Insuring America’s Long-Term Care Workforce

By Joseph Benitez, PHD, MPH
November 22, 2022

This week’s contributor, Joe Benitez, is an assistant professor of health management and policy at the University of Kentucky College of Public Health. His research interests include the impacts of public policy changes on the medically underserved, Medicaid policy and the role of Medicaid as a safety net program. Joseph is a member of the 2022 Tradeoffs Research Council.

Nursing assistants are the backbone of the care provided in nursing homes across the country. Also known as certified nursing assistants or aides (CNAs), nursing assistants provide most of the direct care that nursing home residents receive every day.

Data show that these workers, who care for some of the most vulnerable Americans, are themselves vulnerable in many ways. Nearly half live in low-income households; and they have poorer mental and physical health than others working in long-term care.

Although many employers have been slow to boost these workers’ very low wages or enhance their limited benefits, one recent policy change – the implementation of the Affordable Care Act (ACA) – did significantly change their benefit options outside of work.

In a recent study published in the Journal of Applied Gerontology, researchers Lili Xu and Hari Sharma looked at data from the American Community Survey (ACS) between 2010 and 2019 to assess the impact of the ACA on insurance coverage for low-income (defined as making less than 138% of the federal poverty level) nursing assistants. They found that:

  • Prior to the implementation of the ACA, less than 70% of these workers had any health insurance (private or public).

  • After ACA implementation, nearly 90% of low-income nursing assistants in states that expanded Medicaid had any health insurance – about half through Medicaid.

  • In these expansion states, about half of the gains in Medicaid enrollment were offset by reductions in private insurance enrollment (via the ACA marketplace or an employer).

  • In states that did not expand Medicaid, overall coverage rates also rose but only to near 80%. 

The authors acknowledge several limitations in their study, including that the ACS dataset may include fewer rural respondents and may not capture all “occupation-specific” information.

As employers and policymakers grapple with high rates of turnover and staffing shortages in long-term care, low wages get much of the attention – and rightfully so. But improving access to health insurance is an additional policy solution to consider.

Policymakers will need to decide how to go about improving that access, whether to subsidize or incentivize public insurance or also private options – and the tradeoffs of those choices. For example, as the study authors note, incentivizing employers to offer better insurance options could address the industry’s retention problem by “locking” workers into jobs with benefits they like, but that also reduces their flexibility to pursue other employment opportunities.

Nationwide, the uninsured rate among nursing assistants still hovers around 10%. If employers and policymakers want a long-term care workforce robust enough to care for this country’s aging population, then they should start by ensuring these workers can meet their own health needs first.

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