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In the face of an eldercare crisis

The number of people needing care is far outpacing the number of available care workers.

A home health aide accompanies her client to a vaccine appointment in Queens, N.Y., in March.
A home health aide accompanies her client to a vaccine appointment in Queens, N.Y., in March.JAMES ESTRIN/NYT
Globe Staff/Adobe

Care for the elderly in Massachusetts is in crisis. Recent research by The Care Institute — a national nonprofit focused on improving the nation’s care infrastructure — reinforced what we already knew: Increasing longevity, a fragmented approach to the way eldercare is provided across the nation, and a complex and confusing payment system are accelerating the care gap. Addressing these complex issues is key to rebuilding the economy after the coronavirus pandemic.

By 2050, 26 million people — 1 in 12 Americans — will need paid elderly care, according to the Family Caregiver Alliance. The pandemic has acted as an accelerant, driving a spike in unmet needs. As demand for home and community-based services increases, the supply of care is inadequate. Many care workers have left their jobs due to home demands, safety concerns, health issues, increased unemployment benefits, and alternative employment. In a May 2021 survey of their member organizations, Mass Home Care found that 3,600 people were waiting to be matched with a home care worker.

All states face workforce challenges providing direct eldercare, but Massachusetts’ high cost of living makes its need pronounced. Its median direct care worker annual earnings of $21,550 are just $1,350 above the national average. This leaves 54 percent of caregivers reliant on public assistance —12 percent higher than nationally. Despite the focus on diversity, the care workforce remains 84 percent female (86 percent nationally) and 57 percent people of color (59 percent nationwide).


Structural issues cloud the picture. Medicaid’s focus on those living in poverty has produced adverse implications for the wider population’s access to long-term services. People living longer while managing chronic health conditions and limited resources puts increasing strain on the system, while the wider long-term care support system is overcomplicated and inadequate. Multiple programs within Medicaid vary in system design and eligibility, and the Department of Veterans Affairs, Older Americans Act, non-Medicaid state programs, and the Medicare Advantage Plan form a complex matrix. Traditional Medicaid doesn’t cover long-term care, while a lack of alignment has led to a complex network of payment, eligibility, supply, and demand.


Challenges remain in scaling elderly home care as a full-time profession. While care may be available in two-hour increments three times a week, it’s virtually impossible for an aide to craft a 40-hour week. The work is hugely fragmented in different locations; travel expenses are usually not reimbursed; and making a career across the various systems is challenging. While an estimated 4.6 million people nationally provide services through government-funded programs, another 800,000 serve the private care market, which has little regulation and few certification requirements or integrity-of-service provision measures.

Addressing this crisis is imperative. Massachusetts is investing in innovative ways to create advancement opportunities, address critical needs, and improve the viability and image of elderly care occupations. It has pioneered free online training for entry-level occupations under its Personal and Home Care Aide State Training program and offers enhanced training for home care aides working with Alzheimer’s patients or those patients with mental health or social isolation issues. However, several crucial gaps need to be addressed.

Standards-setting and alignment

At present, a certified home health aide with years of experience is unable to provide that same level of care in a nursing home without completing nurse aide certification. Revising this system could provide tremendous benefits to workers, employers, and patients, at significant cost savings.


National certification

The concept of a “universal aide,” or standardized American eldercare worker, has gained limited traction due to the siloed nature of America’s long-term care system, but it could be a start to professionalizing the occupation and providing better workforce opportunities. While Massachusetts stakeholders have expressed interest in developing a certification, few are getting into the details of making it happen.

Pipeline development strategy

Too few people see direct care as a viable employment option. In Wisconsin, the WisCaregiver Careers initiative is mounting a multimedia campaign aimed at recruiting and training 3,000 new workers. Massachusetts should do the same.

Support from business and citizens

Paid family leave, flexible work accommodations, and affordable and reliable child care and eldercare services require a professionalized sector with family-sustaining wages, training, and support; advancement opportunities; and health care benefits. Businesses and citizens can play a key role in getting the state and federal government to overhaul the system.

One innovation could be a Care Worker Bill of Rights, similar to the one that Senator Elizabeth Warren proposed for essential workers during the pandemic. Adapted for the care workforce, it could include health and safety precautions, collective bargaining, financial protections against food and housing insecurity, and job security reclassification.

Massachusetts and America need a professionalized care sector. These challenging times offer a perfect opportunity to provide one.

Sheila Lirio Marcelo is founder of Care.com and founder and chair of The Care Institute, where Wayne Ysaguirre is the executive director.