Providing the Health Care Everyone Deserves Depends on Workers

Apr 24, 2024

President Biden has repeatedly affirmed that in the United States, health care should be a right, not a privilege.  But guaranteeing everyone access to the health care they need is going to require dramatic action over the coming years, including meaningful interventions to improve the wages and working conditions of the people providing that care.

The COVID pandemic shone a spotlight on the importance of healthcare infrastructure and on the tremendous challenges faced by health care workers, particularly people providing direct care to people with disabilities, seniors, and children. Staffing shortages, already on the rise before COVID, became acute during the pandemic. Today, staffing levels have not yet recovered from the huge strain and short-staffing is at crisis levels even as demand increases for care services.

Whether it’s hospitals, clinics, mental and behavioral health facilities, nursing homes or home based settings–finding qualified and committed health care professionals to provide services to the millions of people who need care is becoming increasingly urgent as the nation faces a mental health crisis, a surge in the senior population and growing number of people with disabilities. But attracting and retaining workers is especially hard in a tight labor market when wages, working conditions and basic respect on the job seem lacking.

Last year saw the biggest strike of healthcare workers in the history of the nation.  Tens of thousands of  Kaiser Permanente employees went on a three day strike over unsafe staffing levels and low wages. But Kaiser is by no means unique. Inadequate staffing and poor pay are a hallmark of direct care work across many healthcare systems and employees as well as in home-based care, where workers in some states make as little as $12 an hour for caring for residents with complex health conditions like dementia and cancer. The vast majority of direct care workers are women, with high numbers of immigrants and people of color making up most of the workforce. While these workers perform jobs that require patience, skill and commitment, many make less than workers in the fast food or hospitality industries.

While many providers downplay the role of low pay and poor working conditions as key factors in short-staffing, the Biden Administration thankfully knows better. President Biden has taken administrative action to start addressing the staffing crisis plaguing our health care system by addressing the root causes of the problem: low pay, unsafe conditions and lack of incentives for workers.

This month, as part of a national commemoration of Care Workers, the Biden Administration has already finalized several new rules designed to ensure more of the federal funding providing for care through Medicaid and Medicare go directly to workers and that long-term care facilities like nursing homes implement increased staffing that reduces workloads and improves safety, which benefits both workers and patients. 

Until now, there’s been little transparency or accountability for nursing home or home based care providers who receive taxpayer money through Medicaid and Medicare to provide services to aging people and people with disabilities. The President’s new regulations establish an important precedent:  federal dollars will no longer be handed over to providers with no strings attached and no questions asked about how those resources are spent, what portion goes to workers providing direct care and what amount actually improves conditions for patients rather than paying for administrative overhead and profit. 

The new “Ensuring Access to Medicaid Services” rule, for instance, creates national standards for how Medicaid funding is to be spent in CHIP and long-term care. Home care providers will be required to direct 80% of Medicaid payments to wages for aides and nurses rather than allowing providers to spend less of their Medicaid funding on staffing. This rule will also require states to be more transparent in how they pay for home- and community-based services and set rates. 

A second new rule, the “Minimum Staffing Standards for Nursing Homes” rule, will for the first time, require a minimum level of staffing for nursing homes that receive federal funding. Currently there is no national minimum number of hours that nursing homes have to provide direct care to residents. The new rule would set a floor at just over 3 hours including a portion of the time provided by a nurse which means that residents would no longer be left 24 hours without any contact with a staff person, help with bathing or toileting, regular meals or interactions. 

Given the staffing crisis in the nation’s long-term care system, these improvements are long overdue in a nation where 11,000 people turn 65 every single day. There’s still a long way to go to implement these rules fully and to build on them so that staffing becomes a top priority in patient care and, as we’re already seeing, there will be intense opposition. Nursing home operators, used to running facilities with little oversight, have trenchantly opposed the new rules which will for the first time require many of them to increase their staffing and spend a bigger portion of their Medicaid funding to do it. 

According to a new KFF analysis, fewer than 1 in 5 (19%) nursing facilities currently meet the minimum staffing standards set out in the new rule. Some facilities will qualify for an exemption and providers will have a timetable to meet the new requirements but not increasing staffing will no longer be an option. And, though providers insist that it’s impossible to find more staff and that some facilities will have to close because of lack of staffing, the new rules will at least require that for the first time a larger share of Medicaid funding be dedicated to wages, which is a key element of attracting and retaining staff. 

The Biden Administration has taken important first steps that rightly recognize that care for patients cannot improve without prioritizing pay and fairness for the workers who are delivering it. Now, advocates, providers, patients, families must double down to implement these rules and build on them if we are to truly make healthcare a right for all.