Home Health Aides: Unsung Health Care Heroes

Loneliness and the loss of control over the basics of life are dreaded consequences of serious illness and aging. Needing help with toileting, bathing, walking, and managing ones household is sometimes feared more than death. Many older Americans struggle in these "shadows of life," and the aging of the baby boomer generation will lead to more people in such circumstances. One ray of light in these difficult moments is the help of home health aides.

Home health aides, an often overlooked part of the health system, can make the difference between comfort and dignity vs. suffering and neglect. Aides are lifelines for elders in need and family caregivers who often have extensive caregiving duties on top of their work and other responsibilities. At challenging moments in life, aides' contributions to human health can be greater than that of doctors, nurses, and medications.

Home health aides can create great financial value by helping at risk individuals remain in their homes. This lowers the costs of unnecessary hospitalization and nursing facility use for families and the taxpayer supported Medicare and Medicaid programs.

Aides are mostly women, and are among the lowest paid categories of workers. This is a role that requires substantial skill and special personality traits. They do difficult and intimate work tending to our parents and grandparents, our veterans and retired community leaders--the people who made our country great. Home health aides are typically working for people with complex medical conditions like Alzheimer's disease and dementia, heart disease, stroke, and cancer. This isn't easy work and it's really important that this is an attractive job for caring and talented people.

Much of the funding for aides comes through state Medicaid programs (and insurance companies that subcontract with some state governments), these funds are generally restricted to disabled elders who have spent down or outlived their monies and are now living in poverty. For people not meeting poverty criteria, personal out-of-pocket payments are typically required to hire aides. In some cases, Medicare home health and hospice benefits pay for narrowly defined, time-limited aide services. Long term care insurance, the Veteran's Affairs system, and local programs also play a role in funding home health aide services.

Unfortunately, the rates that many state Medicaid programs (and their insurance company subcontractors) pay home health agencies are so low it's difficult for agencies to remain in the black while following all the regulations, paying a "living" wage, offering benefits, providing close supervision, and creating career development opportunities. In private out-of-pocket financed home health care there's widespread "under the table" hiring by cash strapped families; avoiding taxes, immigration laws, employment laws, and home health regulations. These arrangements are potentially risky for disabled elders who are vulnerable to neglect and exploitation, and they also diminish stable job opportunities for aides.

It is time to help more Americans age in place by improving the situation for home health aides and the people who need their help. Here are a few ideas to do just that:

Create more opportunities for home health aides to learn and grow
• Develop educational grants and loan forgiveness targeted toward aides seeking new skills.
• Expand the role of aides in the Medicare home health program to include broader and more flexible duties related to chronic illness management when performed under nurse supervision.
• Provide grants for experimentation to promote innovation in the home health aide role in working with new technologies such as robotics, videoconferencing, mobile applications, and remote monitoring.

Create stable private care jobs for home health aides by shrinking the black market
• Eliminate all taxes and penalties on 401k, IRA and other tax-deferred retirement account withdrawals that are used for privately hiring home health aides in legitimate arrangements.
• Develop savings plans, similar to 529 plans for college education, to use for privately hiring aides.

Make home health care desirable work for healthy older people

• Eliminate payroll taxes for Americans over age 65 that work as aides; because of demographics we need healthy older Americans to work in the care of the sick and disabled.
• Develop grants for special training initiatives that target older people for 'twilight' careers as home health aides.

Pay for these initiatives by broadening the tax base by reducing "under the table" arrangements, and through expanding innovations in Medicare and Medicaid that increase the proportion of beneficiaries that stay healthy at home rather than in more costly facilities. We must reward the essential contributions of home health aides and make this an attractive job. By lifting up the aides we can elevate independence, keep families intact, support women, improve Medicare and Medicaid, and make a big difference in the lives of millions of older Americans.