Kim Thomas is tired.
Of course she's tired. You would be, too, had you awakened before sunrise and spent the next 12 hours driving all over the Triangle—Raleigh to Durham to Wake Forest to Youngsville and back to Raleigh, the same trip she makes every day, some 600 miles a week—to care for people who, because of age or infirmity, need help caring for themselves.
You would also be worn out if you did this six days a week, 13-, 14-, 15-, 16-hour days, no vacation, no sick leave, no benefits, if you had to use FaceTime and Skype to connect with your two children and one grandchild, if your significant other had split because you worked too much.
This is Kim Thomas' life. And for all of that—even after seven years as a personal care aide and having been certified as a nursing assistant and later becoming a licensed practical nurse (LPN)—she makes between $10 and $11 an hour, cobbling together a living through part-time work for three different agencies, upward of 15 clients a day.
"The work is very intense," Thomas says, her voice weary but cheerful. "It's very laborious and very intense. It's not for the weak."
She's sitting on a stiff metal chair outside of a Cold Stone Creamery in Northeast Raleigh, not far from her townhome, at the end of yet another very long day. She arrived for a meeting 20 minutes late—an Alzheimer's patient was having difficulty remembering where she was, she explains. She looks exhausted, yes, but there's still a glint in her eyes, a sense of joy or at least pride in talking about what she does.
What she does are the unpleasant but necessary things, the things most of us either can't or won't do, even for those we love: cleaning trach tubes, lifting people out of bed to take them to the toilet or shower, feeding the bed-bound, reminding clients to take their meds, assisting with light exercise and physical therapy.
So why not get a job somewhere else? The average LPN earns nearly $18 an hour, according to payscale.com. Surely she could do better in a hospital.
She doesn't like hospital politics, Thomas responds. And she's always liked caring for people; as a child she wanted to be a nurse, before life got in the way. She circled back to the profession after helping care for her dying mother.
Besides, says Thomas—now an activist with Raise Up for $15, a progressive coalition seeking better wages for fast-food, child care and home care workers—"I really enjoy working with the people that are in their homes. And why shouldn't I stay in this business? Why not allow them to age in place? I'm not really an arrogant-type person, but I'm good at what I do. Very good at what I do."
North Carolina will need more very good home care workers in the coming years—a lot more. The state's elderly population is booming; by 2050, the number of residents over 65 will more than double to 2.8 million, according to a report released last month from the left-leaning N.C. Justice Center. And here, as throughout the country, more and more people are opting to age in their homes rather than a nursing facility; indeed, full-time home care is roughly half the cost of living in a nursing home.
That's one reason personal care aides are among the fastest-growing professions in the country, with a projected 49 percent increase between 2012 and 2022, according to the Bureau of Labor Statistics (BLS).
Despite the glaring and growing need, however, pay is anemic: Personal care aides average just $9.57 an hour nationwide, according to the BLS. In North Carolina, median wages for personal care aides are just $9.18 an hour, less than $2 over the minimum wage of $7.25; for home health aides, average pay is even worse, $9.03 an hour. That's about $19,000 a year, poverty-level wages—unless, of course, you work 70 or 80 or 90 hours a week, as many caregivers do if they can.
But even that isn't always an option. Work is notoriously unsteady. As a result, almost half of home care workers live in households that receive public assistance. More than half live in households that receive food stamps.
To make matters worse, almost 70 percent lack any paid sick leave, even though injury rates are much higher than most other occupations, according to the N.C. Justice report. In North Carolina, almost half don't have health insurance. (Thomas buys insurance on the federal exchange.) Nineteen percent are covered by Medicaid, a mostly federally funded but state-run health care program for the poor and disabled.
Given all that, it's understandable that turnover is high and morale is low, a reality that can trickle down into the quality of care the state's elderly receive. As Thomas points out, if you're worried about your power being turned off, you're probably not paying full attention to your client.
These conditions aren't just a matter of the free market in action. Rather, much of the reason home care wages throughout the state are so low, experts say, is because the state's Medicaid reimbursements for these services fall well below national norms, and Medicaid comprises over half of the state's home care business.
"The wages for home care workers are largely a representation of the Medicaid reimbursement rate," says Matt Wolfe, who lobbies for the Association for Home & Hospice Care of NC. "Most home care agencies rely on Medicaid for most or all of their reimbursements."
Right now, North Carolina's Medicaid reimburses home care services at $13.88 per hour. Since these payments are funneled through third-party agencies, which have their own overhead costs, a rate that low makes it virtually impossible for workers to be paid anything approaching a living wage.
North Carolina's rate is about 25 percent below the national average of $18.20 an hour, and even further below states like Washington, California, New York and Oregon, which pay around $20 an hour or more, according to the N.C. Justice report.
The state's Medicaid program didn't always pay so little. In 2013, even after the budget hemorrhaging that accompanied the Great Recession, the reimbursement rate was still $15.52 an hour. Ever since then, however, the Legislature has been mandating cuts, says Christal Kelly of the N.C. Department of Health and Human Services.
Since the recession, adds Allan Freyer, director of the Workers' Rights Project at N.C. Justice, the Legislature has eyed Medicaid as a place where it could save money.
In fact, the state's rate has gotten so low that several agencies have either gotten out of the business or reduced their presence in North Carolina, says Tracy C. Colvard, vice president of governmental relations and public policy for the Association for Home & Hospice Care.
"Our best providers are dropping this service line," Colvard says. "The cream of the crop are gone now."
One of them is Bayada Home Health Care, which was founded in Pennsylvania four decades ago. North Carolina was the second state Bayada entered.
"We are not getting out of the business," says Dave Totaro, Bayada's chief marketing and governmental affairs officer. "We are taking clients much more selectively."
While it once had a major presence in home care in North Carolina, that service line now constitutes less than 3 percent of Bayada's business in the state, Totaro says.
The reason is simple: If Medicaid only pays Bayada $13.88 an hour, Bayada can only afford to pay its aides $8 or $9 an hour. At that level, Totaro says, "It becomes more difficult to find and hire quality aides."
This is an issue even with home care companies that mostly take private-pay clients. Ari Medoff, president of the Durham-based Nurse Care of NC, can bill his clients and their long-term health insurers at market rate, some 50 percent more than what Medicaid pays. But even then, his average certified nursing assistant (CNA) only receives about $10 or $10.25 an hour. That's not good enough, he says. "Our opportunity and challenge is to introduce a new business model," he says, "which will help us recruit and retain better talent."
The new model he envisions involves moving away from billing by hour and toward package rates. If he can convince clients and insurers to embrace that idea, he says, he'll be able to pay his workers a living wage and provide them with more consistency. Because of that, he says, he'll get better, happier and more reliable employees.
"Could Medicaid do the same?" asks Medoff, a graduate of Duke and Harvard Business School. "Absolutely. They do that in some states. It takes a sophisticated system. ... The status quo is not sustainable."
- Photo by Alex Boerner
- Thomas pours Dorothy Katz a glass of water.
The Legislature could, if it wanted to, hike the state's minimum wage or force employers to offer paid sick leave. Neither of those things is likely to happen in the current environment. If the General Assembly did raise the minimum wage, the most likely scenario is that some private-pay home care agencies would fold, while others would pass the additional costs along to their clients. If the Legislature raised the minimum wage without addressing Medicaid reimbursement, it's difficult to see how any company could afford to care for the state's needy.
While the Legislature is currently considering a sweeping Medicaid-reform bill—the legislation would place Medicaid services under the auspices of for-profit companies, rather than nonprofit providers, as a cost-saving measure—there's no indication that reimbursement rates are going up any time soon.
"We're focused on trying to maintain the program," Colvard says. "Keeping the rate flat is a victory."
Bayada's Totaro is more sanguine. "We do see some optimism going forward," he says. Republican state Sen. Ralph Hise, whose district sprawls from Tennessee to South Carolina, "has indicated it's time for us to take another look at this program," Totaro says. (Hise did not respond to the INDY's requests for comment by press time.)
For home care workers like Niki Cannady, that second look can't come soon enough.
Until she landed a full-time job in hospice care a few weeks ago—$13 an hour plus benefits and paid time off, which she says feels too good to be true—she spent two decades toiling for less than $10 an hour caring for Medicaid patients. Like Thomas, Cannady tried to compile part-time work from several agencies into something resembling a full-time living, even if doing so required upward of 90 hours a week. But even then, she struggled.
"I'm telling you right now," says Cannady, also a Raise Up activist, "it's sad to say in home health, but if it wasn't for my family and my boyfriend, I wouldn't have had a stable place to stay."
"When you pay people more," says Wolfe, the lobbyist, "that provides more stability. ... If you increase the reimbursement rate, you're going to increase the quality of care. In North Carolina, as the rate goes down, companies drop off. People that need these services are kept waiting."
This article appeared in print with the headline "Hard for the money"