What will older Americans do if their paid caregivers lack health insurance?
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Among America’s working poor are a vast workforce of paid caregivers—nearly 5 million nursing assistants, home health aides, and personal care aides who provide daily supports to older Americans and people living with disabilities. These workers assist with bathing, dressing, mobility, and meal preparation, among other important activities. The work, which is mostly done by women and people of color, is physically and emotionally demanding, yet not highly valued in our economy. Many of these workers live on the edge of poverty, with annual earnings averaging $16,500. For many of these low-wage workers, access to health care coverage was an ongoing struggle—until the Affordable Care Act (ACA).

A new analysis of health coverage data from PHI shows that between 2010 and 2014, half a million additional direct care workers accessed health coverage, leading to a 26 percent drop in the uninsured rate. These gains were the result of expanded employer-based coverage, as well as new options made possible by health insurance marketplaces and the expansion of Medicaid. It has been the latter, however, that has made the greatest impact.

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Overall, between 2010 and 2014, Medicaid coverage for direct care workers increased from 17 percent of the workforce to 22 percent—a 30 percent rise in coverage. In the 31 states that expanded coverage in that time frame, Medicaid coverage rose 40 percent. What impact did these increases have on overall health coverage? Medicaid expansion states saw a 33 percent decrease in the rate of uninsured direct care workers, while states that did not expand coverage saw a 21 percent decrease in the uninsured rate. While direct care workers still face barriers to accessing coverage, the uninsured rate nevertheless decreased from one in four workers prior to the ACA to one in five workers by 2014.

The debate in Congress over the Affordable Care Act, and particularly the restructuring of Medicaid financing, makes it clear that many in Congress view Medicaid as a government “hand out” to “people who should instead be working to earn a living.” There is little understanding that America’s working poor, including direct care workers, do not earn incomes sufficient to afford health coverage. Among home care workers, for example, 37 percent live below 138 percent of the federal poverty level, the Medicaid income-eligibility threshold in states that expanded coverage. One in every two home care workers lives in a household that relies on public benefits.

Direct care workers are providing critical life-sustaining services to individuals and families. Many love their work, and provide a lifeline to people who would otherwise be forced into institutional care. Yet with low wages, affordable healthcare is crucial to direct care workers, many of whom struggle with chronic conditions common among impoverished Americans. Preventive screenings and timely medical visits are vital to their well-being and that of their clients. After all, if the caregiver gets sick and does not have access to a physician, who will be help people shower and dress, have a healthy meal, or remember to take their medications?

America faces a growing caregiver shortage, with providers unable to retain sufficient staff and families struggling to find paid caregivers. Attracting workers to these physically and emotionally challenging jobs is difficult, but without affordable coverage it will become impossible. Moreover, when direct care workers don’t access health care, chronic conditions and on-the-job injuries go untreated, forcing workers to miss work or leave the workforce altogether. As a nation, we simply can’t afford to lose these dedicated professional caregivers – family caregivers badly need their support to sustain their own careers and family incomes.

We are asking the administration and Congress to think about this critical workforce as they debate the future of the Affordable Care Act and Medicaid. In a worst-case scenario, direct care workers could be left without access to the health care they need, leaving older Americans and people with disabilities without the daily support they need.

Daniel R. Wilson is the Director of Federal Affairs for PHI, the nation’s leading authority on the direct care workforce.


The views expressed by this author are their own and are not the views of The Hill.