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Who Will Care for Us
In a sentence
As America's aging population drives an explosive rise in demand for long-term care, this book argues that transforming the disrespected, low-wage direct care workforce by expanding their roles is both feasible and essential to better care, lower costs, and reduced inequality.
Paul Osterman's Who Will Care for Us? confronts a looming national crisis: the number of elderly and disabled adults needing daily assistance will nearly double in twenty-five years, yet the direct care workers—home care aides and certified nursing assistants—who do the day-to-day caregiving are poorly paid, poorly trained, disrespected, and confined to a narrow scope of practice. Drawing on nationally representative surveys, administrative data, and nearly 120 interviews across the long-term care system, Osterman documents who these workers are, how the fragmented financing and regulatory system constrains them, and why expanding their role would simultaneously improve care quality, attract the workforce we need, and save the health care system money by reducing emergency room visits, hospitalizations, and nursing home stays. Situating direct care within the larger challenge of America's low-wage economy, the book offers an industry-specific model for making good jobs out of bad ones—aligning the interests of consumers, workers, and payers—and lays out the demographic, financial, and political forces that could finally move a stagnant system toward reform.
The four lenses
- Science
- Statistics
- Systems
- Strategy
The model
A causal model in which contextual conditions (financing structure, occupational regulation, cultural attitudes) and design levers (expanded scope of practice, enhanced training, improved compensation, integration into care teams) shape psychological and behavioral states of direct care workers (commitment, motivation) and behavioral patterns (turnover, task performance), which in turn produce outcomes for care quality, system cost, workforce supply, and worker well-being.
Medicaid Financing Structurecontextual condition
The welfare-based, federal-state Medicaid program that is the dominant payer for long-term care, characterized by low reimbursement rates, state budget pressures, cross-state variation, and misaligned incentives between Medicaid and Medicare.
Occupational Scope-of-Practice Regulationcontextual condition
State nurse practice acts and scope-of-practice laws, together with occupational rivalries (notably with nurses), that legally define and restrict the tasks direct care workers may perform, such as administering medication or eyedrops.
Cultural Attitudes and Respect Toward Direct Care Workerscontextual condition
The prevailing disrespect, low expectations, and stereotyping of direct care workers as unskilled babysitters, rooted in racism, sexism, medical elitism, and turf protection, which shapes willingness to invest in and expand their roles.
Expanded Scope of Practicedesign lever
A design lever whereby direct care workers are permitted and enabled to perform a broader range of tasks—health observation, wound care, health coaching, medication assistance, physical therapy support—beyond basic ADL and IADL help.
Enhanced Trainingdesign lever
A design lever providing direct care workers with more hours and higher-quality, adult-centered, experiential training in areas such as chronic conditions, health coaching, dementia care, and observation and communication skills.
Integration into Medical Care Teamsdesign lever
A design lever incorporating direct care workers as recognized members of interdisciplinary health care teams, with regular communication with doctors and nurses and participation in care planning and transitions.
Compensation Leveldesign lever
A design lever concerning the wages, benefits, and hours available to direct care workers, currently at poverty levels and capped by Medicaid reimbursement in the agency sector.
Worker Commitment and Motivationpsychological state
The psychological state of direct care workers' attachment to their occupation, desire to learn and do more, emotional involvement with clients, and job satisfaction, which mediates between job design and behavior.
Worker Turnoverbehavioral pattern
The behavioral pattern of direct care workers leaving employers or the field, distinguishing movement between agencies (high) from movement out of the occupation (lower), driven substantially by low pay and poor conditions.
Task Performance and Care Contributionbehavioral pattern
The behavioral pattern of direct care workers effectively performing expanded tasks—serving as 'eyes and ears,' coaching, managing chronic conditions, and supporting transitions—that contributes to client outcomes.
Care Quality and Client Outcomesoutcome metric
An outcome metric encompassing client health status, chronic condition control, satisfaction, continuity of care, and reduced adverse events resulting from effective direct care work.
Health Care System Costoutcome metric
An outcome metric of total spending on care, reduced when better-trained aides prevent unnecessary emergency room visits, hospitalizations, and nursing home stays, and when tasks shift to lower-paid workers.
Workforce Supply Adequacyoutcome metric
An outcome metric of the availability of paid direct care workers and unpaid family caregivers relative to demand, projected to fall into large shortfalls absent job improvement.
Worker Economic Well-Beingoutcome metric
An outcome metric of direct care workers' economic security, escape from poverty-level earnings, and improved job quality resulting from higher compensation and expanded roles.
Demographic Demand Pressurecontextual condition
A contextual condition of the aging baby boom and growing disabled population that dramatically increases demand for care while the pool of potential caregivers shrinks, generating pressure for reform.
Managed Care Integration of Medicare and Medicaidcontextual condition
A contextual/design condition in which insurance companies receive capitated payments covering both acute and long-term care, creating incentives to keep clients healthy and out of hospitals and nursing homes and thus to value expanded aide roles.
Union and Coalition Advocacycontextual condition
A contextual force of organized labor and consumer-worker coalitions that press for higher wages, expanded scope of practice, and greater Medicaid appropriations for direct care workers.
How they connect
- expanded scope of practice → predicts task performance
- enhanced training → predicts task performance
- enhanced training − influences worker turnover
- compensation level − influences worker turnover
- compensation level → predicts worker wellbeing
- integration into care teams → influences worker commitment
- worker commitment → mediates task performance
- task performance → predicts care quality
- task performance − predicts system cost
- care quality → correlates workforce supply
- worker commitment → influences workforce supply
- medicaid financing structure − moderates compensation level
- occupational scope regulation − moderates expanded scope of practice
- cultural attitudes toward workers − moderates expanded scope of practice
- demographic demand pressure − predicts workforce supply
- managed care integration − moderates system cost
- managed care integration → influences expanded scope of practice
- union advocacy → predicts compensation level
- union advocacy → influences expanded scope of practice
- medicaid financing structure → moderates system cost
A candidate measure
Who Will Care for Us — derived measurement candidates
Medicaid Financing Structure
Medicaid-to-Medicare reimbursement ratio; LTSS expenditures per resident by state; Medicaid share of state own-source revenue; Percentage of LTSS spending from Medicaid
self-report suitability: low
Occupational Scope-of-Practice Regulation
Number of medical tasks permitted by state; Presence/absence of advanced aide titles; Consumer-directed scope exemptions
self-report suitability: low
Cultural Attitudes and Respect Toward Direct Care Workers
Percentage of workers agreeing they are respected; Manager attitude assessments; Frequency of stereotyping in interviews
self-report suitability: medium
Expanded Scope of Practice
Count of authorized tasks; Count of performed medical/coaching tasks; Advanced credential attainment
self-report suitability: medium
Enhanced Training
Training hours; Curriculum content coverage; Pre/post knowledge test scores
self-report suitability: high
Integration into Medical Care Teams
Frequency of team meeting attendance; Collaboration rating scales; Number of clinician communications
self-report suitability: medium
Compensation Level
Median hourly wage; Median annual earnings; Percentage full-time; Benefit provision rate
self-report suitability: high
Worker Commitment and Motivation
Occupational attachment measures; Job satisfaction ratings; Years in field; Voluntary training participation
self-report suitability: high
Worker Turnover
Annual agency turnover rate; Occupational retention rate over time; Transitions between occupations
self-report suitability: medium
Task Performance and Care Contribution
Documented interventions and communications; Clinician ratings of contribution; Observed task execution quality
self-report suitability: medium
Care Quality and Client Outcomes
HgA1c and blood pressure readings; 30-day readmission rates; Satisfaction survey scores; ADL deficiency counts
self-report suitability: medium
Health Care System Cost
ER visit costs; Inpatient days and costs; Nursing home admission rates; Labor cost mix
self-report suitability: none
Workforce Supply Adequacy
Projected supply vs. demand counts; Pull rates by age group; Production-function ratios
self-report suitability: none
Worker Economic Well-Being
Earnings vs. poverty threshold; Number of jobs held; Self-reported financial security
self-report suitability: high
Demographic Demand Pressure
Population projections by age; Disability prevalence rates; Ratio of caregivers to care recipients
self-report suitability: none
Managed Care Integration of Medicare and Medicaid
Number of states with dual managed care; Enrollment counts in integrated programs; Presence of fully capitated models (PACE)
self-report suitability: low
Union and Coalition Advocacy
Union density among home care aides; Negotiated wage rates; Number of scope-of-practice advocacy efforts
self-report suitability: low
The story
The reader A policymaker, advocate, provider, or engaged citizen who wants a humane and effective long-term care system and a way to make good jobs out of bad ones.
External problem
A rapidly aging population will double the demand for long-term care while the workforce that delivers it is poorly paid, poorly trained, disrespected, and shrinking relative to need.
Internal problem
They feel overwhelmed by a bafflingly complex, fragmented system and anxious that no one will be available to care for their loved ones or themselves.
Philosophical problem
It is simply wrong that the people who do the most intimate, essential caregiving are treated as disposable babysitters and consigned to poverty-level jobs.
The plan
- Understand the full long-term care system and the workforce embedded within it.
- Recognize and gather evidence that direct care workers can perform effectively in expanded roles.
- Establish training and scope-of-practice reforms that let workers do more.
- Use financial incentives, managed care integration, and regulatory levers to reward better care delivery.
- Build a political coalition of consumers and organized workers to demand reform.
Success
- Elderly and disabled people receive higher-quality, continuous care that lets them stay in their homes and communities.
- Direct care workers earn decent wages, receive respect, and have career paths within health care.
- The health care system saves money by reducing avoidable emergency room visits, hospitalizations, and nursing home stays.
- A powerful coalition of consumers and workers sustains an aligned, humane long-term care system.
At stake
- Chronic shortages of hundreds of thousands of paid workers and millions of unpaid family caregivers leave the aged and disabled without adequate care.
- Direct care work continues to swell America's low-wage workforce and entrench inequality.
- Families face devastating financial and emotional burdens navigating a fragmented, unaffordable system.
- The nation muddles through, wasting the human potential of caregivers and the opportunity for better, cheaper care.
Questions this book answers
- Who will provide care for America's rapidly growing elderly and disabled populations?
- Can the role of direct care workers be expanded, and would doing so improve care and reduce costs?
- What obstacles—cultural, financial, political, and regulatory—block the improvement of direct care jobs?
- How can the interests of consumers, direct care workers, and payers be aligned to reform long-term care?
- How does improving direct care work serve as a model for upgrading low-wage jobs across the economy?
Glossary
- Medicaid Financing Structure
- The characteristics of the Medicaid program as the dominant welfare-based, federal-state payer for long-term care, including reimbursement levels, eligibility rules, state budget dependence, cross-state variation, and incentive alignment.
- Occupational Scope-of-Practice Regulation
- The legal and professional framework of state nurse practice acts and scope-of-practice laws, shaped by occupational rivalries, that determines which tasks direct care workers are permitted to perform.
- Cultural Attitudes and Respect Toward Direct Care Workers
- The prevailing beliefs, expectations, and degree of respect held by decision-makers, clinicians, payers, and society toward direct care workers, and workers' own perceptions of being respected or disrespected.
- Expanded Scope of Practice
- The extent to which direct care workers are permitted and enabled to perform a broader range of health-related tasks beyond basic assistance with activities of daily living.
- Enhanced Training
- The quantity and quality of instruction provided to direct care workers, including hours, curriculum content, pedagogy, and setting, aimed at building skills for expanded roles.
- Integration into Medical Care Teams
- The degree to which direct care workers are recognized and included as functioning members of interdisciplinary health care teams with communication channels to clinicians.
- Compensation Level
- The wages, benefits, and hours available to direct care workers, reflecting economic reward for their work.
- Worker Commitment and Motivation
- The psychological attachment of direct care workers to their occupation, including job satisfaction, desire to learn and expand their role, and emotional involvement with clients.