[Senate Hearing 118-006]
[From the U.S. Government Publishing Office]



 


                                 


                                                        S. Hrg. 118-006
 
                      UPLIFTING FAMILIES, WORKERS,
                      AND OLDER ADULTS: SUPPORTING
                          COMMUNITIES OF CARE

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             MARCH 9, 2023

                               __________

                           Serial No. 118-01

         Printed for the use of the Special Committee on Aging
         
         
     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
     
     
     
     


        Available via the World Wide Web: http://www.govinfo.gov
        
        
                          ______

             U.S. GOVERNMENT PUBLISHING OFFICE 
 51-747          WASHINGTON : 2023
     
        
        
        
        
        
        
        
                       SPECIAL COMMITTEE ON AGING

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      MIKE BRAUN, Indiana
RICHARD BLUMENTHAL, Connecticut      TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      MARCO RUBIO, Florida
MARK KELLY, Arizona                  RICK SCOTT, Florida
RAPHAEL WARNOCK, Georgia             J.D. VANCE, Ohio
JOHN FETTERMAN, Pennsylvania         PETE RICKETTS, Nebraska
                              ----------                              
               Elizabeth Letter, Majority Staff Director
                Matthew Sommer, Minority Staff Director
                
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
Opening Statement of Senator Mike Braun, Ranking Member..........     3

                           PANEL OF WITNESSES

Kezia Scales, Ph.D., Vice President of Research and Evaluation, 
  Paraprofessional Health Institute (PHI), Durham, North Carolina     6
Hannah Maxey, Ph.D., MPH, Associate Professor of Family Medicine 
  and Director of The Bowen Center for Health Workforce Research 
  and Policy, Indiana University School of Medicine, Fishers, 
  Indiana........................................................     8
Pam Lowy, Executive Director, Great Bay Services, Dover, New 
  Hampshire......................................................    10
Jacinta Burgess, Home Caregiver/Direct Care Worker, Harrisburg, 
  Pennsylvania...................................................    12

                                APPENDIX
                      Prepared Witness Statements

Kezia Scales, Ph.D., Vice President of Research and Evaluation, 
  Paraprofessional Health Institute (PHI), Durham, North Carolina    31
Hannah Maxey, Ph.D., MPH, Associate Professor of Family Medicine 
  and Director of The Bowen Center for Health Workforce Research 
  and Policy, Indiana University School of Medicine, Fishers, 
  Indiana........................................................    39
Pam Lowy, Executive Director, Great Bay Services, Dover, New 
  Hampshire......................................................    45
Jacinta Burgess, Home Caregiver/Direct Care Worker, Harrisburg, 
  Pennsylvania...................................................    47

                        Questions for the Record

Hannah Maxey, Ph.D., MPH, Associate Professor of Family Medicine 
  and Director of The Bowen Center for Health Workforce Research 
  and Policy, Indiana University School of Medicine, Fishers, 
  Indiana........................................................    57
Pam Lowy, Executive Director, Great Bay Services, Dover, New 
  Hampshire......................................................    59

                       Statements for the Record

The American Network of Community Options and Resources (ANCOR) 
  Statement......................................................    63
The Volunteers of America' (VOA) Texas Statement.................    66
ADAPT Community Network Statement................................    68
The Alzheimer's Association Statement............................    70
The Phoenix Residence, Inc., Statement...........................    75
The Argentum Statement...........................................    77
The National Partnership for Women and Families Statement........    86
AARP Statement...................................................    92
Suzzanne Ott, Home Care Worker Statement.........................    96
MOSAIC Statement.................................................    99
The Oak Hill and Easterseals of Oak Hill Statement...............   101
Tatia Cooper, Home Care Associates Statement.....................   103
Yvette Beatty, Home Care Associates Statement....................   107


                      UPLIFTING FAMILIES, WORKERS,



                      AND OLDER ADULTS: SUPPORTING



                          COMMUNITIES OF CARE

                              ----------                              


                        Thursday, March 9, 2023

                                        U.S. Senate
                                 Special Committee on Aging
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:33 a.m., Room 
106, Dirksen Senate Office Building, Hon. Robert P. Casey Jr., 
Chairman of the Committee, presiding.
    Present: Senators Casey, Gillibrand, Blumenthal, Kelly, 
Warnock, Braun, Scott of Florida, Vance, and Ricketts.

                 OPENING STATEMENT OF SENATOR 
                 ROBERT P. CASEY, JR., CHAIRMAN

    The Chairman. The hearing will come to order.
    I want to thank everyone for being here for the first Aging 
Committee hearing of this new Congress, and we are grateful 
that we could start in such a big room. We usually don't have 
the big room, so we are grateful for that.
    I do want to welcome everyone today and to thank you for 
being here, those who are in the audience and those who are 
providing testimony. I am delighted that Senator Mike Braun of 
Indiana will serve as the new ranking member of the Committee. 
He has been not only a member of the Committee, but a very 
diligent member. He has been to a lot of hearings, and we are 
grateful for that and grateful for his work as ranking member.
    I wanted to start as well by welcoming new members of the 
Committee, and as many of you know, at these Committee 
hearings, especially on a Thursday, where we often have our 
hearings, people are in and out. Members are going to multiple 
hearings. I was almost much later for this hearing because I 
had to testify briefly at a hearing on the derailment in Ohio 
that affected Pennsylvania as well, so you will see Senators 
that will come in and out, but we have three new members of the 
Committee who are also new members of the Senate--Senator J.D. 
Vance of Ohio, Senator Pete Ricketts of Nebraska, and Senator 
John Fetterman of Pennsylvania, so we are grateful for their 
membership of the Committee and look forward to working with 
them and their contributions over the next two years.
    As many of you know, the Aging Committee has historically 
been a Committee that fosters both bipartisanship and 
collaboration, as we examine difficult issues facing so many 
older Americans, and as I continue as chairman, I hope to 
continue the same spirit of bipartisanship and advance an 
agenda to build both health and economic security for seniors, 
people with disabilities, and their families.
    Today's hearing will discuss the caregiving workforce, both 
paid and unpaid, and those who are providing so-called, as the 
acronym--like everything in Washington has an acronym--HCBS, 
home and community-based services, and so important to focus on 
that.
    The United States is in the midst right now of a caregiving 
crisis. There is no other way to describe it, and home and 
community-based services are not only important, but they are 
not readily available for those who need them, and we have got 
to change that. We have a lot of work to do to accomplish that.
    In a new report just released last week, ANCOR and United 
Cerebral Palsy found that 63 percent of home care providers 
have discontinued services or programs because of staffing 
shortages. Eighty-three percent of service providers reported 
turning away families because they don't have the staff to 
provide the services. The report also found that ninety-two 
percent of service providers are struggling to meet quality 
standards because of lack of staffing. Ninety-two percent of 
service providers having a staffing problem.
    When it comes to the staff who are providing this critical, 
back-breaking work, home care workers often struggle to support 
their own families because they are paid an average of just 
$19,000 per year. This workforce, the majority of whom are 
women of color, are more likely to live in poverty than the 
general public. Many work only for their wages and have few or 
no benefits, including paid leave or even sick leave.
    It is time we make the smart economic choice for the 
country--to help our families, to invest in our families, to 
invest in caregivers--and strengthen this workforce by making a 
generational investment in home care services. That is why in 
January, I reintroduced, with 39 co-sponsors, the Better Care 
Better Jobs Act. It is Senate Bill 100. It should be easy to 
remember that.
    This Bill focuses on home and community-based services, and 
I want to describe what those are. Some people have a general 
sense of it. Here is what we are talking about when we talk 
about so-called HCBS. A variety of medical and human services 
that enable older adults and people with disabilities who need 
assistance to live in their own homes or in a home-like setting 
and remain part of their communities instead of living in an 
institutional setting.
    Now most institutional settings do a really good job, and 
people can get really good care there, but Americans should 
have another option, and most Americans do not, do not have 
that other option.
    Home and community-based services can include the 
following--assistance with the activities of daily living; home 
healthcare, of course; physical and occupational therapy; 
skilled nursing care, like you receive in an institutional 
setting like a nursing home; home meal deliveries can be part 
of this; transportation; and so much more.
    This Bill, the Better Care Better Jobs Bill, is an 
investment in better jobs for home care workers, better care 
for seniors and people with disabilities, and better support 
for family caregivers. More than 50 million Americans provide 
help for their families every day of the week.
    This investment is about services. It is also about turning 
poverty jobs into family supporting jobs. It is about creating 
a workforce that is paid a living wage so that home care 
workers do not need to work 60 hours a week, 70 hours a week, 
80 hours a week just to feed their families. It is about 
creating a workforce that is professionalized and respected so 
that we can recruit and retain the workers to provide more of 
these critical services.
    This investment is how we begin to address the healthcare 
workforce shortages that we have spoken about to support 
American families. It is also about supporting family 
caregivers, as I mentioned before, who are often unrecognized 
and unpaid caregivers, providing support every day to their 
loved ones.
    As we know, the overwhelming majority of people with 
disabilities and older adults want to live and remain in their 
own homes. We need to ensure that families have a real choice 
when it comes to the supports and services that their loved 
ones need, so that is why I will also be introducing today the 
HCBS Access Act, so that everyone eligible for Medicaid long-
term care services and supports will have the ability to choose 
home care and remain in their communities without fear of being 
put on a long waiting list.
    The Better Care Better Jobs Act and the HCBS Access Act are 
complementary. The first one is an investment to create a 
robust HCBS provider infrastructure for the recruitment and the 
retention of workers. The second bill establishes a permanent 
funding stream to keep the infrastructure strong and make sure 
that we are able to continue to pay direct care professionals 
at a rate that ensures qualified, reliable services and a 
qualified, reliable workforce into the future. The HCBS Access 
Act also creates real choice for individuals and families to be 
able to choose between home care supports and institutional 
care.
    Taken together, these bills will revitalize the caregiving 
workforce and create sustained changes for home and community-
based services. We should pass these common sense bills so 
families don't have to face difficult decisions about how to 
care for a loved one. We, as a Nation, must come together to 
address the needs of the workforce that will help us care for 
those who need support.
    I look forward to hearing from our witnesses about the need 
to create and sustain a strong home care workforce, and now I 
turn to Ranking Member Braun for his opening remarks.

        STATEMENT OF SENATOR MIKE BRAUN, RANKING MEMBER

    Senator Braun. Thank you, Chairman Casey.
    He is correct. This is a Committee that in the time I have 
been here, we have covered more terrain--we really can't 
legislate through it, but we can talk about a lot of issues, 
and it is one where I think especially as it relates to all of 
us that will be there some day in that aging category, and so 
many things that we do as a Federal Government--Social 
Security, Medicare, Medicaid--take a much broader discussion 
than what we have here today. It needs to be fixed. It needs to 
be saved.
    I come from the world of where I have run stuff before I 
got to the Senate for 37 years, and no other place quite works 
like this place, and I have never seen so many--a place where 
so many people look to it and depend upon it, so that is always 
a factor as we look at what we are going to do, try to do it 
more efficiently, more cost effectively.
    On the Committee, as a business owner, my priority was to 
have healthy employees. I took on healthcare in general many 
years ago and did some things entrepreneurially, like turning 
my employees into healthcare consumers. Asking them to own 
their own well-being, so when they get in that elderly category 
they can enjoy life and not be riddled with having to fight 
healthcare issues. The old ``ounce of prevention being worth a 
pound of cure'' goes a long way.
    When it comes to like reforming Medicaid to support, 
Senator Casey was talking about it, home-based care, that is 
important. It is probably a way that if you get that right, you 
get the workforce training kind of orienting in that direction, 
you can save money and maybe do it more efficiently.
    Community-based services I think are going to gain stride 
and become more important each year we get down the trail. Not 
only for Hoosiers, but for folks across the country. That 
dynamic I think is going to be in play, and we need to make 
sure we get it right.
    Now, one in five Americans, one in five, is a family 
caregiver. I mean, that is a big number. When you take 20 
percent of 330 million, that is a lot of people that probably 
are not going to be really ready to go when that time comes, 
and we got to get better at it to make that work.
    I got one example, Cornerstone Lutheran Church in Carmel, 
Indiana. Decades ago, members of this church recognized the 
need to support family caregivers, so they established what 
they called a ``Friendship Group.'' Now Friendship Groups have 
grown across the State, helping family caregivers know where to 
turn for support. I think that is important.
    Whenever we can do it from the grassroots up, it is 
probably going to be done a little better, and it is probably 
going to be more cost effective, too.
    Federal policies should support family caregivers. The 
Administration's proposed Independent Contractor Rule will hurt 
caregivers, in my opinion, by restricting the independent work 
and the flexibility it offers. Seventy-four percent of 
independent workers say they prefer the arrangement because it 
gives them flexibility to be one of those one in five of all 
Americans that are going to be caregivers eventually.
    Women, who make up the majority of caregivers, will be 
disproportionately harmed by restricting independent 
contracting. That is a whole other issue we have to deal with 
to make sure that dovetails into what we are trying to 
accomplish here.
    Inflation is still high and widespread. It is not going to 
go away anytime soon. It impacts all of us as we try to recruit 
and retain new employees, including caregiver employers. The 
Better Care Better Jobs Act, which was talked about earlier, I 
think is going to maybe add to inflation, so sometimes we do 
things here, even though well intended, might be 
counterproductive.
    The Federal Government wants to rebalance spending on long-
term services and supports from institutional care to home-
based services. Rebalancing means shifting weight from one side 
to the other. It doesn't mean putting more weight or more 
burden on trying to do it, so we have to be careful there.
    I introduced the bipartisan JOBS Act with Senator Kaine to 
expand Pell Grant eligibility to shorter-term job training 
programs. I think that is going to be a win-win. I hope Senator 
Casey joins us on that, and I think that has got a good chance 
of making it through this Congress.
    I also reintroduced the Prioritizing Evidence for Workforce 
Development Act to fund education and workforce programs with 
proven outcomes. I think that is important. This Bill would 
help scale successful programs like the Goodwill Excel Center, 
which helps adults earn their high-school diplomas and provides 
training so they can enter the high-demand, high-wage fields.
    In our State of Indiana, 135,000 jobs need a better high 
school education. We export four-year degrees in our State. Our 
guidance counselors at many schools do not even tell kids about 
jobs like will be needed for caregiving in the home.
    We also need to make sure that the wages are there, so it 
is attractive for people to get into fields. This needs to all 
be guided. It needs to be promoted, and kids coming out of high 
school, regardless of what your trajectory is--doctor, 
astronaut, plumber, electrician, anything in between--need the 
skills that we seem to not be delivering, and it would really 
come into play when it comes to what we are talking about here 
today, so as long as I am here, I am going to push that from 
this level. Don't dismiss what can be done in your own States, 
a lot of times where the laboratory of finding things that work 
and you can pay for actually occur.
    I yield back.
    The Chairman. Thank you, Senator Braun, for your opening 
remarks and grateful for the work you are doing as Ranking 
Member.
    I want to start with our witnesses. What I will do is 
introduce each of you, and then we will start with testimony, 
but I will introduce each of you first, and I apologize in 
advance for the brevity of our introduction because that 
doesn't, of course, capture all the work that each of you does.
    I want to start with our first witness, Dr. Kezia Scales. 
Dr. Scales is Vice President of Research and Evaluation at the 
Paraprofessional Healthcare Institute, or PHI. For nearly 
fifteen years, Dr. Scales has been studying person-centered, 
high-quality, long-term care with a focus on direct care 
workers.
    Thank you, Dr. Scales.
    I am going to now turn next to Ranking Member Braun to 
introduce our second witness.
    Senator Braun. My pleasure to introduce Dr. Hannah Maxey, 
Associate Professor of Family Medicine and Director of the 
Bowen Center for Health Workforce Research and Policy at 
Indiana University School of Medicine. She is a nationally 
recognized expert in health workforce policy, with a specific 
focus on State solutions for recruitment, retention, and 
regulation.
    Dr. Maxey has been a licensed dental hygienist in Indiana 
for over twenty years. She spent nearly a decade practicing in 
public health clinics operated by the Marion County Public 
Health Department, prior to pursuing both a Master of Public 
Health and a Doctorate of Philosophy in Health Policy and 
Management, both at Indiana University.
    Her experience as a practicing healthcare professional in 
public health clinics provides perspective on the critical role 
of health workforce. She serves as an expert consultant to the 
National Governors Association and has worked on issues ranging 
from family--from health workforce data collection to policy 
design and implementation. Most recently, she has provided 
expertise for Indiana's Direct Service Workforce Plan.
    She is honored here today to be joined by her 15-year-old, 
Sebastian, in the row behind. Welcome to both of you to the 
hearing today.
    The Chairman. Thank you, Senator Braun.
    Our third witness is Pam Lowy. Pam is the Executive 
Director of Great Bay Services. Great Bay Services is an 
organization dedicated to providing support for adults with 
intellectual and developmental disabilities. We thank her for 
her testimony.
    Our fourth and final witness is Jacinta Burgess from 
Harrisburg, Pennsylvania, which is right in the southcentral 
part of our State in Dauphin County. Jacinta is a caregiver for 
her mother and a strong advocate for her mother's needs. She 
will share her experience as a caregiver.
    I want to thank Jacinta for being here today, and I also 
want to thank your mother, Stephanie, whom I met earlier, and 
your brother William, who are in the audience. We are grateful 
for all of you being here today.
    Before I turn to our first witness, I wanted to mention 
that some of our Senators will be here asking questions and 
appearing virtually, not in person, and that is something that 
we provide an opportunity for, and I know that Senator 
Gillibrand is appearing at the hearing today in that fashion.
    We will start with our first witness and then proceed one 
after the other. We will start with Dr. Scales.

        STATEMENT OF KEZIA SCALES, PH.D., VICE PRESIDENT

          OF RESEARCH AND EVALUATION, PARAPROFESSIONAL

         HEALTH INSTITUTE (PHI), DURHAM, NORTH CAROLINA

    Dr. Scales. Good morning. Thank you, Chairman Casey, 
Ranking Member Braun, and members of the Committee, for the 
opportunity to testify on the importance of investing in the 
home care workforce and supporting our communities of care. It 
is an honor and a privilege to be here today.
    As noted, I am Vice President of Research and Evaluation at 
PHI, a national New York-based nonprofit organization that 
works to transform elder care and disability services by 
promoting quality direct care jobs, including home care jobs, 
as the foundation of quality care.
    More than 2.6 million home care workers, primarily women, 
people of color, and immigrants, assist older adults and people 
with disabilities across our country every day, because the 
population is rapidly aging and because most of us wish to age 
in place, nearly a million more new home care workers will be 
required by 2030. That is more new jobs in home care than in 
any other occupation in the United States.
    Yet, as Chairman Casey spoke about, we are facing a 
workforce shortage right now because home care worker wages are 
too low, employment benefits are inadequate, training and 
career development opportunities are limited, and these jobs 
are insufficiently recognized, respected, supported, and 
valued. Existing and potential home care workers are being 
forced to choose more viable employment opportunities in other 
industries, leaving home care providers struggling to maintain 
services, and individuals and families without the support they 
desperately need.
    Investing in home care jobs is a critically needed strategy 
to strengthen and stabilize this workforce to meet ever-growing 
needs, and I use the word ``investing'' because it will pay 
off.
    First of all, raising wages for home care workers will lift 
these essential workers out of poverty and enable their 
economic independence. Currently, 53 percent of home care 
workers rely on public assistance like Medicaid and SNAP just 
to meet their basic needs. If we raise wages, we will 
substantively reduce expenditure through these and other public 
programs, and what is more, these jobs will become more 
attractive and sustainable, thus reducing costs associated with 
recruitment, turnover, and contract staffing.
    Second, by investing in a more stable, sufficient, and 
well-prepared workforce, we can better ensure home care 
continuity and quality, which, in turn, can prevent or delay 
more costly outcomes. In other words, if individuals receive 
the support and services they need when they need them, their 
experiences and outcomes will improve, and the total costs of 
care, particularly to Medicaid and Medicare, will decrease.
    Third, family caregivers will benefit financially. We know 
that family caregivers, the bedrock of our long-term care 
system, experience significant employment challenges, often 
having to reduce their hours, forgo promotions, or leave their 
jobs entirely. With more paid care available, family caregivers 
will continue to support their loved ones, but without having 
to compromise their economic productivity, financial security, 
and overall well-being.
    Finally, investment in the home care workforce--again, one 
of the largest, but lowest-paid occupations in our country--
will stimulate consumer spending and support economic growth 
overall. A living wage will provide millions of workers with 
more income to spend on food, housing, healthcare, 
transportation, and other basic necessities, generating new 
jobs and building wealth in local communities across America.
    The Better Care Better Jobs Act exemplifies the potential 
for Federal leadership on this important issue. Through this 
legislation, States would be eligible for a permanent increase 
in the Federal match for their Medicaid home and community-
based services, or HCBS. This legislation is so important in 
recognizing the indivisibility of job quality, workforce 
stability, and service delivery.
    To receive the funds, States will have to regularly assess 
and update their reimbursement rates to fully cover labor costs 
and ensure that increases actually benefit workers. They will 
need to strengthen training and credentialing opportunities for 
both paid and unpaid family caregivers, and they could receive 
additional funds to build their consumer direction programs and 
related workforce, and they will be expected to evaluate and 
report on their success, thus ensuring accountability and 
helping build the evidence base on high-quality, cost-effective 
home and community-based services.
    The Better Care Better Jobs Act would be transformational, 
and it is not the only solution. We also need to enhance 
equity, as Chairman Casey was speaking about, by putting HCBS 
on equal footing with other long-term care options across 
States, as promoted by the HCBS Access Act.
    We need to test new approaches to workforce recruitment, 
retention, training, and advancement and scale up those that 
achieve the best value. We need to ensure that home care 
workers and family caregivers have access to paid leave so that 
they can afford to take time off without sacrificing their 
employment, and more.
    Now is the time to embrace these solutions for the benefit 
of everyone who has a stake in strong communities of care, 
which is every single one of us.
    Thank you very much. I look forward to questions.
    The Chairman. Dr. Scales, thanks very much.
    Dr. Maxey.

        STATEMENT OF HANNAH MAXEY, PH.D., MPH, ASSOCIATE

          PROFESSOR OF FAMILY MEDICINE AND DIRECTOR OF

         THE BOWEN CENTER FOR HEALTH WORKFORCE RESEARCH

            AND POLICY, INDIANA UNIVERSITY SCHOOL OF

                   MEDICINE, FISHERS, INDIANA

    Dr. Maxey. Thank you.
    Good morning. Thank you for your time, Chairman Casey, 
Senator Braun, distinguished members of the Committee.
    Time waits for no man. The issues of the aging are the 
issues of us all. I applaud the Committee's commitment to 
supporting the communities of care for our honored aging 
citizens.
    As Ranking Member Braun mentioned, my experience as a 
healthcare professional and a workforce researcher are broad 
and have extended more than two decades. I am here today as a 
health workforce policy expert to speak to the solutions that 
States are developing and implementing to build and strengthen 
their home and community-based services workforce, or HCBS 
workforce.
    I am delighted to be joined by my son, Sebastian, who is 
currently working on his Eagle Scout project back in Fishers, 
Indiana, and is deeply interested in American government.
    In the balance of power between the Federal and State 
governments, States oversee policy and programming related to 
workforce development, occupational regulation and public 
protection, and social services. All of these have a direct 
impact on the HCBS workforce. Keeping a finger on the pulse of 
related State efforts is critical to understand the national 
landscape and ensure policy alignment from the halls of 
Congress to our State general assemblies and, ultimately, 
within the homes of our seniors.
    I am delighted to have provided research support to my home 
State on the Indiana Direct Service Workforce Plan. This 
initiative is a foundational part of LTSS reform in Indiana, 
seeking to enhance access to HCBS services. Indiana is one of 
numerous States that have engaged in planning to develop and 
strengthen this workforce. Many of the strategies I will 
discuss today are a part of Indiana's plan.
    Also I would like to note that although these strategies 
may be beneficial for the private sector, my research and 
expertise on these matters is focused on State solutions.
    HCBS quality metrics recently released by CMS are 
appropriately focused on member experience. What is not in 
writing is that achieving many of these metrics hinges upon the 
availability and dependability of a competently trained 
workforce. HCBS workers require certain skills to care for our 
honored aging. Regardless of whether that worker is employed by 
a provider or a self-directed consumer, training standards 
support a minimum level of quality.
    Some States have developed portable credentials for 
individuals that have met training standards. Frequently, these 
are implemented through registries for qualified workers. 
Portable credentials empower workers by demonstrating their 
training achievements and facilitating their pursuit of 
economic opportunity among new employers, in new settings, or 
through additional academic training and stackable credentials. 
Empowered workers power our economy.
    Training registries can also empower employers and self-
directed consumers by enabling them to verify that a worker has 
achieved training standards prior to entering into 
arrangements. When coupled with incident reporting and high-
fidelity investigation processes, State registries can also 
protect the public from bad actors. Self-directed consumers and 
employers alike can query these registries to ensure that a 
worker does not have any substantiated abuse, neglect, or 
exploitation claims against them.
    In addition to consumer protection, registries offer States 
an opportunity to collect supplemental information on their 
workforce. Such information is useful for workforce 
assessments, targeting development initiatives, and evaluating 
the impact of these initiatives. Indiana is a leading State in 
this space, recently having leveraged such information to 
identify and strengthen career pathways for the facility-based 
direct care workforce.
    Wage is commonly cited as the greatest challenge to the 
HCBS workforce recruitment and retention. State Medicaid 
programs are the single largest payer for LTSS services in the 
United States, but the true costs associated with our public 
LTS services are even greater when we account for the many HCBS 
workers who qualify for and receive public assistance, such as 
Medicaid, SNAP, or TANF, based on their income.
    Recognizing Medicaid's influence over HCBS workforce 
markets and wages, many States, including Indiana, have 
developed targeted initiatives to enhance wages and benefits. 
Such strategies include competitive rate setting, wage 
passthroughs, and value-based incentives. A conundrum within 
these discussions is the impact that wage enhancements can have 
on worker benefits.
    As I just mentioned, many HCBS workers receive public 
assistance. Strategies which increase wages to just over public 
assistance qualification can negatively impact overall income. 
This is commonly referred to as the benefits cliff. States are 
exploring where these cliffs exist to ensure their solutions 
are data driven and have a net positive impact.
    I would like to thank you for this opportunity to brief you 
on the great work going on in Indiana and States across our 
Nation to uplift older Americans and the workforce that is 
supporting them.
    Thank you also for your leadership on this topic and your 
commitment to supporting and advancing State solutions.
    The Chairman. Dr. Maxey, thanks for your testimony.
    Ms. Lowy, you may begin.

STATEMENT OF PAM LOWY, EXECUTIVE DIRECTOR, GREAT BAY SERVICES, 
                      DOVER, NEW HAMPSHIRE

    Ms. Lowy. Thank you, Chairman Casey, Ranking Member Braun, 
and members of the Committee, for the opportunity to testify on 
the importance of investing in the home care workforce.
    In particular, I want to recognize my home State Senators, 
Senators Shaheen and Hassan, for their support of Senate Bill 
100, and Senator Hassan for her co-authorship of Senate Bill 
1437, who are watching this remotely.
    My name is Pam Lowy, Executive Director of Great Bay 
Services, a provider of home and community-based services along 
the northern coast of New England. Our organization was founded 
in 1954. We started the first New Hampshire school for children 
with disabilities, opened a training center to provide 
employment for adults with disabilities, and helped close down 
the last New Hampshire institution for disabled citizens.
    We serve adults with intellectual and developmental 
disabilities, such as those with Down syndrome, autism, and 
cerebral palsy. This population is low-income, most with co-
occurring mental health diagnoses--most commonly depression and 
anxiety--and 60 percent of whom live with caregivers over the 
age of 60. My own brother David is a Great Bay Services client 
who lives at home with our 89-year-old father.
    We facilitate the independence and personal fulfillment of 
the people we serve, putting a lot of time, thought, 
conversation, and effort into what each person considers to be 
a meaningful day. For some, this includes working, in which we 
support them. For others, this includes volunteerism.
    My brother David, after volunteering at a soup kitchen, at 
the ASPCA, or greeting returning servicepeople at Pease Air 
Base, always tells me ``I helped today. I am proud of myself.''
    Caregiving is essential work, and that work is only 
accomplished with skilled caregivers. However, we are 
experiencing a significant shortage. One reason is the wages 
for a caregiver. The Massachusetts Institute of Technology 
living wage calculator estimates the living wage for an adult 
with one child in our region is approximately $35 per hour, 
working 40 hours per week. The current wage we are offering 
direct support professionals, or DSPs, is $16 an hour, and the 
majority of the supports we offer are contracted by Medicaid 
for a maximum of 30 hours per week.
    DSPs live paycheck to paycheck. When their vehicle needs 
repairs or they have out-of-pocket medical expenses, they have 
to make some very difficult decisions, because our supports and 
workforce are such an integral part of our clients' daily 
lives, going fully remote, even for a short time at the start 
of the COVID-19 pandemic, significantly affected their well-
being. One program participant's mental health suffered so 
greatly that he was hospitalized. Others needed emergency one-
on-one supports to ensure they wouldn't experience a similar 
breakdown.
    As Executive Director, I have found myself repeatedly in 
situations where I have had to make the ethical choice--raising 
wages and mileage reimbursement despite Medicaid not covering 
the increase, temporarily closing programs after COVID 
exposures--and pray that it wouldn't bankrupt us.
    The average wage for DSPs in our region is $13 to $15 an 
hour. Even with a starting wage of $16, it is not enough at 
Great Bay Services. We continue to lose potential workers to 
other employers, and I am regularly forced to advise 
interviewees who State they cannot afford to accept my job 
offer that they would earn more working elsewhere.
    Staff in our field are financially struggling, barely 
making ends meet, but constantly agonizing over what would 
happen to the people we support if they don't come to work. 
DSPs in general tend to be older workers. Our average staff age 
is 46, with over 10 percent of our staff being 65 or older. Our 
longest-serving staff came to us straight out of college in the 
early 1970's and 1980's. They have decades of experience in the 
field and decades-long relationships with our clients.
    The average wage for DSPs across the U.S. is not a living 
wage. One of our staff members confided in me that they had 
been homeless for their first few years in the field, 
struggling to raise a child on what was then barely above 
minimum wage.
    The ARPA funding Congress provided enabled us to pay 
tenure-based bonuses to our staff who stayed with us through 
COVID. One staff member cried in my office in gratitude that 
they could pay their oil bill as a result of that bonus. We 
were able to offer new hires bonuses, as well as more robust 
trainings to all staff because of that increased funding.
    This has had an important impact on our hiring and 
retention, but it will not be a lasting impact. External 
financial stressors regularly impact the individuals we employ 
and can spill over into their work and their interactions with 
our clients in obvious ways, such as a vehicle breakdown, and 
less obvious ones. A stressed human support worker is less able 
to provide the empathetic, compassionate support our clients 
deserve.
    These DSPs are individuals from whom we expect a similar, 
if not higher, level of skill compared to other positions, 
which, unlike DSPs, have standard occupational classifications, 
such as certified nursing assistants, home health aides, and 
personal care assistants. DSP work is complex and goes well 
beyond caregiving, requiring skills including behavioral 
assessment and prevention, medication administration, and many 
personal and intimate caregiving tasks.
    I ask Congress to provide adequate funding for HCBS to keep 
Great Bay Services and organizations like ours from going 
bankrupt and to keep our staff able to provide the necessary 
daily supports for Americans with disabilities. We make it 
possible to keep older adults and people with disabilities 
safe, stable, and in their homes, workplaces, and out in their 
own communities in which they play a vital role and where they 
prefer to be.
    Thank you for the opportunity to share my story, which is 
similar to that of thousands of providers across the country. I 
look forward to answering your questions.
    The Chairman. Ms. Lowy, thanks very much for your 
testimony.
    We will conclude our testimony with Ms. Burgess.

   STATEMENT OF JACINTA BURGESS, HOME CAREGIVER/DIRECT CARE 
                WORKER, HARRISBURG, PENNSYLVANIA

    Ms. Burgess. Good morning, and thank you, Committee 
Chairman Casey, Ranking Member Braun, and members of the 
Committee, for inviting me to speak today.
    My name is Jacinta Burgess. I am a home care worker from 
Harrisburg, Pennsylvania.
    I have cared for my mother, Stephanie, full time for 
roughly three years. My brother is her part-time caregiver as 
well. I am honored that they are here with me today.
    We believe that the best way for our mother to receive care 
is at home with the people and things she loves. I care for my 
mother because she did her best to raise me. It is my duty to 
do my best to care for her now, but love can't pay the bills.
    My mother suffers from a number of neurological conditions, 
including essential tremors, which cause her body to 
involuntarily and painfully shake, sometimes for hours. Her 
condition also leads her to become confused. One time, she 
accidentally turned the stove's gas on, and it leaked for 
hours, and before she stopped driving, she almost hit a group 
of children crossing the street. These experiences led me to 
start caring for her full time.
    I am my mother's eyes, ears, voice, and hands. As her 
caregiver, I make sure that she is living a happy, comfortable, 
full life, while managing her illnesses and chronic pain. When 
my mom wakes up, I am there to ask her what she needs to start 
her day. She might need help bathing and getting dressed or a 
massage to relieve her pain. I help her with day-to-day duties 
that most healthy people take for granted, including opening 
doors, walking, getting into a car, cooking, or even pouring a 
glass of water.
    I am here to tell you that home care workers like me are 
struggling. The pay is not something you can live on. There are 
no paid days off. There is barely any training, and there are 
no medical benefits.
    When I officially became my mother's caregiver, I was paid 
around $12.39. Over the past three years, my wages have 
increased by just 99 cents.
    In 2023, with the cost of living skyrocketing, $13.38 is 
not enough for me or any working person to pay all their bills 
and live comfortably. My mother has to help me pay the rent and 
utilities out of her monthly Social Security benefits. If we 
didn't have each other, my mother and I would be homeless and 
struggling even more than we are now.
    Everything branches out from me. I am the head of the 
household with my head on a swivel. I am a queer black woman 
living in America, and I also have to worry about caring for a 
parent. Most mornings I don't want to get out of bed. I 
struggle with deep depression and anxiety but can't afford the 
mental healthcare I need to stay strong for myself and my 
mother.
    How is anyone supposed to enjoy their life if all they have 
to look forward to are the struggles they face? It may sound 
silly, but our cats are sometimes our only source of comfort. 
My mom massages my cat Chaka to calm herself frequently. I love 
our cats, but they should not be our support system.
    If I had a livable wage, I could live, not just survive. I 
could afford to buy a car so that we wouldn't be dependent on 
rideshares. I could purchase a home so I can afford the 
standard of living and stability I want for my family. Our 
current apartment has roaches and ventilation issues that make 
it hard for my mother to breathe.
    What keeps you up at night? I toss and turn worrying about 
whether I forgot to pay a bill, an autopayment overdrafting my 
account, and the condition of my apartment. I fight with a 
number of things I want to change so badly but can't because of 
my lack of money and resources.
    There are so many care stories I could tell. Like my cousin 
Venetia, who requires 24-hour care but doesn't have a 
consistent caregiver, and they generally don't last for longer 
than a few weeks. There is a severe shortage of home care 
workers, or my friend and union buddy Genale, who cares for her 
mother and struggles to find time to care for herself, but 
without Genale, there is no guarantee her mother would be safe 
or cared for.
    For decades, home care workers have organized, advocated, 
and rallied for justice. My union, SEIU Healthcare 
Pennsylvania, has made a huge difference in my life. My union 
is a community of support and inspiration.
    I have a vision of America where long-term care is 
accessible, affordable, and consistent for all. We need our 
elected officials to champion efforts to make home care jobs 
full-time, respected union careers and raise standards of care 
for consumers.
    I am important. My mother is important. My cousin Venetia 
is important. Genale is important, and every care worker and 
care consumer is important.
    Thank you.
    The Chairman. Ms. Burgess, thanks very much for bringing 
your personal story to this hearing.
    I will start my questions, my first question directly to 
you. Before I do that, though, I wanted to mention as well. We 
have--as I mentioned earlier, with Senator Gillibrand appearing 
virtually, we also have Senators who appear as part of this 
hearing. Senator Warnock and Senator Scott--Senator Rick Scott 
of Florida, and we will have other, as I also mentioned, other 
Senators coming in to ask questions as we go.
    Ms. Burgess, let me start with you. As you know, in many 
parts of the country, this workforce that we have been talking 
about, the home care workforce that you are part of, is 
characterized by low wages, limited to no benefits, and high 
turnover, and that is just a brief summary.
    The need for more Americans to do this work has never been, 
I think, more apparent. You heard Dr. Scales mention, what is 
it, a million, we will need a million people between now and 
2030, not even a decade away. A million more people to do this 
work.
    Ms. Burgess, you mentioned in your testimony that you make 
$13.38 an hour, and I believe you said that that had only 
increased by, what was it, 90----
    Ms. Burgess. Ninety-nine cents.
    The Chairman [continuing]. Ninety-nine cents since----
    Ms. Burgess. I started in 2021, so it only increased at the 
beginning of last year.
    The Chairman. About a year?
    Ms. Burgess. Yes.
    The Chairman. Going into your third year, I guess. The 
Better Care Better Jobs Act would improve the compensation for 
workers such as you, and I think that is critically important. 
Paying home care workers a living wage is not just the right 
thing to do for that individual, it is the right thing to do 
for all of us because you can't have good care if you have 
consistently low wages over time.
    It is also important for our economy. If we are going to 
call ourselves the greatest country in the world with the 
strongest economy, we got to have the best caregiving in the 
world, and we have work to do to achieve that.
    Ms. Burgess, what would a living wage mean for you? What 
would it mean for your family? What do you believe it would 
mean for other care workers?
    Ms. Burgess. As I previously stated before, a livable wage 
would mean that I could own my own home instead of paying into 
a system that I feel disrespects me and takes advantage of me. 
I could own a car, pay car insurance, save money for a rainy 
day. Take my pets to the vet instead of putting off their care.
    I could also assist my mother in her medical bills, and I 
could also pay my own medical bills and my own debts. It would 
make things so much better for not just my family, but other 
families in the care system.
    Home care workers wouldn't have to struggle so much, and 
they wouldn't have to stretch their money as far and wide as 
possible. They would no longer have to be living paycheck to 
paycheck without this cloud over their head.
    The Chairman. And your work, what comes with your work is a 
lot of stress, I imagine.
    Ms. Burgess. Yes.
    The Chairman. Is that true?
    Ms. Burgess. Yes, a lot.
    The Chairman. I think we have to ask ourselves as 
Americans, would we want the person who is caring for us or 
caring for our mother or our father or loved ones, would we 
want that person to be someone who is paid a very low wage and 
has a lot of stress in their life? Think about that for a 
moment. Is that the kind of healthcare that we want for our 
country? I think most people would say the answer is a 
resounding no to that question.
    Dr. Scales, I want to keep to my time because I will be 
telling my colleagues to stay within their time, so I don't 
want to go over, but, Dr. Scales, the legislation I have 
introduced would make a substantial investment in home and 
community-based services. This investment would directly 
improve the lives of older Americans and people with 
disabilities and help the workforce.
    Can you speak to how these investments would benefit the 
workers, also benefit American families more broadly and our 
economy?
    Dr. Scales. Absolutely. Thank you, Chairman Casey.
    For home care workers, I feel like Ms. Burgess has spoken 
to this truth so compellingly already, but these investments 
would mean the ability to really make a living while supporting 
the lives of others, ideally without having to rely on public 
assistance programs to make ends meet. That means the ability 
for job seekers across the board to be able to choose to do 
this work, for home care workers to be able to continue to do 
it over time, and to be respected and valued for that 
commitment.
    With regards to families, these investments would make a 
meaningful difference in the availability of paid respite care 
and ongoing assistance, and that, in turn, would support family 
members' abilities to manage their caregiving responsibilities 
without undermining their own jobs and careers.
    It is important to say also that more paid support would 
also allow family caregivers to safeguard their own health and 
well-being, which would have positive implications for their 
ability to show up for their family members and in their jobs.
    At the systems level, in terms of our country's economy, I 
will say again that I think that we can achieve net economic 
benefits from investing in HCBS and the workforce, because by 
spending more money upstream on these jobs and these services, 
we will see downstream savings in terms of reduced spending on 
public assistance, reduced spending through Medicare and 
Medicaid on more costly settings of care, and more 
contributions to the economy from these millions of workers 
that we are talking about.
    I think the challenge really is here to just follow the 
money to see, to be able to demonstrate the systems-level 
return on investment and strengthen coordination and 
integration where possible so that we do really realize that 
goal.
    The Chairman. Dr. Scales, thanks very much.
    Before turning to Ranking Member Braun, we are joined by 
Senator Ricketts. I mentioned the new member of the Committee 
and new member of the Senate. Welcome, Senator.
    Senator Braun.
    Senator Braun. Thank you, Chairman Casey.
    Back in Indiana, I know that we have got some institutions 
like Ivy Tech that has got a program to kind of upskill. I am 
interested in getting your comments on that, and it looks like 
in our State we are going to need about 14,000 more caregivers 
over the next 10 years. That is a lot.
    Whenever you can have skills upgraded--and I know career 
and technical education is an important thing. We are the 
biggest manufacturing State per capita, and we have got lots of 
jobs that are begging because we don't have those basic skills 
coming out of high school where you need to kind of upgrade 
them a little bit in some cases, so I have got a bill out 
there, the JOBS Act, with Senator Kaine that would allow Pell 
grants to be used for this type of training and certification.
    I would like you to weigh in on how big a deal that would 
be to get these skills kind of upgraded, and then in our own 
State, we have heard the wage level, which does not seem to be 
a living wage, what is that stratification in Indiana for home 
caregivers? By upgrading your skills, will the market pay a 
better wage if you are doing that?
    Dr. Maxey. Thank you so much for your question, Senator 
Braun.
    With regards to support for training programs, cost can be 
a major barrier to individuals pursuing training and pursuing 
career pathways. As States are considering, including Indiana, 
developing and formalizing training programs, there will likely 
be costs associated with those, so any types of programs that 
can defray or reduce the barrier to cost to training that can 
qualify an individual for jobs I think will hopefully go far to 
advancing and addressing our workforce shortages.
    Regarding wages in Indiana, I would love to get you the 
formal information on where we stand today and kind of where we 
have been, and I would be happy to followup with that. I do 
believe that as we move toward an Indiana--and I know other 
States are doing the same--toward having some type of training 
standards, that those training standards, once an individual 
has them, they will be empowered to negotiate with their 
employers, also to seek out new employment opportunities.
    Ideally, we want people to be retained in their positions 
and roles, but we also want to empower people to find the best 
job situations for themselves, so I do think that we will see 
some advancement of wage through training.
    Senator Braun. How long have we had Ivy Tech devoting 
special training toward caregivers in the home? How long has 
that been in our own State?
    Dr. Maxey. To my understanding, more recent that Ivy Tech 
has been working specifically with the direct support 
professional training program with the State of Indiana, and we 
are really looking forward to see how that might be expanded to 
help support home and community-based workers in other 
settings, including with the aging.
    Senator Braun. Well, not only whatever you need in terms of 
the extra skill enhancement, this is something, too, that I 
believe we need to take all the way back into secondary 
education to where you are trying to do some of these things, 
because when it looks to be so many people working in a given 
arena, why wait until after high school to get with it.
    This is going to become a bigger issue rather than a 
smaller one, so I think it makes a lot of sense that across 
this array of career and technical education that we start 
giving it its due in high school, that we don't guide against 
it, stigmatize some of these pathways because they are needed.
    As Ms. Burgess said, you can't make a living on the wages 
that we are currently devoting to it, so, to me, to solve this 
and really do it, it has got to occur way back in even middle 
school and high school to where you start pointing out where 
the need is, and then if you need extra training after high 
school, fine, but try to get started back there.
    I Yield back.
    The Chairman. Thank you, Senator Braun.
    Now next we will turn to one of our new Senators, and I 
know Senator Ricketts was here just a little bit before Senator 
Vance, but technically, technically, Senator Vance has 
seniority.
    Senator Ricketts. He was here first.
    The Chairman. Senator Vance, you are recognized.
    Senator Vance. Thank you, Mr. Chairman.
    Pete, I guess you should get out of my chair then. I should 
sit a little closer to the member there.
    Well, let me just--let me start here by offering a few 
thoughts. One of the things I worry about, of course, is that 
we have a really weird demographic situation in our country--
and I apologize for coming late. I am sure that we have 
discussed that issue a little bit, and I am sure it is 
something all of you are very aware of.
    We have an aging society. Most American families are having 
fewer children, and if you play that experiment out long 
enough, what you end up with is a lot of people who are a 
little on the older side who need more care and fewer and fewer 
people on the worker side who can provide that care. That is 
true whether you are talking about in-family care. That is true 
whether you are talking about nursing homes and so forth.
    I guess where I would start here is the job of caregiver is 
almost a saintly calling here. If you think about this, it 
includes a number of unglamorous duties. I am sure I am not 
telling you guys anything that you don't know there.
    It is a tough job in a lot of ways, and what my staff has 
found, that some of the initial, entry-level postings for these 
caregiving roles are something like $15 an hour, which is hard 
for a lot of people, even those who want to do healthcare, to 
swallow, so they often don't appeal to Americans in the middle 
of their lives, and I don't doubt that these jobs are richly 
rewarding for devoted caregivers, but caregiver work can, of 
course, include duties such as bathing elderly wards, some of 
whom are suffering from dementia and may not remember who the 
caregiver is by the end of it. In short, this is very hard and 
often thankless work.
    I guess the first question that I would ask, given how 
stressed the industry is, and I sort of direct this to 
everybody, but is how are the caregivers doing psychologically? 
We talk a lot about the economics and the statistics, but do 
you feel like the caregivers you guys are seeing, are they 
doing well? Are they happy? Are they feeling the stress? I 
would love to hear your feedback on that.
    Ms. Burgess. As a home care worker myself and as part of 
SEIU Healthcare Pennsylvania surrounded by home care workers 
all the time, I, myself, am not doing well. I struggle with 
depression and anxiety. My friends often are struggling. My 
friend--actually, Genale, she takes care of her mother. Her 
mother has dementia. She is often, you know, emotional.
    Many people in this field are overwhelmed and often 
overworked because we don't have any other person really to 
rely on besides our family, and sometimes it is hard to get 
other home care workers to come in, depending on what area you 
live in, to relieve you of duty, so it is very hard.
    Senator Vance. Well, I appreciate that, Ms. Burgess, and 
thank you for what you do, and I am sorry to hear that, but we 
certainly admire what you do.
    I guess maybe sort of one followup question then--again, to 
whoever on the panel would like this--is what do we do about 
this, right? I mean, if you have overstressed caregivers, you 
have a demographic situation that seems to be going in the 
wrong direction, it is going to get worse, it seems like, 
before it gets better just because of the aforementioned issue.
    Let me just ask a very direct question. Do you think the 
starting wages of caregivers are too low?
    [Witnesses nodding.] That is a yes. Okay. What do you 
think, if I am right that it is about $15 an hour--and if I am 
wrong, please correct me, but what do you think the right 
number is here for entry-level caregivers to entice younger 
workers into this profession to begin with?
    Ms. Burgess. I can say for me I only get paid $13.38. I 
don't make $15, and most of my union members do not either. Now 
the starting wage would preferably be probably in the $20 
range. I will let someone else speak.
    Senator Vance. Sure. Thank you.
    Dr. Scales. Can I add--oh, go ahead.
    Ms. Lowy. It feels a little bit like Price is Right. We all 
want to jump in with this question.
    I do wonder whether or not a lot of us have the same number 
in mind. I do appreciate the question, and as Jacinta pointed 
out that where we are at right now is absolutely too low. I 
would say we are about $5 an hour behind where we should be for 
the skill level we are expecting.
    I have a beautiful graphic that was put together by the 
National Association for DSPs that shows the crossover between 
DSPs, LNAs, home healthcare aides, and these other positions. 
Generally speaking, their entry-level wage is about $20 an 
hour, so the fact that we are paying $16, really trying to push 
it, trying to be staffed.
    I am sorry, Doctor.
    Dr. Scales. Am I allowed to respond?
    Senator Vance. Please. Please do, yes.
    Dr. Scales. Okay. I would just add that the median wage for 
home care workers across the Nation is $14.09 an hour, and 
really where we need to get to are wages that are livable, and 
there are calculations for that, which allow people to pay 
their bills, achieve economic independence, reduce reliance on 
public assistance, but also that are competitive to wages in 
other industries that are pulling from the same labor pool, 
because to your point about the changing population, our 
changing population structure, we need absolutely more people 
to be choosing these jobs, and right now, we are losing them to 
jobs that require the similar level of training and experience 
or even less, and what we see across the board in every single 
State, the median wage for home care is less than the median 
wage across these other industries that are offering sort of 
reasonably competitive jobs.
    Senator Vance. Thank you. I realize I am at the end of my 
time here, but I fear that we are in a bit of a spiral here, 
and we need to get out of it, because as I said earlier, the 
problem is going to get worse before it gets better.
    Thank you all for being here, and thank you, Mr. Chairman.
    The Chairman. Senator Vance, thanks very much.
    Senator Ricketts, you are rewarded for your patience.
    Senator Ricketts. Thank you very much, Mr. Chairman.
    This obviously is a difficult situation. As Governor of 
Nebraska, this was something that we faced as well. I think 
just generally in the country between 2008 and 2018, we saw the 
number of people who were 65 or older go from something like 39 
million to 52 million, and by 2060, I think that number is 
supposed to be 95 million.
    In Nebraska, in the last Census, something like 16.4 
percent of our population was above 65, and we have got about 
200 skilled nursing facilities and assisted living facilities 
and about 100 hospitals that also are providing different 
levels of care. The hospital is providing different level of 
care to seniors.
    The workforce shortage is one of the things that we hear 
from this industry, as well as other industries. I also think 
there might be some analogies here to the childcare industry as 
well, but it is certainly a big challenge.
    We have had a number of our nursing facilities close in 
Nebraska. Certainly workforce is part of the challenge, but 
also one of the things I have seen is census, too. A lot of 
times when we are looking at these, particularly in rural areas 
when they close, they are at 50 percent census. They would have 
capacity to take on more people, so that is one of the other 
challenges we have.
    When we are talking about licensures and things like that, 
that also kind of plays into this and the qualifications. Dr. 
Maxey, based on your research on how to better support 
caregivers, do you believe industry standards for training and 
credentials will remove employment barriers?
    Dr. Maxey. Thank you for your question, Senator Ricketts.
    I would like to be clear that I am not necessarily stating 
licensing for HCBS or direct care workers, but rather some 
training standards that States can implement and then 
potentially coupled with training registries. I do feel as 
though training standards will empower those workers. They will 
have set skills. They will be able to demonstrate those skills 
to their employers, and I do believe that that will help to 
retain people in these jobs as well as help put them, those 
that would like, on a trajectory for career pathways, whether 
they are in healthcare or some other related field.
    Senator Ricketts. Also, Dr. Maxey, I think there is about 
30 States right now that require agencies to obtain a personal 
care license, and licensure across States vary. Is there a 
State that you believe should serve as a model for others to 
follow?
    Again, you are talking about training versus licensure. Is 
there, again, somebody you point to and say, hey, this is a 
State that has done it well? Maybe it is not licensure, but 
maybe it is training. Just talk to me about kind of what has 
your research shown as far as like who is doing a good job of 
this?
    Dr. Maxey. You know, States are all very unique, and so I 
would say that their strategies range, and I would like to 
clarify agencies--licensing of agencies would be different than 
licensing of the specific worker, so there are numerous States 
that license these agencies, and then the agency is responsible 
for training the workers and maintaining their own training 
activities.
    There are other States that actually have the training 
provisions in statute and implement those in varying ways. I 
would be happy to get back with you with some very specific 
information on the States that take those different approaches 
and what it looks like within them.
    Senator Ricketts. Is there a State, though, that you can 
point to and say, hey, this is a State that seems to be 
addressing the issue better than other States with regard to 
workforce and how to provide care and that sort of thing?
    Dr. Maxey. I would say that based on my work right now, 
there are States across the Nation and pretty much every State 
is looking for solutions, and again, they really truly vary 
based on what a specific State's environment is and how their 
home and community-based services are structured. I would 
hesitate to say one leading State in these spaces. I would 
rather provide you with a list of those that are taking these 
different approaches.
    Senator Ricketts. Just out of curiosity, just again 
Nebraska, we have urban areas. We have rural areas. Typically, 
where we have had problems with nursing homes closing has been 
in our rural areas. Is that similar for Indiana as well?
    Dr. Maxey. Yes. Rural areas definitely are having more 
extreme workforce challenges. I can't necessarily speak to 
agencies and facilities because I work more on the workforce 
side, but I can definitively tell you that rural communities in 
Indiana and rural communities in many States are grappling with 
these same issues.
    Senator Ricketts. Great. Thank you very much.
    I yield back, Mr. Chairman, and I note that I actually made 
it in on time.
    The Chairman. You did.
    Senator Ricketts. Unlike my colleague here.
    The Chairman. There will be--you get free Pennsylvania 
candy for that.
    Thank you, Senator Ricketts. Senator Kelly?
    Senator Kelly. Thank you, Mr. Chairman.
    As a kid, one of my favorite trips was going to Hershey, 
Pennsylvania, so I remember it well.
    Thank you to all our witnesses for being here today.
    Dr. Scales, I hear from employers across Arizona how 
challenging it is to find direct care workers, and I know this 
is not unique to our State, but the need is serious. Nearly a 
fifth of Arizona's population is over the age of 65. The 
University of Arizona in our hometown of Tucson projects that 
our State is going to need about 55,000 more direct care 
workers by 2030. Not too far away.
    We have seen our providers come up with some pretty 
creative solutions to try to get by and continue providing 
high-quality care for Arizonans. In Tucson, high school 
students are getting engaged in career and technical education 
programs in the caregiving space, and our public university 
system is working to build out online curricula to provide 
frontline workers with a base level of geriatrics training that 
they can translate into their everyday work, and we are trying 
a variety of different things in the State.
    One idea I would like to focus on is viewing direct care as 
an opportunity for long-term career growth. That is what might 
get the high schooler excited about becoming a certified 
nursing assistant, and it is not only to work as a CNA in your 
high school program, it is getting the opportunity to grow in a 
field where you can make a difference in somebody's life and 
see your income increase as you advance professionally and 
build a meaningful role in our healthcare team.
    Now you have done some research on this on career 
advancement models in direct care, so what does your research 
tell us about the most effective ways to grow direct care as a 
career path?
    Dr. Scales. Thank you for the question, Senator Kelly, and 
thank you for all of the exciting work that is happening in 
Arizona around training and career development for this 
workforce.
    I think what is really important is that, for the most 
part, when we think about career advancement for direct care 
workers, we often think about it as moving up the nursing 
ladder, so moving from a direct care role to a licensed 
practical nurse or a vocational nurse and to registered nurse, 
and that is a really important pathway.
    The step from being a personal care aide or home health 
aide or even CNA to that next step on the career ladder, that 
can be a really big step in terms of the time it takes, the 
financial resources required, educational experience, and more, 
especially for workers who are juggling multiple jobs and 
family caregiving responsibilities as well.
    I think we need to think about how to bridge that 
significant gap and also create advancement opportunities 
within direct care as ends in themselves, so that is what we 
really are looking at, at PHI, is how to build out these 
different advanced roles that can be stepping stones or can be 
really richly rewarding career steps in themselves.
    We are looking at senior aide roles, condition specialist 
roles, peer mentor roles, and transition specialist. All 
different kinds of roles that take the core competencies of 
direct care and elevate them with additional training and 
responsibilities and earning potential as well.
    Just to give you one quick example. We pilot tested an 
advanced role called the Care Connections Senior Aide role in 
New York City with home care agencies and a managed care plan, 
and through this program, home health aides were elevated to a 
salaried position, and in that role, they coached the full home 
care workforce team. They helped manage sort of more acute 
caregiving challenges, and they served as a recognized role on 
the interdisciplinary care team.
    What we saw through our demonstration project was that that 
made a meaningful difference in terms of clients, patient 
outcome, as well as job satisfaction for those involved, and 
reduced caregiver burden, so it is really--I think our 
challenge is to--there are these innovations happening in the 
field, and our challenge is really to invest in them, evaluate 
them robustly so we can look at replication and scale up.
    Senator Kelly. Are you going to scale that pilot program?
    Dr. Scales. It has a lot of potential, yes.
    Senator Kelly. What can the Federal Government do to help?
    Dr. Scales. Well, that is where the Federal Government 
could really take a role in identifying and supporting some of 
these innovation efforts, innovative efforts. Really looking 
kind of across the types of models, geographies, conditions 
involved and so forth so that we can really do a cross-section 
of robust testing in order to build the evidence base for what 
we really should invest in going forward through a sort of more 
structural means like payment streams and so forth.
    Senator Kelly. Thank you, Dr. Scales.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Kelly. Senator Blumenthal.
    Senator Blumenthal. Thanks, Mr. Chairman.
    I want to thank our chairman. As I am sure everybody here 
and everybody listening knows, he has been a steadfast champion 
of home healthcare. I have been proud to support many of his 
efforts, including the American Rescue Plan Act, which was 
hopefully transformative in making the kind of significant 
investments that he has led and others of us have supported, 
because one of the most important investments we made was in 
the Medicaid home and community-based services section, 
providing States with a 10 percent increase, as you know, in 
Federal home and community-based service dollars if they expand 
and strengthen and enhance these services.
    I think these kinds of investments and incentives have 
enormous payback. They are truly an investment with tremendous 
dividends, and I hope that we will continue funding these kinds 
of services.
    Last month, I was honored to join SEIU 1199 in Connecticut 
to help kick off their Support Long-Term Care Workers campaign, 
and I want to mention this union because I think, in fact, 
organized labor and unions are so important in representing 
home healthcare workers and urging us to do better by them so 
that they can do more and better for the people they serve. 
That union proudly represents 26,000 workers.
    Think of it for a moment, 26,000 workers in Connecticut, 
including home care workers who fight for the people they care 
for. Not just themselves, but people they care for. It seems 
clear to me that an investment in healthcare workers, 
especially at a time when there are shortages, lack of 
training, and burnout, that is an investment in the people that 
they serve.
    I know that Senator Casey has asked Ms. Burgess about a 
true living wage and how it would impact you, and your story is 
powerful and heartbreaking. I wonder if the panel could speak 
to the importance of training, as well as proper compensation?
    Dr. Maxey. Thank you, Senator Blumenthal.
    My name is Hannah Maxey. I would be happy to take that.
    I am sure you are aware that CMS has finalized a set of 
competencies for HCBS workers, but those serve more as a 
guidepost to States, whereas in other occupations or facility-
based settings, there are stronger guidelines or regulations 
regarding that. Training standards are critically important for 
these workers and can help support a consistent level of 
quality and service across the different consumers that they 
might work with and the different settings that they are in.
    Ms. Burgess. I wanted to say thank you for that question.
    In Pennsylvania, we just recently won funding for paid 
training programs, first of their kind in the State, which just 
rolled out earlier this year. Caregivers who have never 
received any healthcare training are now getting certified in 
everything from CPR to dementia capability care, nonviolent 
crisis intervention. It is very important like to have that 
training so that we know what we are doing on the spot.
    Even when I think of the care that I give my mother, her 
care is going to progress. She is going to need more, and my 
knowledge needs to grow, so the training that we would be 
provided would be lifesaving.
    Senator Blumenthal. Very important comment. Thank you.
    Thank you all for your service.
    The Chairman. Thank you, Senator Blumenthal.
    I know we are going to have to wrap up soon. I might have 
one more question. Senator Braun.
    Senator Braun. One more.
    The Chairman. One more? Okay.
    I wanted to turn to Ms. Lowy. I know that you shared your 
organization's experience providing care during the COVID-19 
pandemic. As we heard, direct support workers went above and 
beyond to provide essential care during that crisis, often at 
great risk to their own health and their own safety, and too 
often that wasn't recognized. We didn't highlight that.
    We do know that in the American Rescue Plan, we allocated 
$12.7 billion in dedicated home and community-based services 
funding for States to address the urgent needs caused by the 
pandemic, including supporting the workforce, and we know this 
was kind of a short-term investment.
    We have also noticed that a lot of States have used those 
dollars to begin to build more of a foundation for home and 
community-based services, so tell us, what would it mean to 
recruiting and retaining HCBS workers when those Rescue Plan 
dollars are expended?
    Ms. Lowy. Thank you, Senator Casey.
    Sustained Federal investment in HCBS would enable us to 
raise wages. With the ARPA funding that we received, we were 
able to give bonuses because it was a short-term investment, 
but we weren't able to have a sustained investment in raising 
wages. That obviously is the foremost challenge in recruiting 
and retaining staff.
    We also would like to offer a career path for DSPs with 
skill and responsibility-linked raises. Obviously, as both of 
the doctors have talked about, it is so important to have these 
additional skill sets fostered and that training funded, but at 
present, because we don't have any titular or financial 
recompense available to staff members who are interested in 
these additional training avenues, it is difficult even if we 
have the funding for the training in order to encourage folks 
to pursue that.
    I also wanted to mention that there are--we need to be able 
to provide these career paths for young workers, and our 
industry at present is not able to offer it, and in addition, 
these specialized training avenues that we could offer people, 
DSPs could specialize in things such as memory care. A lot of 
people don't realize that 50 percent of adults with Down 
syndrome develop dementia by the age of 50, and so that is an 
area we would love to be able to train staff in, but the 
motivation isn't there if we are not able to give them a career 
path in that direction.
    Obviously, also program development is very important. Just 
as for teachers or social workers, one size does not fit all 
for the folks that we support, so being able to develop 
challenging programming.
    Then, finally, I wanted to mention that transportation and 
transition services are two areas that vary greatly from State 
to State, from underfunded to nonexistent, so those would be 
two areas I would love to be able to invest more in.
    Thank you.
    The Chairman. Thanks very much. Senator Braun.
    Senator Braun. Thank you.
    My final question is going to deal with something I did in 
my own company roughly 15 years ago, when I was sick and tired 
of hearing how lucky I was premiums are only going up five to 
ten percent each year. I took the entire system, kind of turned 
it on its head. We were able to self-insure, but that made a 
big difference once we became the insurance company, when I 
found out how much profit they were making on our plan back 
then.
    A cornerstone was to really emphasize prevention and 
wellness, giving all the tools to my employees to become 
engaged healthcare consumers owning their own well-being. I 
would like Dr. Scales and Dr. Maxey to weigh in on can we weave 
prevention and wellness into whatever the model is to keep the 
elderly more healthy, to where you lighten the load for the 
caregivers that are already overburdened?
    Can that work even as you are already old? I know it works 
when you can catch all this early on, and it has kept us--you 
won't believe the results. We have not had a premium increase 
in 15 years, so we fixed it by taking a different approach. 
Wellness, an ounce of prevention worth a pound of cures.
    Go ahead, Dr. Scales.
    Dr. Scales. Thank you.
    I absolutely agree that the more that we can provide 
opportunities for individuals to safeguard their health and 
wellness throughout their lives will make all the difference as 
we get older. I absolutely think we need the structural 
conditions in place to enable people to do that, and that means 
having health insurance, being able to seek preventive care, or 
address issues earlier rather than later in their trajectory.
    What I would add is that that question, to me, brings up 
the importance of the home care workforce, because so much of 
what home care workers do is enable people to maintain their 
optimum health and well-being, to maintain their functionality, 
to stay active, to stay engaged in their communities. All 
things that actually will keep them on a better healthcare 
track for longer rather than having to go without those needs 
being met and ending up sooner in the hospital, in the 
emergency department, in a nursing home before it is really 
necessary for them to be there, and so forth.
    Senator Braun. Dr. Maxey.
    Dr. Maxey. Yes, thank you.
    I am going to bring it back training, but maybe instead of 
formalized training, home and community-based workers or even 
informal family caregivers need to be equipped with the 
information to help support the individual they either serve or 
their loved ones in what prevention is.
    That might look like a registered nurse that cares for that 
individual at their medical appointment providing some health 
education to the caregiver. I think there are many ways that 
that can happen, but I absolutely think that the caregiving 
workforce, either the formal employed or the informal, can 
absolutely be a part of supporting prevention and wellness for 
individuals that are receiving home and community-based 
services.
    Senator Braun. Thank you.
    The Chairman. Thank you, Senator Braun.
    We will now turn to our closing statements, and we want to 
again thank the witnesses for their testimony.
    As we heard today, investing in the direct care workforce 
will have major economic benefits for many Americans. Studies 
have repeatedly demonstrated that paying home care workers will 
improve the financial security of those families, both the care 
recipients as well as the workers, and an investment in this 
workforce will boost the economy in communities across the 
country.
    It is not a surprise that every State, every single State, 
participated in the American Rescue Plan Act HCBS program to 
provide more funds to bolster home-based services. The rescue 
legislation had about $12.7 billion, and every State took 
advantage of that.
    We must build on the investment now and certainly in the 
future and fortify a workforce that helps millions of Americans 
live better lives, safer lives, and more independent lives.
    Ms. Burgess and all the care workers are long overdue for a 
raise, and I noted in your testimony, Ms. Burgess, you said, 
``It was my duty to care for my mother,'' and I think you 
summed up pretty well in your written testimony what this means 
for the worker. You said, ``I care for my mother because it is 
the right thing to do, and I would do so even if I weren't 
getting paid, but love can't pay the bills, so we depend on the 
wages I earn for this work, but it is not nearly enough to make 
ends meet.''
    I think that says it all in terms of the challenge our 
country faces, so one of the bills that we should consider is 
the Better Care Better Jobs Act, as well as the new HCBS Access 
Act, to improve the recruitment and retention of direct care 
workers and provide the home care supports that older adults 
need and people with disabilities need.
    The Committee has received 10 statements for the record 
that support the need for an investment in these services, so 
be assured that every single American will either require long-
term care services and supports or need to support a loved one 
at some point in their lives.
    I look forward to working with my colleagues to address the 
needs of millions of Americans and their families in need of 
supports and services.
    I now turn to Ranking Member Braun for his closing remarks.
    Senator Braun. Thank you, Mr. Chairman.
    Enjoyed the conversation. We always learn a lot, always 
having great witnesses that live it in the field each day.
    We are transitioning everywhere across America, where we 
obviously got an underpaid workforce. We are trying to find 
that right solution. The problem obviously is going to grow. 
Nearly all countries are dealing with the same issue. For us, I 
think we are just at the cusp of it, just due to population 
growth and the whole dynamic of where our country is headed.
    I think it is going to be necessary to look to what we can 
do here to make it easy. A lot of times folks look to the 
Federal Government, and I think we should be leading and set 
the general context.
    However, we don't mind our own house very well. For all the 
places that depend on this place, we are currently running 
nearly $1.5 trillion in deficits each year, and that is roughly 
30 percent of our budget. That is a bad business plan for all 
the folks that look to the Federal Government. Where, in the 
past, you know, we have been there, but we have not done it by 
borrowing from future generations.
    I think it is even more important for these solutions to 
probably be crafted in the States where the rubber meets the 
road, where all the action is happening, where most of the 
workforce training is going to occur, and make sure we find 
best practices there. I am going to keep promoting legislation 
that is doable, that can get across the finish line.
    The JOBS Act that Senator Kaine and I are promoting, just 
to put more money into Pell grants--or not more money into Pell 
grants, but being able to use it for job training, stuff like 
that, and then I am hoping that the entrepreneurs, the 
caregivers, all of you that do the work and the heavy lifting 
on the ground keep weighing in on what you need, where you need 
more help, and hope this place gets its house in order to where 
it can do a better job and make sure you push hard at the State 
level as well.
    Thank you.
    The Chairman. Thank you, Ranking Member Braun.
    I want to again thank all of our witnesses--Dr. Scales, Dr. 
Maxey, and Ms. Lowy and Ms. Burgess--for your testimony, for 
being here today in person and providing us the benefit of your 
experience, both personally and professionally.
    If any Senators have additional questions for the record or 
statements to be added to the record, the hearing record will 
be kept open for another seven days until next Thursday, March 
16.
    We want to thank you all for participating in today's 
hearing, and we are adjourned.
    [Whereupon, at 12:01 p.m., the hearing was adjourned.]



      
      
      
      
      
      
      
      
      
      
      
      
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