long-term care, and invest in their career development,” Vogleman said. 

Some hearing witnesses testified in favor of access to worker supports and protections. You can read witness testimony on the hearing website.

The Long-Term Care Workforce Support Act is endorsed by 44 organizations, including the Center for Excellence in Assisted Living, or CEAL@UNC; the Gerontological Society of America; the Coalition to End Social Isolation and Loneliness; the American Geriatrics Society; the National Coalition on Aging; and Justice in Aging.

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Bill promises ‘generational investment’ in senior living and care workforce