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WASHINGTON — May helped care for her elderly aunt for years. When her aunt died, May, who is 41, decided to leave her part-time job as a telemarketer and become a full-time home health aide.

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She said the thought of making other people like her aunt more comfortable felt like a calling. “Just the joy of helping,” May said.

In the 11 years she worked as a home health aide, May estimates she looked after 100 elderly clients in their homes. Some just needed a light meal prepared, but others required much more help. “They couldn’t move at all. I had to change them, feed them, bathe them, everything.” 

A  home health aide prepares a cup of tea for her patient. Seventy percent of adults over 65 are expected to need some form of basic assistance, but there aren’t enough home health aides to meet that demand. Credit: Michael M. Santiago/Getty Images

Tens of millions of older Americans want to age at home. But the critical shortage of people to take care of them will require more than the Biden administration’s proposed billions of federal dollars for home-based long-term health care. It will take a complete and substantial change in the training system, career pipeline, pay and work conditions of home health aides, experts and advocates say.

If those things aren’t fixed, the suffering will be felt not only by the “millions and millions of people [who] work very hard at very difficult and important jobs and get poverty wages,” said Paul Osterman, a professor of human resources and management at MIT and author of the book  “Who Will Care for Us?” It will affect everyone who wants to age at home or has a loved one who does, he said. The burden of caregiving will fall on unpaid relatives, affecting their financial and mental health.

“It’s a real problem for society,” Osterman said.

The need for home health aides is projected to grow by 34 percent between 2019 and 2029

It’s also an example of how job training in the United States is not well ordered, lacks incentives for people to take on critical work and often leaves consumers to fend for themselves and spend more money on their educations than is justified by what they’ll earn.

There are about 54 million Americans over 65, according to the U.S. Census Bureau. That number is expected to rise to 95 million by 2060. Older adults have shown a clear preference for remaining in their homes, for the independence but also the comfort and community connections.

Aging in place is typically more cost effective than moving into long-term nursing facilities and proved a far safer option during the Covid-19 pandemic, when more than 184,000 residents and staff died in nursing homes and assisted living.

Related: When nurses are needed most, nursing programs aren’t keeping up with demand

Key to enabling more older adults to remain at home is expanding the number of home health aides, workers usually seen as being on the lowest rung of the health-care ladder. These aides provide day-to-day support such as feeding and dressing as well as doing shopping and laundry, and a much-needed respite for overwhelmed or absent relatives.

There is already a shortage of health aides, and demand is skyrocketing; one study estimated that 70 percent of adults over 65 are expected to need some form of basic assistance. But attracting and retaining home health aides is challenging; it’s exhausting work, with low pay, often no benefits and little respect and is overwhelmingly done by women of color and a dwindling number of immigrants.

President Joe Biden wants to increase the supply through an infusion of $400 billion into home- and community-based care for the elderly and people with disabilities over the next eight years, close to doubling what’s being spent now.

Los Angeles County home care workers march to demand an increase in pay. The median wage for a home health aide is $24,000 a year, or about $500 more than for a fast-food cook. Credit: Luis Sinco/Los Angeles Times via Getty Images

The president’s goal of “creating new and better jobs” will mean overhauling the current system of training, which is disorganized and overpriced and blocks home health aides from advancing to the next level, according to Matt Sigelman, CEO of Emsi Burning Glass, a labor analytics firm. He said training programs are often run by for-profit players that charge far more than is merited by what the jobs pay.

Most of the time, May loved working with her clients. They talked to her about trips abroad and gave her relationship advice. One taught her to sew, another how to make deviled eggs. “They had so much wisdom. They taught me a lot about life,” she said.

But it was hard to make a living. May started at $7 an hour and eventually got up to $12, but with no benefits. She and other home health aides asked that their last names not be used for fear of retaliation at work or in case they applied for new jobs.

When the pandemic hit, she wasn’t offered “hazard pay,” even though she was a designated essential worker. Then schools shut down and she decided to stay home with her children. Now she isn’t sure if she’ll return to her old job because it doesn’t cover her bills. “I can’t live on my salary,” she said.

In a Zoom class at a nonprofit training center for adults, instructor John McIntyre was giving his 17 students a verbal quiz. The class, at the Opportunities Industrialization Center of D.C., or OIC-DC, trains people to be home health aides. It’s 15 weeks long and is held at 6 p.m. because many of the students have jobs or need to look after their children during the day.

“When you’re helping a client who has a stroke, on which side should the home health aide stand ­— the stronger side or the weaker side?” McIntyre asked.

Twenty-four-year-old Dashia raised her hand. “The stronger side?”

“Hmm. Think about it for a minute.” Dashia did, and changed her answer.

“That’s good! That’s good!” said McIntyre. “We always assist on the weaker side.”

McIntyre praises his students often. He knows they have overcome obstacles to be here. The minimum requirement is that they test at the eighth grade reading level and seventh grade math. Some students who apply need extra tutoring before they can enroll.

Related: Biden’s infrastructure plan would create plenty of jobs, but who will do them?

Dashia was laid off from two restaurant jobs during the pandemic. She’s now working as a teacher’s aide while taking classes in the evenings to be a home health aide.

“There is such a shortage,” she said. “So I thought, why not take a course?”

Dashia called all seven District of Columbia-approved home health aide training programs for information. They cost between $1,500 to $2,100, she said. Dashia would also have to pay for transportation, her home health aide certification ($105), first aid and CPR certification ($85) and a background check ($25). “I definitely don’t have that money,” she said.

She ultimately got into the one free program in the district, OIC-DC, which is subsidized by the district government and private funds. Otherwise, she said, she wouldn’t have been able to enroll. “My credit is bad so I can’t get a loan, and my family doesn’t have money, either,” she said. “Everyone is struggling.” 

The cost of training can be prohibitively expensive for students who are among the most vulnerable and poorly paid workers.

“It wouldn’t even be something they consider, because it’s just out of their range.,” said DyAnne Little, director of training at OIC-DC.

Even though her program is free,  Little said, some of the students have to save for months to be able to afford their scrubs, white Crocs and watches with a second hand. Advocates say having these students take out loans or borrow from family members is unjust, unfair and exploitative,  because it’s unlikely they will be able to pay back that money even after they start working.

Home health aide is the fifth lowest-paying among the 25 lowest-paid jobs held disproportionately by people of color, according to a 2020 study of workforce equity in the United States. Other jobs near the bottom include dining room attendant and dishwasher.

The median wage for a home health aide is $24,000 a year, said Sigelman — about $500 more than for a fast-food cook. “So the notion of taking out a loan and going into debt to get into a job that pays you the same as you would make in a fast-food restaurant is pretty hard to swallow.”

Communities across the country are realizing it’s essential to increase the numbers of home health aides. In Washington alone, 16,700 people 65 and over are unable to live independently without support, a study found. Those numbers are expected to rise by at least 10 percent every five years, according to the D.C. Coalition on  Long Term Care, which conducted that study.

“It’s a full-fledged crisis,” said Neil Richardson, who works on aging issues for DC Appleseed Center for Law and Justice, a nonprofit in Washington.

A home health aide does her patient’s laundry. President Joe Biden has proposed spending $400 billion over eight years on long-term care, but demand for home health aides far exceeds supply. Credit: Michael M. Santiago/Getty Images

This shortage of direct care workers mirrors the national demand, said Johan Uvin, who was acting assistant secretary for the Office of Career, Technical and Adult Education under President Barack Obama. That demand has increased “exponentially” because of Covid, he said. “It’s exacerbated the shortage that already existed.”

And the need is expected to grow, up by 34 percent between 2019 and 2029, according to the U.S. Bureau of Labor Statistics, far outpacing the less than 4 percent projected growth, on average, for other jobs.

For years the U.S. relied on immigrants to fill the roles of long-term care workers, said Gail Kohn, coordinator of Age-Friendly DC, a government program. But “what we’re seeing recently, at least in the last four years, is the reduction in the number of people who immigrate to this country, which has made it almost impossible to get people into the field.”

Almost 40 percent of home health aides are immigrants, according to the Migration Policy Institute, many of them from the Dominican Republic, Mexico and Jamaica.

Related: How a decline in community college students is a big problem for the economy

Being a home health aide can be physically exhausting. Some clients need to be turned every two hours to prevent bedsores; others have to be lifted out of their beds to be bathed. Not all private homes are equipped with devices such as lifts and slings that can help with these tasks.

Thalia, who worked for five years as a home health aide before she stopped because of Covid, said she hurt her foot lifting a client but didn’t have health insurance to pay for physical therapy. She had to stop working for months. “You don’t work, you don’t get paid,” she said.

But Thalia considers herself lucky because, with rest, her foot healed. Her neighbor, also a home health aide, injured her back on the job and had to stop working because her agency refused to pay for treatment and she had no insurance.

“The notion of taking out a loan and going into debt to get into a job that pays you the same as you would make in a fast-food restaurant is pretty hard to swallow.”

Matt Sigelman, CEO, Emsi Burning Glass

Aides also have to deal with the irascible nature of some elderly clients. Many have dementia or are frustrated that they need assistance. Others, as May put it, “for whatever reason, just don’t like you. They cuss at you and call you names.” One home health aide said a client accused her of stealing her glasses and didn’t apologize when she later found them on a bedside table. Another, an immigrant from Nigeria, said clients would complain her “food smelled” when she was eating lunch. Yet another said a client mocked her accent. Then there is the emotional impact on aides who become close to clients who eventually have to be taken away and institutionalized or die.

Home health aides also feel disrespected by other medical workers. Some say they are routinely ignored by nurses when they give updates on their clients’ health and aren’t seen as part of the health care team. In general, these positions are “poorly trained, poorly compensated, disrespected and restricted in their duties,” MIT’s Osterman said.

Osterman argues for expanding the duties of home health aides. In many states they cannot give a client medication or change a bandage.  Expanding the scope of their jobs would help clients with chronic illnesses stay healthier and stay out of hospitals. “That would also save money, by taking over some of the work from much higher-paid nurses.” Osterman said those savings could go toward better salaries.

Aides are also at the mercy of their staffing agencies for assignments. Thalia said she has seen family members of clients doing drugs and has felt unsafe in some houses, but has never reported anything because she needed the work hours. Working conditions can be harsh, she said.

“Sometimes,” Thalia said of one client’s home, “the kitchen would be a disaster, and in order for me to get her meals prepared, I would have to clean up the mess that was left by family members.” Clients’ families have also asked her to do their laundry and clean their rooms. Thalia said she did whatever she was told, for fear the families would ask her agency to send someone else.

Related: ‘Millions upon millions’ in employer-funded education benefits go unused

The disrespect affected May’s decision to quit. “No one believes this is a real job,” May said. She’d like the title “home health aide” to be “changed to something with ‘medical’ in it,” in the hope of getting more respect. “We do a lot of work, and we’re not recognized for it.”

When she graduates from her home health aide class, Dashia said, she wants to continue studying and move up in the health care field. She hopes she can one day earn a degree. “I want to do something that’s not just for the moment,” she said.

Experts say showing students such as Dashia a clear career path is one way to increase the supply of home health aides and make the profession more desirable. But that doesn’t happen often.

One study Emsi Burning Glass conducted with the nonprofit JFF looked at health care jobs that didn’t require a college degree and put them in three buckets. Two allowed people to move up the career ladder. The third, Sigelman said, were usually “dead-end jobs.“ Home health aides, he said, fall “squarely in that category.”

Sigelman said home health aides are just a few training courses away from gaining additional skills to move up and into jobs that pay a living wage with benefits, such as certified nursing assistant ($31,000), medical assistant ($36,000), health information technician ($44,000) or licensed practical nurse ($49,000). None of these professions requires a college degree. But he said upward mobility doesn’t happen by accident. “It requires that we help people make that jump. And unfortunately, that doesn’t happen too often.”

Johan Uvin said if there isn’t this “supported progression” for home health aides, they may move out of health care altogether and look for different occupations. In some cities, “you can get a job cleaning rooms at a hotel for $22 an hour.”

Uvin said there are encouraging signs of innovation. Some training institutions offer clear pathways from, say, home health aide to certified nursing assistant to licensed practical nurse to registered nurse. “It’s a very worker-centered way of thinking about it,” he said.

Uvin said this moment presents an opportunity to change things not just at the grass roots, but also at the policy level.

For example, students could be given access to federal financial aid such as Pell grants for short-term career training programs. Other inducements for training programs could create more comprehensive pathways for their home health aide students. “There’s a lot we can do with incentives through policy,” Uvin said.

He said the current system, requiring home health aides to go through a training program and get certified in order to get a job that doesn’t even pay “survival” wages, will just “magnify the inequities that already exist.”

“And that’s just unjust.” 

This story about home health aides was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for our higher education newsletter.

This story was supported by the Higher Education Media Fellowship at the Institute for Citizens & Scholars. The Fellowship supports new reporting into issues related to postsecondary career and technical education.

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Kavitha Cardoza is an award-winning journalist covering education, children and poverty. Her stories have appeared on NPR, PBS NewsHour, WAMU Public Radio, Atlantic.com and The Washington Post among others....

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