Print Friendly, PDF & Email

The single factor most critical to high quality of care and quality of life for nursing home residents is the staff who provide residents with care.  Most direct care in nursing facilities is provided by nurse aides, primarily women of color, who are poorly paid and often poorly treated.  In a sobering new report, Raise the Floor: Quality Nursing Home Care Depends on Quality Jobs,[1] the Paraprofessional Healthcare Institute (PHI)[2] describes the growing care crisis in nursing facilities.  Fewer people are available and willing to take direct care positions while a rapidly aging population needs care.  PHI calls for a “new public investment, along with greater accountability, to ensure that funding is directed to the needs of frontline workers rather than administrative overhead and nursing home profits.”[3]

The Issues

Nurse aides earn “near-poverty wages.”[4]  Nationwide, the median wage is $11.51 per hour, an annual salary of $19,000.[5]  Half of direct care workers earn even less.  Nearly 20% of workers live in households below the federal poverty line.[6]  More than a third of them (38%) rely on various public benefits, including public assistance, Medicaid, food stamps, and cash assistance.[7]  Adjusted for inflation, workers’ wages “have decreased by 7 percent over the last decade.”[8]  Since most of the nurse aides are female (91%) and non-white (53%), gender and race contribute to the marginalized nature of the direct care workforce.[9] 

PHI suggests “Attracting nursing assistants to the field requires better pay – but keeping them requires sufficient preparation for an increasingly complex job.”[10]  Here, too, the nursing home industry falls short. 

Federal requirements for training for direct care workers have not changed since the federal Nursing Home Reform Law[11] was enacted in 1987.  Federal rules continue to require just 75 hours of training, although 13 states now require between 120 and 180 hours.[12]  Since 1987, the acuity of residents has increased, making aides’ jobs more complex[13] and the need for more training more acute. 

Workers suffer high rates of injury, “three-and-a half times the national average for all other occupations, and musculoskeletal injuries . . .  nearly six times the national average.”[14]

Although there is general recognition that nursing homes are understaffed, PHI estimates that 75.6% fail to meet the staffing levels recommended by the Centers for Medicare & Medicaid Services nearly 15 years ago, in its 2002 report,[15] a time of lower resident acuity.

The result of low wages, poor training, high injury rates, and understaffing is high rates of turnover, costing $3500 per worker[16] and $6 billion annually.[17] 

The nursing home industry is becoming increasingly for-profit,[18] chain-operated,[19] and, in the most recent trend, owned by private equity firms.[20]  Although PHI reports that ownership by private equity firms, in particular, is associated with higher profit margins,[21] the Medicare Payment Advisory Commission reported in January 2016 that Medicare profit margins for the nursing home industry have exceeded 10% for the past 15 years.[22]  Medicare pays for 14% of residents, Medicaid for 63% of residents – a total of more than $80 billion in public funding in 2014.[23]

Policy Solutions

PHI offers a variety of policy solutions including “payment reform . . . combined with a commitment to higher wages, better training and support, and restructured jobs.”[24]

PHI cites the growing movement for a $15 per hour wage,[25] the “Fight for $15” campaign that was described by Leslie Frane, Director of Service Employees International Union (SEIU) Healthcare, and Sarita Gupta, Co-Director of Caring Across Generations at the Center for Medicare Advocacy’s April 1 National Voices of Medicare Summit.  PHI suggests that increases in public reimbursement must be targeted to workers’ salary and benefits through such programs as wage pass-through programs, “voluntary supplemental payments for improving wages,” “direct-service requirement,” and greater transparency about workers’ wages.[26]  Direct care workers need higher wages, benefits, better training, and opportunities for career advancement.[27]


As attorneys and advocates for people who need long-term care services, the Center for Medicare Advocacy strongly supports the movement to improve direct care workers’ lives.[28]  PHI’s comprehensive report sets out the issues and the solutions.

April 14, 2016 – T. Edelman


[1] PHI, Raise the Floor: Quality Nursing Home Care Depends on Quality Jobs (April 2016) [hereafter Raise the Floor],
[2] PHI’s mission is promoting quality care through quality jobs.
[3] Raise the Floor, supra note 1, 4.
[4] Id. 6.
[5] Id. 7.
[6] Id. 7.
[7] Id. 8.
[8] Id. 3.
[9] Id. 13.
[10] Id. 17. 
[11] 42 U.S.C. §§1395i-3(a)-(h), 1396r(a)-(h), Medicare and Medicaid, respectively.
[12] Raise the Floor, supra note 1, 19. 
[13] Id. 19.
[14] Id. 20.
[15] Id. 19.  CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II, Vol. II, (March 2002),
[16] Raise the Floor, supra note 1, 19.
[17] Id. 27.
[18] Id. 11 (70% of nursing facilities are operated on a for-profit basis).
[19] Id. 11 (more than half of nursing facilities are operated by chains).
[20] Id. 11.  See “Nursing Facilities Owned by Private Equity Firms: Fewer Nurses, More Deficiencies,” (CMA Alert, Aug. 20, 2014),
[21] Raise the Floor, supra note 1, 12.  See Government Accountability Office, Private Investment Homes Sometimes Different from Others in Deficiencies, Staffing, and Financial Performance, GAO -1-571 (July 2011),
[22] Raise the Floor, supra note 1, 12, citing Medicare Payment Advisory Commission, Kate Bloniarz and Ariel Winter, “Assessing payment adequacy and updating payments: physicians and other health professional services” (slide 14) (Jan. 14, 2016),
[23] Raise the Floor, supra note 1, 12.
[24] Id. 21.
[25] Id.21.
[26] Raise the Floor, supra note 1, 23.  PHI cites legislation in Pennsylvania that would create a living wage certification program.  See Center for Medicare Advocacy, The Public Cost of Low-Wage Nursing Home Jobs: Pennsylvania Proposals to Stop Hidden Public Subsidies to Nursing Home Injury” (CMA Alert, Dec. 23, 2015),
[27] Raise the Floor, supra note 1, 23-26.
[28] The Center has written about many of the worker issues before.  See “The Public Cost of Low-Wage Nursing Home Jobs: Pennsylvania Proposals to Stop Hidden Public Subsidies to Nursing Home Injury” (CMA Alert, Dec. 23, 2015),; “Is the Movement for a Higher Minimum Wage Coming to Health Care?” (CMA Alert, Jun. 4, 2015),


Comments are closed.