April 16, 2024 Washington, DC — As Senate leaders today focus on long-term care workforce issues, LeadingAge, the association of nonprofit providers of aging services, applauds the attention being paid to this important and multi-faceted topic.
Seizing the moment, in written for-the-record comments submitted for The Long-Term Care Workforce: Addressing Shortages and Improving the Profession hearing held today by the Senate Special Committee on Aging, President and CEO Katie Smith Sloan provides policymakers with numerous recommendations to address the major shortcomings of our country’s current patchwork approach to funding and regulating the care and support older adults and families need to age with dignity. At the same time, her comments also offer specific proposals to improve the Long-Term Care Workforce Support Act, introduced April 15 by Senators Bob Casey (D-PA), Tim Kaine (D-VA), and Tammy Baldwin (D-WI).
“Two looming regulatory changes—the nursing home staffing mandate and the workforce provisions of the Enhancing Access to Medicaid Services rule—if implemented as proposed, will negatively impact older adults’ and families’ ability to access needed care and services,” said Sloan. “America’s population is aging, and demand for care and services is growing. Caregiving is an urgent issue.
If policymakers and other stakeholders are truly serious about addressing the chronic shortages that all care providers serving older adults—including our mission-driven, nonprofit members—are forced to navigate, bold, creative action on multiple fronts is needed. With the Long-Term Care Workforce Support Act, Senators Casey, Kaine, and Baldwin take a big step in the right direction.
However, as experienced advocates with a rich history in helping to craft laws and regulations regarding the financing and delivery of long-term services and supports, we can say with confidence that the devil is truly in the details. We urge policymakers to pay attention to necessary refinements on particular issues such as funding for the education and training initiatives needed to build and sustain the workforce and investment in coordinated state and federal infrastructures to ensure programs achieve their desired goals.”
Specific recommendations and needed actions included in the comment for the record:
Challenges in Current Long-term Care Services and Supports Workforce
Mismatched Reimbursement Mechanisms
Recommendation: Congress should pass the following bills to stop proposed payment cuts and address inadequate reimbursement mechanisms: Preserving Access to Home Health Act of 2023 (S.2137 / H.R. 5159), HCBS Relief Act (S.311 / H.R. 6267), Better Care Better Jobs Act (S.100 / H.R. 4131), Expanding Veterans’ Options for Long Term Care Act (S.465 / H.R. 1815) and the Expanding Service Coordinators Act (H.R. 5177).
Education and Training
Recommendation: Congress should pass the following bills to expand the nurse educator workforce – the Train More Nurses Act (S. 2853) and the Palliative Care and Hospice Education and Training Act (PCHETA) (S.2243).
Discordant Federal and State Training Requirements
Recommendation: Congress should consider developing and streamlining federal training requirements for direct care professionals and nurses. This should include an exploration of how Licensed Vocational/Practical Nurses (LVN/LPN) and experienced direct care professionals can assume increased training responsibilities for professional caregivers. This should be done with a focus on developing stackable certifications and opening pathways for aging services staff to engage in a lifetime of career development and learning.
Limited Clinical Training Sites
Recommendation: Congress should enact the bipartisan Ensuring Seniors’ Access to Quality Care Act that would eliminate the rigid provisions found in the Omnibus Budget Reconciliation Act of 1987 (OBRA) and grant the Centers for Medicare and Medicare Services (CMS) greater flexibility in reinstating valuable CNA training programs.
Supported Pathways and Services
Recommendation: In addition to the targeted federal medical assistance percentage (FMAP) increase, we urge Congress to increase reimbursement to allow providers to respond to the unique needs of their workforce. This should include providing support services and emergency assistance to staff, on an as needed basis, to increase recruitment and retention. To address shortages across the aging services continuum, we encourage Congress to pass the Supporting Our Direct Care Workforce and Family Caregivers Act (S. 1298).
Immigration
Recommendations: Congress should pass legislation that addresses critical gaps in the U.S. immigration system, including significantly increasing caps on employment-based visa programs, prioritizing nurses, and caregiving professionals. We urge Congress to pass the following bills to expand immigration pathways and increase supports for immigrants working in the aging services sector: Asylum Seeker Work Authorization Act (H.R. 1325), Assisting Seekers in Pursuit of Integration and Rapid Employment (ASPIRE) Act (H.R. 4309 / S. 2175), Healthcare Workforce Resilience Act (S. 3211), Leave No Americans Behind Act (H.R. 6205), and the Immigrants in Nursing and Allied Health Act (H.R. 3731).
Ensuring Access to Medicaid Services
Recommendations: Congress should delay the implementation of the 80/20 requirement contained in the proposed HCBS Medicaid Access Rule until a comprehensive plan is in place to fund a substantive expansion of the aging services workforce that includes affordable and accessible education, increased availability of nurse educators, and a focused FMAP increase to support infrastructure development and ensure competitive wages for all aging services workers.
Proposed Nursing Home Staffing Standard
Recommendation: Congress should enact the Protecting American Seniors’ Access to Care Act (H.R. 7513) to stop the implementation of the proposed staffing standard.
Long-Term Care Workforce Support Act
Title 1 Creation of a Cliff
Recommendation: States submit a plan as to how they propose to sustain and support higher wages once federal funding ends – but that these plans cannot not rest solely on the backs of providers.
Waiting Lists
While we do not want people in need of services to continue to wait, waitlists have not been found to be a precise indicator of need in each state. From LeadingAge’s perspective, if the funds are balanced toward clearing waiting lists, they may not reach older adults or the direct care professionals who serve them. The bill’s focus on waiting lists may also limit the number of states that are able to take advantage of the money
Recommendation: Please consider dedicating a specific fund to clearing waiting lists. These funds should be distinct, ensuring that other potential uses do not get crowded out.
Passthrough Threshold
Similar to our comments on the proposed HCBS Medicaid Access Rule, we are supportive of the intent of an 85% passthrough threshold, particularly the fact this applies to the additional funds proposed in the bill. But without additional funds to fully support the workforce and the infrastructure that supports it, an 85% passthrough is not tenable for LeadingAge members. We fear unintended consequences, including significant administrative burden should a pass through, as proposed by CMS, that is applicable to the entire Medicaid rate be enacted.
…We recognize two important distinctions between the bill’s proposal and the proposed HCBS Access Rule. The first is that this bill provides funding. The second is that the Chair intends that the threshold elements be designed with stakeholder input. We intuit this from page 16, lines 32-33 (of the LTC Workforce Support Act draft dated 04-08-2024) which refers to page 16, lines 20-27 of the same document. The proposed HCBS Access Rule threshold design did not consider the costs of critical elements like clinical supervision, training, travel, technology, and more. A stakeholder process would allow for these elements to be considered.
…Finally, the infrastructure does not exist to make a passthrough work. As Medicaid programs vary, so too do states’ data collection processes. Few states require cost reporting for home and community-based services. Any type of uniform requirement regarding wages must have a universal reporting structure and any data collection infrastructure needs to be inclusive of the information on rates.
Recommendations: We strongly encourage that the phrase “but may also include” be removed from page 16, line 26 (of the LTC Workforce Support Act draft dated 04-08-2024). Providers must be included both in the rate-setting process and in the formation of any passthrough threshold for which they will be held accountable by their states.
At a minimum, the thresholds must align with their timelines for implementation and structures for reporting. We urge you to contemplate a delay in the payment adequacy component of the proposed HCBS Access Rule to align with the bill’s timelines. We recommend the Chair provide specified funds from the bill to create this infrastructure rather than imposing a passthrough requirement. This could begin with reporting requirements related to these specific dollars and how they are tracked.
Title II Complex Grant Structure
We applaud the significant financial investment in training and pathway development through education and wrap-around support services such as transportation and childcare. A seismic investment of this kind requires an equally developed infrastructure to ensure these dollars are well spent and accessible to the communities that need them most.
Recommendation: Where possible, combine the grant funds under one authority, such as the Bureau of Health Workforce within the Health Resources and Services Administration (HRSA). This office would be charged with educating potential grantees on the various streams of funding, providing technical assistance, and ensuring timely and comprehensive reporting and analysis.
Title III
We highlight four provisions for particular attention: Written Agreement (Subtitle B, Sec. 312): Fair Scheduling Practices (Subtitle B, Sec. 313): Workplace Violence Prevention Standard (Subtitle C): Improving Access to Job Benefits: Paid Sick Leave (Subtitle D):
Recommendation: We request that home health (section 1891) and hospice (section 1814) be added to the definition of long-term care setting (page 9, line 14-25 of the LTC Workforce Support Act draft dated 04-08-2024). They should be eligible for funds through the various grant programs – they use direct care workers, and those workers deserve the same opportunities for professionalization, training, pay, etc. as their counterparts across the long term care workforce. Home health and hospice are critical services and should be included in these funding opportunities so that they can compete for and afford quality staff.
Recommendation: Remove the phrases “as applicable” or “but may also include” in reference to including employers or providers in stakeholder engagement, advisory groups, grant opportunities, etc. in this legislation. If providers, like our members, are not engaged in the process of improving the workforce, the impact is not going to be what the proposed legislation envisions. We want to have well-paid, highly trained, and dedicated staff and want to be engaged in activities that are trying to achieve these goals. Providers’ voices are important, and we ask that the bill be clear at every opportunity that providers are a critical stakeholder in these important efforts.
