A new study in HealthAffairs Scholar hones in on homecare workforce challenges in the southern United States of America. By calculating a ratio of available full-time equivalent (FTE) caregivers compared to potential clients who have functional limitations, the researchers examined workforce shortages and potential gaps in care.

Overall, the research concluded that, in general, “the ratio of home care workers to likely consumers was significantly lower in the Southern United States compared with other regions in the country combined.”

The researchers found the workforce problems are likely to persist for at least another decade and southern states have the largest gaps between care at home workers and the demand for HCBS. By 2035 states in the American south will need more than 500,000 direct care workers to meet the future demand for care at home.

“Low wages, physical and emotional burnout, limited benefits, and minimal career advancement opportunities impede workforce recruitment and retention efforts,” wrote the researchers. “Across all industries, workers in the South are paid less and provided fewer benefits compared with their equivalents in the Northeast, West and Midwest. The resultant workforce deficit exacerbates consumer burdens, such as limited respite for unpaid family caregivers and increased reliance on costly institutional care.”

Researchers found that many states used funds allotted by the American Rescue Plan Act (ARPA) to temporarily increase wages for direct care workers during the COVID-19 pandemic. Texas and Louisiana increased HCBS rates and ordered a wage pass-through of 90 percent and 70 percent respectively. Some other states, such as Arkansas, Florida, and South Carolina, used ARPA funds to offer HCBS workers a hiring or longevity bonus, but the payment occurred only one time. While effective in the short term, these temporary or one-time moves did not produce any long-term improvements in attracting and retaining direct care workers, according to the report.

“While ARPA provided some relief, there is concern about the sustainability of those investments,” the report states. “To build a stable and equitable workforce, Southern states may consider adopting a combination of permanent strategies, such as enacting wage floors and establishing pass-through requirements.”

Permanent initiatives to bolster the size of the direct care workforce include wage floors and wage parity laws, would make direct care work more attractive compared to other entry-level employment and standardize pay across the industry, according to the researchers.

The National Alliance for Care at Home appreciates the focus on identifying gaps in access for those who need home care services as well as potential solutions to the challenges. We note that many of the states covered in this analysis have Medicaid reimbursement rates significantly lower than the national averages, which we stress are contributing factors to the challenges in workforce capacity. Though the authors highlight potential wage-related solutions to the gap in caregiver availability, we stress that such solutions without permanent increases from Medicaid funding will lead to Agency closures and will therefore increase capacity challenges.

The Alliance strongly supports reasonable, achievable, efforts to increase workforce compensation that address the root causes of low wages and benefits – namely, poor government reimbursement. We believe that these solutions should be developed and enacted holistically in collaboration with state Medicaid programs, provider Agencies, and direct care workers.