Montana’s home health care shortage

Over the past 28 years, Delphine Camarillo has assisted dozens of people in the Billings area with some of the most routine aspects of their daily lives. She’s done laundry, shopped for groceries, taken out garbage and reminded clients to take their medications. Occasionally those clients have family or friends who pitch in, but often Camarillo is their primary avenue to an independent life in their home community.

“Sometimes you’re going to be the only one they’ve seen in the last two days, and you’re going to be the only one they see in the next two days,” Camarillo said. “It kind of gets to you. They’re not family, but doggone it, they’re people and they need help.”

Camarillo got her start in the field as a personal care attendant for HomeCare Montana, a nonprofit offering at-home health care services for elderly and disabled Montanans across the state. These days she’s a certified nursing assistant, still working with the same organization and performing many of the same duties. The work is demanding, she said, both physically and mentally, but her passion for the job has kept her going despite systemic wage issues that are contributing to a widespread labor shortage. Even with her experience and CNA license, Camarillo said, she makes less than $15 an hour.

“I know there’s people out there who want to work,” she said, “but it’s hard to come to a job and have to do the task we have to do at that wage when you go to one of these stupid fast food places and make a bigger wage for probably less stress.”

Concern about a shortage of home health care workers in Montana — or, more pointedly, the low wages many advocates point to as its primary cause — has grown in volume in the past few months. Camarillo and other workers, along with the Service Employees International Union that represents them, have repeatedly called on Congress to pass a massive federal spending package that would pour hundreds of billions of new dollars into Medicaid, a primary funding mechanism for at-home care services. Similar pleas have been raised across the country as other states wrestle with an imbalance between health care supply and demand.

According to Jacquie Helt, SEIU’s Montana state director, the wage-induced shortage has been compounded this year by the steadily rising cost of living and increased vacancies in other low-wage jobs. Many private and nonprofit health care providers now find themselves competing directly with other service sector employers for the same labor pool, Helt said. The situation is exacerbated by the stress and pressure placed on home health care workers throughout the pandemic as they sought to navigate new challenges including quarantining and potential exposure to COVID-19 in home settings.

“This still tends to be a population of workers that are living paycheck to paycheck and feel like they’re really treading water while they’re providing intimate daily care to human beings,” Helt said. “If you were to ask yourself, ‘If I can make anywhere between $8.75 and $9 an hour as a server plus tips, or maybe make $10.50 as a caregiver,’ that tends to make people think twice.”

Statewide, SEIU represents roughly 1,500 personal care attendants, one of the primary job positions under the home health care umbrella. Workers typically fall into two categories: those employed by a provider, and those who work directly for a specific client, an arrangement known as self-direct. While some services are paid for directly by clients, much home health care in the state is reimbursed through Montana’s Medicaid program. The hours clients are able to bill under that model vary, Helt said, requiring providers and caregivers to cobble together shifts that maximize limited staff time to meet client needs.

The types of clients requiring home health care are equally diverse, ranging from the elderly to youth and adults with disabilities or mental health issues. Their needs can include help with such essential tasks as bathing, dressing and managing personal finances. But the availability of such services is not always guaranteed, Helt said, especially in light of the shrinking workforce. She estimates the current waitlist for Medicaid-backed home care in Montana is around 2,000, and demand is expected to increase as the state’s population continues to age.

“Today there are four people of working age for each elderly person in Montana,” Helt said. “But projections estimate that by 2030, that ratio will be reduced to only two people of working age for every elderly person. The demand for caregivers who can meet increasingly complex care needs is high, and it’s only going to get higher.”

At AWARE, a nonprofit providing home- and community-based care services to roughly 4,000 people statewide, CEO Matt Bungi said he’s felt the sting of the labor shortage firsthand. His staff includes personal care attendants, group home managers, licensed therapists and teachers assigned to federally funded Early Head Start programs. If fully staffed, Bungi said, AWARE would have 900 employees. It currently has 750.

Bungi has taken measures to attract new workers, offering a $1,000 sign-on bonus as well as a $1,000 referral bonus for current employees who successfully recruit new hires. AWARE’s entry-level wage was previously $12.25, Bungi said, but that was increased to $14 this year. While the raise may make AWARE more competitive in the labor market, the increase has other consequences. 

“We experienced increased costs to run quarantines in group homes where we basically locked up an entire group home for a two week period of time,” Bungi said, adding that there was no corresponding increase in revenues. “So overtime payments really went through the roof. PPE, costs like that, to just keep the ship running really increased significantly.”

Fast forward to this summer and Bungi said his existing staff is “exhausted.” Recruitment and retention problems have become more prevalent than before, despite the new financial incentives.

“We’re seeing some people take a sign-on bonus and work for a short period and then leave,” Bungi said. “In some of the hiring pools, we have somebody where we think we have an accepted offer and they don’t show up for their first shift. We’ve had some people walk off on their first shifts.”

An additional financial lift is on the way statewide. During the final days of the 2021 Montana Legislature, lawmakers approved an amendment to the state budget, House Bill 2, establishing bonuses for direct care workers in home-based care. The total funding appropriated for those recruitment and retention bonuses is just over $3 million over the next two years. Rep. Mary Caferro, D-Helena, crafted the amendment and considers it a near-term victory for a pool of workers she once belonged to. Caferro was a direct care worker in a group home for Montanans with developmental disabilities in the late 1980s and early ’90s.

“Back then we got paid well,” Caferro said. “We had excellent training and we had full benefits including a good insurance plan. Since then it’s gone downhill and the budget has been cut, cut, cut and we have never gotten back to where we needed to be. Those services have never been restored.”

Caferro recognizes that bonuses alone won’t be enough to address the state’s workforce shortage, and is continuing to advocate that Montana use federal American Rescue Plan Act funds to increase base wages for home health care workers. That would require directing ARPA funds to increase the rate providers are allowed to bill for Medicaid reimbursement, though Republican lawmakers made it a point this year to avoid committing one-time federal relief dollars to budget items that would necessitate increased state spending once the federal money dries up. A similar effort involving tobacco tax revenues spearheaded by Caferro in the 2017 session failed, but, she said, the problem has not gone away.

“The workforce is committed to what they do and to the people they serve, but the issue is money,” Caferro said. “How can some people work when they can’t even pay their own bills at the wage offered?”

SEIU’s members nationwide remain hopeful that Congress will take action on the proposed investments in what Helt calls “human infrastructure.” Whether decisive action comes from the federal government or the state, Bungi agrees that a wage increase is ultimately the most logical and urgent solution. AWARE’s move toward a $14 entry wage won’t be sustainable long-term without an infusion of cash from somewhere.

“We’ve got Montana sitting on the biggest pot of money I’ve seen in my lifetime, and I hope that we can figure out how to use one-time funding with ARPA to help fix some of these systems issues,” Bungi said. “It’s going to take funding to get there.”