Idaho’s direct care workforce is in ‘crisis,’ state legislative panel hears

Staffing in Idaho’s direct care workforce — those who care for people with disabilities and older Idahoans — is in “crisis,” the Joint Legislative Oversight Committee heard in testimony on Friday at the Idaho State Capitol in downtown Boise.

The committee heard follow-ups to a February report issued by the Office of Performance Evaluations that found Idaho’s direct care workforce is short about 3,000 workers compared to national staffing levels. That report identified low pay as an issue for the program primarily paid by Idaho Medicaid, whose rates “do not support sustainable competitive wages for direct care workers,” and create a “wage cap,” the report found. The typical nursing assistant in direct care made $14.16 per hour and could earn 39% more by leaving direct care, the report said.

“It is true today we are at a four alarm crisis due to the lack of qualified direct care workers in our Home and Community Based Services,” said Idaho Council on Developmental Disabilities Director Christine Pisani. “The council is working on the issue every day. We view this issue as the most critical issue facing the disability community at this time.”

OPE Principal Evaluator Amanda Bartlett said even national staffing levels represent a shortage.

Recommendations on how to help Idaho’s direct care workforce issues

The report recommended Idaho Medicaid improve its reimbursement rates to support competitive wages, including accounting for different direct care occupations, inflation and regional differences. The report also recommended that Idaho Department of Health and Welfare work to help make a career ladder for direct care workers. 

If Idaho lawmakers approve $46 million in the Idaho Department of Health and Welfare’s budget request for provider rate increases for direct care workers, it’d be a good start, Idaho Department of Health and Welfare Director Dave Jeppesen told lawmakers. All told, that would add up to $300 million in increases over three years, if approved, he said, including $230 million in fiscal year 2023 and $25 million in fiscal year 2024.

“We are at the very beginning of solving this problem, not at the end,” said Jeppesen, who called the shortage of workers “very acute and something we take very seriously at the department.”

Idaho Medicaid Director Juliet Charron said many direct care providers had not received a rate increase in more than a decade. The Legislature has improved the situation recently, but, she said, “We’re really playing catchup as compared to many of our other provider types.”

Medicaid, though, does not have control over how much reimbursement rates for services go directly toward caregivers, Charron said, noting that providers have overhead costs. The federal Centers for Medicaid and Medicare Services has proposed a rule to require that 80% of reimbursements go to direct care staff, but the rule is not final. 

Charron, in response to a question, said she couldn’t comment on where the funds from an increased reimbursement rate would go. The department is working to understand how the funds from reimbursement rates are spent, she said.

“We do see what agencies post for starting wages and whatnot,” Charron said. “Sometimes it reflects some of the reimbursement increase and sometimes it does not, but I think that’s probably a question for some of the providers to answer.”

Idaho man testifies direct care crisis affects his daily life

Noll Garcia, a 51-year-old man with cerebral palsy, told the committee because of the crisis in the direct care workforce, he’s spent every day over the last three years “never knowing” if his services would show up.

He told the committee he needs help with day-to-day tasks like preparing meals and bathing, as well as transportation.

“I have not had people to support me to do the most basic human things. Or things that make my life with living. For the past three years, I’ve been existing, but not living,” he said. “I’ve become like a plant. I may get water, but I receive very little sunshine to help me grow.”

He said his life has been a “complete crisis” the past three years, in and out of different support agencies, seeking help from his parents and later couch surfing. Pisani told the committee Garcia lived with her for a time in the early 2000s.

“It is my prayer for myself and other people with disabilities that wages and the training for the direct care workforce and our Home and Community Based Services becomes a high priority for the Legislature this year,” Gacia said. “My life depends on it. Having well qualified, well paid direct care workers is the difference between my life as a plant and me having a life.”

Training is required for direct care workers, but Charron told the committee that “we know at times those trainings are not enough.” She said many of the new staff in direct care are directly out of high school, some of whom are considering becoming nurses.

“It’s not someone who’s going to stay in this work for the long term,” she said.

Rep. Steve Berch, D-Boise, said the report justifies an immediate $3-4 an hour increase for direct care workers, before the state plans for the future of the program.

“The people who are skilled in this job are leaving, probably to flip hamburgers to make more money to pay their own expenses, their own family, “ he said. “We don’t need more strategy to know that we need to increase what we pay caregivers to the extent that the state controls it.”

Idaho legislative committee discusses Medicaid’s increased staffing request

Pisani said the council recommends funding Medicaid’s request for 60 new staff and to fund two existing staffers “to begin to resolve this issue in the coming year.”

“Funding these positions will provide the staffing and expertise needed to implement these critical recommendations and provide the level of oversight most needed in our service system today,” Pisani said.

Earlier in the committee hearing, Sen. C. Scott Grow, R-Eagle, told Charron the state was anticipating general fund revenue projections being down $300 million in the last two months compared to when lawmakers set the budget. He cautioned her on Medicaid’s budget request, saying that legislators will ask about the request for more staffing even as the department recently removed over 100,000 people from Medicaid. 

“You may want to reprioritize some of these things and maybe have to decrease some of your expectations,” Grow, who co-chairs the legislature’s budget committee, told Charron.

Rep. Douglas Pickett, R-Oakley, said the Medicaid budget is “out of control” and questioned the need for more Medicaid staffers when the report highlighted a need for more direct care workers.

“We need more boots on the ground than we need 62 positions in the department,” he said. 

Charron responded that the staff request does support people accessing direct care.

“I need staff who are going to support this population,” Charron said. “And that is from policy to implement some of these recommendations to support direct care staff. I need care managers in my developmental disability staff. Quality folks, data analysts — it all supports the care that we give.”