As our population ages, we are faced with a number of policy challenges. One, in particular, stands out: how will we provide care for those who need help?

Our next episode in the series around Demographic Shifts explores the policy implications of the aging population and the people who will help care for them.

California expects to see its population of seniors rise from 15 to 25% in the next 40 years. While the challenge of caring for an aging population will expand as the population grows, there are real policy issues today. The Direct Care industry, which includes home care workers and care facility workers, faces many challenges. In this episode, Reem Rayef (MPP/ERG ’21) and Sarah Edwards (MPP ’20) speak with experts to unpack the challenges of today and tomorrow. Robert Espinoza from PHI National, a research and advocacy organization, shared the national perspective. Tanya Bustamante and Cuidonce Corona from Berkeley Aging Services Division ground the challenges in what is happening in Berkeley.
Interested in learning more? Check out Berkeley’s Age-Friendly Plan.

Read PHI’s most recent report.

Stay tuned for another episode exploring Demographic Shifts and the role of policy!

Transcript

Sarah: [00:00:01] We're getting older. The U.S. as a whole and California in particular, is facing a growing population of older people.

Reem: [00:00:09] What exactly do these exact numbers look like?

Sarah: [00:00:12] As of 2016, California was about 15% seniors. By 2060, it's expected to be nearly a quarter of the population.

Reem: [00:00:21] That's a significant chunk of the population. But it seems like this big demographic shift hasn't really been a policy focus.

Sarah: [00:00:28] That's right. It's not really coming up in the presidential debates, doesn't have some catchy slogan, and it's not in the major work of think tanks that get splashed around the news.

Reem: [00:00:39] But with an expanding share of Americans over 65, we do need to start thinking about if and how policies will shift to meet the needs of this older population. I'm Reem Rayef.

Sarah: [00:00:52] I'm Sarah Edwards and this is Talk Policy To Me. This is one of our episodes in our series around demographic shifts. We're asking what are the changes in the demographic makeup of our country and our state, and how does that tie to policy? Is policy keeping up with these changes? In this episode, we're exploring one particular policy intersection related to aging. We're focusing in on the population of people who provide supportive care to older folks.

Reem: [00:01:30] According to the research and advocacy organization PHI National. There are about 4.5 million workers in the direct care workforce over the next ten years. It's expected that the industry will add over 1 million new jobs.

Sarah: [00:01:46] But what are the challenges that these workers face? What are the policy tools that can be used to change this landscape? We turn to Ohio National to understand the bigger picture and to Berkeley aging services to hear about what this looks like on a local level.

Reem: [00:02:04] Today on the podcast, talking aging and direct care work. In our first interview of the episode, Sarah speaks with Robert Espinoza, the vice president of policy at PHI National, an organization that aims to transform elder care and disability services.

Sarah: [00:02:24] I wanted to talk to Robert about his work, understanding the needs of the seniors receiving direct care support, about the challenges for the direct care workforce and what the policy looks like in this space. First off, who are we talking about when we talk about direct care workers?

Robert: [00:02:43] So direct care workers includes home care workers and nursing assistants who provide daily support to older people and people with disabilities around the country. They help with daily living, so they help support with items such as housekeeping, basic supports in the home that allow older people and people with disabilities to really live the lives that they want to live. They also offer respite and support to family caregivers whom we often find are strained financially and emotionally and and rely on direct care workers to be able to offer that kind of support so they can also live the lives that they need. It is a really valuable work force to millions of people around the country.

Reem: [00:03:30] And based on all the data, direct care work will be an even higher demand in the future.

Robert: [00:03:36] People are living longer, and so with increased longevity come the type of issues and conditions that require daily supports. More also seeing growing numbers of older people. We're rapidly aging country, a rapidly aging world, and with those two realities come an increased demand for direct care workers. I also think that people are our clients that they serve are becoming increasingly complex and more diverse. So we're seeing, you know, a high end rate of conditions that require specific supports like dementia, cardiovascular disease. We're also seeing populations emerge like we're seeing the first generation of our LGBT people, and we're seeing a broad, diverse population of people of color and immigrants that also need specific supports that are culturally and linguistically competent. And so direct care workers as the paid front line of care in this country, will be essential to making sure that all of us get the kinds of services and supports that we need.

Reem: [00:04:40] According to a report, nearly 20 million adults in the U.S. need help with self-care and other daily tasks due to physical, cognitive, developmental and behavioral conditions. People with these personal assistance needs rely first and foremost on family members, friends and neighbors. These personal relations, who you might not even recognize as a part of the story, make up 43 million caregivers whose economic contribution represents $470 billion of unpaid labor.

Sarah: [00:05:12] But clearly, there are still cases where people need outside help. How can we think about direct care workers in relationship to family caregivers? Are they playing the same role?

Robert: [00:05:22] You know, I think when you look at the full caregiving system and you're looking at both family caregivers and direct care workers, you see two segments of caregivers that are facing major challenges despite all the value they provide to many of us in this country. You know, family caregivers are critical to the supports of all of their loved ones and of older people and people with disabilities. And yet too often they are strained financially and emotionally, and many of them are women. Although men are a growing percentage of family caregivers, I think they're at around 40%. Direction workers also are struggling in jobs that are not paying enough or not offering those same level the proper level of training or career advancement, and because of that, are leaving the sector and leaving families and families are left with other kind of supports they need. So the more we think about both supporting each of them in terms of the kinds of unique needs they might have, but also optimizing the relationships so that the family caregiver is working with the client and the home care worker and other members of the care team, the social workers, the physicians and others. I think we're going to see stronger, more cost efficient systems and approaches to care.

Sarah: [00:06:38] What is the demographic makeup of the direct care worker industry and what is it like for people to be working in this space?

Robert: [00:06:45] Yeah, the vast majority of workers are women. About 60% or more are people of color. About one in one in three are immigrants or less than one in three are immigrants. This is a population that spans the age spectrum of the median age is in the forties. And one in four is actually 55 and older. And so I think we're seeing a workforce that is comprised of populations that also struggle with inequities and marginalization in the broader world. Women of color, immigrants are people who have long. Faced marginalization on the job and in daily life. And so they're entering these jobs with those kinds of challenges. In addition, the job doesn't have the level of support or valuing that it should have given the centrality to people's lives.

Reem: [00:07:38] Robert went on to share the three major challenges facing these workers. First, wages themselves are low. Second, the hours are less than full time and can be unstable. Third, training opportunities are limited and training systems are inconsistent or nonexistent. You'd think that training would help direct care workers perform better at their jobs and then advance upward in a career in care working. But that's not really what happens. It turns out that there isn't a strong career track for this type of work, so becoming more skilled or more advanced doesn't set people up to be making more money or gaining more responsibility. It's ultimately a dead end.

Robert: [00:08:20] The primary challenge we see with workers relates to compensation. Wages are too low. They hover around $11. So we're seeing a workforce that unfortunately, despite the value that they have for millions of older people and their families, especially in the future, we're not seeing the kinds of supports and high quality jobs that these workers deserve.

Sarah: [00:08:42] And as a result of these low wages, more than two in five direct care workers require some form of public assistance through our social safety nets. This is clearly a policy failure. And so we need to think about solutions both for today and as our aging population grows. Now, we're curious what is driving the projections for growth of this industry?

Robert: [00:09:06] You know, the two drivers that we see spurring demand for direct care workers are, one, the changing demographics, the growing demand caused by growing numbers of older people and increased longevity as the two main factors. And the other reason is that because the jobs are so poor and quality turnover in the sector hovers around 60% or higher. It means that workers enter these roles and either they haven't been prepared or the jobs are so low and quality that they just don't stay in these roles. And what that does is it means that consumers aren't able to access the workers they need to to live the lives that they want. We often see that workers leave direct care in many states for other sectors like fast food or retail, where wages are higher, schedules are more stable, and arguably their jobs are easier or less rewarding. Probably, but they don't have the kind of physical and emotional demands a director requires. The kind of emotional labor that many workforce advocates talk about. And so that's creating a real crisis, I think, more and more. We're seeing a wide range of leaders across industries, whether it's in the long term care industry, in health care, in workforce development, acknowledge that we need to really increase the investment in this workforce in order to have the kind of care that all of us need.

Sarah: [00:10:35] I'm glad to see that it's being recognized as an area that needs greater investment and more policy effort to improve it. But what does this actually look like in the day to day? What would it mean if we really did prioritize the issues faced by the elderly and by those who care for them?

Reem: [00:10:52] To answer this, we turn to the city of Berkeley's aging services division. Sarah spoke with division manager Tanya Bustamante and case manager Cuidonce Corona. The city of Berkeley has been tackling the issues of the aging population and the policies necessary to better support them through its age friendly Berkeley plan. Tanya provided us with an understanding of what exactly this plan is and does.

Tanya: [00:11:17] So our age friendly plan is really a plan with the goal of beginning to address the needs of our growing older adult population and ensuring that our city is age friendly. And what that means is really creating a community that addresses the needs of all ages, but with a particular focus on our older adult population. Since that is the segment of our population that is going to be increasing quite drastically and continue to increase in the future. So we want to make sure that older adults can live in a community where they feel that they can continue to age and thrive. And so in our plan, we've identified four priority areas, and this is based on feedback that we receive from the community as well as feedback that we received internally from city departments and those priority areas our housing and economic security, transportation and mobility. Health and wellness and social participation and civic engagement.

Reem: [00:12:27] The age friendly Berkeley plan came directly from the testimonies by Berkeley seniors who were given the opportunity to define and clarify their specific needs. One thing that frequently came up was that seniors wanted to quote unquote age in place or continue to live where they've been living as they grow older. As Robert mentioned, this desire to age in place is one of the major drivers of demand for direct care workers. People who may have high needs but are staying in their homes require more assistance and more resources than those who receive care through some kind of care facility like an assisted living home.

Sarah: [00:13:05] Cuidonce shared some of her experiences around this as a case manager for seniors in Berkeley, and it sounds like she's seen it all.

Cuidonce: [00:13:12] In the field, I'm definitely noticing. I think to kind of separate issues, one is a large one of people wanting to, you know, remain in their homes and have you know, you have people who are fortunate enough to either have own their home and be able to continue to afford it or be in an affordable type of housing situation. It's still often a hurdle to get them. The actual caretaking that they require. A lot can depend on kind of their health insurance and what kind of health insurance they have and, you know, how progressed any sort of a health or medical condition might be that would then warrant approval or authorization of those services. And some folks may not be in the position to private pay for either caregiving or, you know, light housekeeping services that they very well need and could greatly benefit from. And that's oftentimes a best case scenario. There's also for those folks who maybe are housed and have a medical insurance, we can access something called in-home supportive services. And it's a wonderful program, but it's heavily impacted. And in an area like the Bay Area where I think it's really expensive for people to live, even though they, you know, IHS has offers, you know, a living minimum wage of sorts. It's very hard to oftentimes find somebody who really is a good fit for the client and really kind of has that heart and that kind of all to really provide those, you know, really sensitive services.

Reem: [00:14:43] Let's unpack this a little bit. So people who need this kind of support can technically have it covered through their insurance under specific conditions. In-Home supportive care is provided through the Medi-Cal program. People can also receive coverage for this kind of care through Medicare. Collectively, Medicare and Medicaid pay for about two thirds of the total home care industry. People can also get support through their private insurance, like a medicare Advantage plan, and those who have the means can pay out of pocket.

Sarah: [00:15:15] The prices set by the government for the direct care provided through Medicaid and Medicare are really low. But the prices for those who pay out of pocket remain pretty high. This creates two completely different price points in the market for direct care work for seniors, And these two different price points ultimately mean different salaries for direct care workers in the public and the private sectors. But how does this end up looking in Berkeley.

Cuidonce: [00:15:43] At least on just my caseload, it seems pretty much like a mixed bag. I have some folks who may be, you know, again, are at the kind of medical point where they can receive like a home health care aide through there, either, you know, whether it's private insurance or state benefit, you know, medical insurance. And then there's some folks who have saved sufficiently and are able to do private pay. It's again, as it's become increasingly more expensive to live in the Bay Area. Another factor is people aren't just doing direct caretaking. This is usually their supplemental income. So they may have a full time job they're trying to navigate and then they're piece milling together, you know, Oh, I have this day and this time available. And so those are, I think, some of the real challenges of what's happening out there right now. I think there's been some creative solutions. For example, some of our like shelter plus care programs, if you know, you're allowed to even get maybe a two bedroom voucher if you need and you have the adequate certification, medical certification to show that you're going to have a live in caregiver. And, you know, given the cost of housing and just how attractive housing often is in Berkeley, that's usually a very high ticket item for folks to say, well, I can't free room and board and a bedroom and a unit in Berkeley and and I can work and be or, you know, in-home supportive services provider or your private pay caregiver if you're able to do that or get paid through your health insurance. Some folks that you know, maybe have a home and have, you know, like a spare bedroom have kind of done that like a trade room and board for a you know, I need caregiving support services. I heard recently in Berkeley, site of a wonderful program that UC Berkeley is doing, pairing up seniors who are isolated with I think it was graduate level students if I got it correct. And I thought, Wow, that's an awesome idea. And I thought it was another, you know, kind of creative solution. In the meantime, I think realistically speaking, in terms of the here and now, like, I think it's awesome that these creative solutions exist and those are the ones we try to go to is kind of like direct case managers trying to really help people with a now need.

Sarah: [00:18:03] It's good to see the creativity, but it still feels like there's a major failure in our systems to adequately provide what people need. How can policy change it for now and for the future? We turn back to Robert for the policy solutions I have identified to make direct care work a livable career.

Robert: [00:18:25] I think the first thing is funding the long term care system. I think too often we see that providers and states and employers are not able to deliver the services that people need and to meet growing demand and they're not able to create quality jobs because the funding is just not there. Right. We're seeing kind of a lot of states challenged with, you know, they don't have enough Medicaid funding. The populations are growing. There are so many other needs that that need supports in any of these budgets. And long term care gets underfunded. And that leaves often older people and people with disabilities who are low income without the support that they need. So I would definitely prioritize creating a strong financing system for long term care that is rooted in a worker centered approach so that quality jobs are being created. Our states are better funding the system.

Reem: [00:19:22] Like all policy issues, this one doesn't exist in a vacuum. Direct care workers are impacted by all sorts of other policy decisions, especially immigration. Robert shared how changes in U.S. immigration policies and the harmful narratives around immigrants present entirely new hurdles for direct care workers.

Robert: [00:19:42] Our research shows that about 30 31% of direct care workers are immigrants, and they're essential to the long term care system to direct care probably to a variety of industries in the U.S. And there are especially important to the future of the direct care sector. I think as we see, you know, more and more people are aging and turning 65 and living longer, we're going to need to think about a stronger pipeline of workers to enter direct care. And immigrants are essential to that solution. I think in the last few years, we've seen a heightened hostility towards immigrants and in rhetoric and public policies and just a general devaluing. And sometimes it's quite vicious of immigrants across the country. And I think with that, I think it does two things. One is it disincentivizes immigrants to come to the US and to feel kind of safe and stable in their communities and on the job. And that, of course, will affect the direct care sector where. Rents are a big percentage of that of that workforce, but also for immigrants who are already in the country. I mean, it's quite scary to see the rhetoric so high end and not know if, you know, tomorrow some new policy will be introduced that will make it harder for you, for your family, for your community members to live and thrive in this country. So often direct here, workers rely on broad networks of people in their communities to live lives, you know, as people in their communities or caregivers or they help with childcare or they just help kind of form the bonds that all of us need, you know, in the community to be able to thrive. And if we're if they're seeing, you know, a community that is under attack and people are scared to live openly and live out in them, you know, and really thrive in the community, I think it's going to make it harder for them to have the kind of wraparound support that they need to thrive on the job. So it's a frightening point in our history that we're seeing, and it really ignores the central role that immigrants play both in health care and our economy.

Sarah: [00:21:48] Right. This really gets at the idea that we've touched on before. We cannot think about policies in isolation, choices made at the federal level on immigration policy cause huge ripple effects that change the lived experiences of many communities, both immigrant and nonimmigrant.

Reem: [00:22:07] What happens when we narrow the lens from national impacts to local ones? Cuidonce shared about how she has seen the impact of immigration policy on direct care workers in Berkeley.

Cuidonce: [00:22:18] I've worked with folks who may be at a point in their life where they were working and able to pay someone for light and heavy housekeeping services, and then maybe they've reached a point where they're not able to and could utilize a government benefit like or a resource like IHS in-home supportive services. But then in finding out they're eligible for that, want to bring on their person as a provider and find out, oh, I can't that person's, you know, doesn't have a social or able to you know, worked. It's kind of straining. They may be people who they trust that they've worked with for decades in some regards, and they're not able to to utilize them. And the persons are usually more than willing.

Sarah: [00:23:04] As we think about our changing population. We also need to consider the ways that the needs of aging people and their families are different now from what they used to be and will continue to be different into the future. The aging population will have a larger proportion of out LGBTQ folks, of people of color, and a larger proportion of immigrant families. The support systems we put in place should reflect that.

Robert: [00:23:31] It is going to become part, I think, of the long term care sector's future to thinking about how cultural norms differ across countries, across nationalities and across just a whole range of factors. Right. But on a personal level, my mother is from Mexico, and about five years ago she transitioned into a nursing home. And I remember having a number of difficult conversations with our family members in Mexico who just could not understand why she couldn't remain at home and really were upset that me, my father and my sister, you know, had agreed to this. Now, at the time, like so many people, a nursing home was the only option given the 24 hours skilled care that she needed. And also because we live in a country that doesn't properly fund that level of care in home and community based services. And so it was really the only option to keep her safe given some of the issues she was dealing with. But the kinds of questions and frustrations that surfaced among our family in Mexico in particular, who just didn't understand that. And it's very different in Mexico and in a lot of Latin America and how long term care and supporting older people looks right, that they just couldn't understand that. And I think that, you know, for immigrants who are living in the U.S., I think, you know, our long term care sector is probably going to need to develop a stronger cultural and linguistic competence to support immigrants who are coming from countries where this isn't the norm and there are other traditions, etc.. And I think we have a lot to learn from other countries around the world, not just Latin America, but, you know, in Europe and in the Asia and other parts of the world where they are also seeing, you know, larger numbers of older people and their countries are grappling as well with the kinds of challenges that we're grappling with in the U.S., including with the workforce. We haven't studied that yet. I think that this is an opportunity for growth if we decide ahead in that direction. But it's something that a long term care industry would need will probably need to become more adept at.

Sarah: [00:25:31] There is so much room for growth and constructive change in this policy area. But where do we begin? How can we get more policy makers and decision makers to really engage around this? Tanya shared from her experience building the age friendly plan here in Berkeley.

Tanya: [00:25:50] Bringing in that personal aspect is important. We are all aging and that is something that we have in common. And really driving that point home I think has been the key piece in our messaging about age friendly. For me personally, you know, I am you know, my parents are aging. And so I have seen this more firsthand. And I know that many of us are in that situation and, you know, are seeing it unfold, you know, in our own homes, in our own families. For my staff, I mean, we see it every day and the clients and the members that come through our doors. I know that other staff and other individuals may be a little bit more removed from that. But when you bring in those personal accounts and those personal stories, it touches a place where I think even if you don't have that happening personally yet in your life, that people can begin to relate to it because we know we're going to get there eventually.

Sarah: [00:26:56] That aligns very closely with Robert's perspective from the national scale. Essentially, people need to have a reason to care about this. Luckily, we are all aging all the time. This issue really should be personal for everyone.

Robert: [00:27:11] Too often we see that, you know, when somebody in government or a reporter or an advocate realizes that this is a major issue, this issue of strengthening direct care jobs, it's because someone in their lives has needed that type of support and they realize, wow, this is a a system that needs quite a bit of support, is inaccessible and it's expensive. And these jobs are not great and workers are staying. And how do we address this crisis? And so I, I think if people realized how valuable these workers are and what type of crisis we're in right now, where these workers are not staying in these jobs because there are just so poor in quality, I think they would become stronger advocates for this workforce and for older people and people with disabilities when they have that aha moment when they someone in their lives encounters this this challenge and struggles to find a worker that meets their needs. Usually that's when they become more political, right? They realize this is a system that needs reform and I can play a role regardless of where I am in the system.

Reem: [00:28:19] Right. So it seems like there are policy level actions for change and some individual level actions as well. So here are our high level takeaways from large scale policy changes that could help resolve some of our system failures. One, increased funding to direct care programs through Medicaid and Medicare and translate that into higher wages for the people in these direct care worker roles to strengthen training programs for direct care workers while building these roles into stronger career tracks. And three, we need to holistically address related policy issues like immigration. We need to be better about viewing aging as a larger part of the policy landscape.

Sarah: [00:29:02] Absolutely. And as individuals, we can each be thinking about what policy challenges we can help to bring into the forefront. In this case, aging isn't just about my parents getting older or my 90 year old grandparents or your grandparents. It's something that we as a society and as policymakers need to address. And to do so, we have to see this as a real issue. In her next episode, under the theme of demographic shifts, we'll be exploring a related topic.

Reem: [00:29:35] I'll be talking about the intersection between transportation policy in the needs of the senior population. How can we make sure that our transportation systems holistically serve this community as we all grow older?

Sarah: [00:29:49] Talk Policy To Me is a production of the Goldman School of Public Policy and the Berkeley Institute for Young Americans. Music heard on today's episode is by Pat Mesiti-Miller and Blue Dot Sessions. Our executive producers are Bora Lee Reed and Sarah Swanbeck. Michael Quiroz is our sound engineer. I'm Sarah Edwards. Catch you next time.