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Chapter 2 Health Care It will not be easy to raise wages and improve advancement opportunities for low-level workers in any American industry. But the way is clearer in the field of health care than in any other because of an unusual confluence of factors. Hospitals, nursing homes, and home health care agencies are increasingly short of staff; as a result, middle-class patients and their families are increasingly dissatisfied with the care that is being provided, and an ever growing number of overstressed workers are represented by unions. All three groups share a strong interest in making caregiving jobs more attractive. And all three know how to bring political pressure to bear on government policy makers, who are a major source of funds in this industry. Thus it is not surprising to find that far more, and more varied, programs to improve the career trajectories of low-level workers have been started in the health care sector of the economy than in any other. These programs offer important models that may be adaptable to other industries. But they also suggest how far we still have to go, for even in the health care industry workers in the lowest tiers-those providing most of the direct, hands-on, hour-by-hour care of patients-do not yet make a living wage. The Shortage of Direct Care Workers As a social scientist. I don't use the word "crisis" lightly. hut I do think that over the next 10 years we face a tme crisis regarding frontline workers in long-term care. Dr. KARL PILLE~IER, director, Applied Gerontology Research Institute, Cornell University HEALTH CARE 25 The shortage of direct care workers is evident at all skill levels, from home care aides to nursing assistants1 to licensed practical nurses (LPNs) to registered nurses (RNs). Since 1995 more and more people have been leaving these occupations and fewer and fewer have been entering them. The number of students enrolled in nursing programs increased by 3·7 percent in 2001 and by 8 percent in 2002, but even with these gains there are ten thousand fewer enrolled than in 1995. Nor is the increase enough to meet the replacement demand by 2010 estimated by the Bureau of Labor Statistics.2 This is primarily because the jobs are stressful and underpaid. Attempts by Medicaid, Medicare, and private insurers to contain health care costs have increased patient caseloads, undermined working conditions , and constrained wages. Moreover, given the industry's traditions and training requirements, the array of unfilled paraprofessional and nursing positions looks less like a career ladder that a low-wage worker might climb than like a series of sealed-off compartments. A glance at the current hierarchy of health care jobs is instructive (table 2.1). The lowest ently-level occupation is that ofpersonal and home care aide. These workers provide housekeeping services and personal assistance, and are employed mainly by home health care agencies and rarely work fulltime . At a slightly higher-skill level are home health aides and nurse assistants . In some states home health aides require more training than nurse assistants, in some the opposite is true, and in others the training requirements are roughly the same. Home health aides make between $8.oo and $10.00 an hour-more in hospitals and doctors' offices than in nursing homes and home health care agencies-but, like home care aides, they seldom work full-time. The majority (65 percent) of nurse assistants work in nursing homes and other long-term care facilities. Although the overall average hourly wage for assistants is $10.12, those working in hospitals earn more than those working in long-term care facilities. LPNs have high school diplomas or Graduation Equivalency Diplomas (GEDs) and, in addition, have graduated from a year-long certification program. They make considerably more than the aides and assistants, an hourly wage of about $16.oo in most types of facilities. Medical technicians, who have completed other, usually longer certification programs beyond high school earn, on average, slightly more than do LPNs. But in all these jobs, as in the lower-paid jobs, there is little opportunity for advancement without significant further education. RNs generally have still more schooling. More than half of them are employed in hospitals at an average hourly wage of $25.02. RNs working in nursing homes make lower wages (an average of $22.44 per hour):3 For RNs, particularly those with a bachelor's degree, there is...


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