Blockchain Papers

Suzanne Meeks, Howard Degenholtz

Workforce challenges are a persistent feature of the long-term care landscape, while the landscape itself is shifting. In the United States, from 1985 to 2015, a decline in the proportion of low-acuity residents has occurred in concert with the growth of assisted living (Silver et al., 2018) and a shift of Medicaid-financed long-term care toward home- and community-based services (Eiken, 2015). As a result, nursing homes serve a larger proportion of people who are admitted from hospitals and paid for by Medicare (Fashaw et al., 2019). As acuity of care needs increases in these settings, the industry increasingly depends on a complex myriad of direct care and specialized workers. Workforce issues intersect with provider and policy interests: The workforce is the providers’ largest cost, whereas policymakers see the workforce as a lever to influence the quality of care. Workforce issues also intersect with larger social issues. For example, immigration policy influences the long-term care workforce, as do state and federal minimum wage laws. The larger economic environment and prevailing wages in other service industries affect the labor supply, especially in long-term care. As we saw in 2020, existing workforce concerns collided with infection control and acute illness care during the pandemic of coronavirus disease 2019 (COVID-19). Lastly, but not least in importance, workforce issues affect the quality of life for the people who live in long-term care settings. In short, workforce issues are the most significant challenges facing the long-term care industry. Although considerable research attention has been paid to long-term care workforce topics, the editorial team at The Gerontologist recognized that important questions remain, prompting the call, in the fall of 2019, for this special issue on workforce issues in long-term care. We little knew when the call for papers went out that a pandemic would throw a bright spotlight on long-term care, especially nursing homes, making this issue even more timely. The articles in this issue paint a picture of stagnated progress and thorny challenges, but their rich and varied methodologies and perspectives also offer the field some glimpses of optimism that we can leverage diverse approaches to improve long-term care. Taking a broad perspective, Foley and Luz (2021) evaluate progress on the workforce development goals set forth in the 2008 Institute on Medicine (IoM) report “Retooling for an Aging America” (IoM, 2008). They highlight the continuing shortages of both geriatricians, a workforce sector that appears to be shrinking despite the increasing need, and direct care workers. Their conclusions are disturbing: Since 2008 only one of the IoM report recommendations has been completely met, and several have not been addressed at all. As the numbers of older patients grow, the United States, at least, has made little progress on meeting the workforce pressures to meet their care needs. Scales’ (2021) Forum article summarizes the current state of the direct care workforce, highlighting the preponderance of women of color and emphasizing how the work of caring continues to be devalued, as manifested in poor compensation, heavy workloads, and inadequate training and support. Despite these ongoing challenges, Scales offers optimism and a call to action, noting the opportunity to leverage the emergency responses to the COVID-19 pandemic and the crisis in long-term care settings it engendered. She calls for disseminating tested interventions, especially upskilling and empowering direct care workers and changing to value-based payment models. Two studies in our collection support these recommendations. Wu et al. (2021) studied the impact of a policy change in Taiwan that instituted a new payment system for home care services. The policy shifted payment from a per-hour rate to a per-service rate, increasing flexibility of home care workers’ time and allowing the opportunity for higher reimbursement for more efficient service delivery, leading to an increase in the workforce. Gleason and Miller (2021) found that supervisor support and degree of control on the job were associated with home health aides’ job satisfaction and intention to leave among respondents to the 2017 Massachusetts Home Care Aide Survey. Together these two studies illustrate how policy and workplace practices might influence workforce size by attracting workers, on the one hand, and retaining them, on the other. Articles by Castle (2021) and Kennedy et al. (2021) are also relevant to the important challenge of retaining direct care workers. Castle points out that the problem cannot be studied adequately if the concept of retention is not operationalized adequately. In this useful measurement study, he compared different definitions of retention, integrating data from the Nursing Home Compare and Certification and Survey Provider Enhanced Reporting databases. He concludes that the best indicators of care quality are 3- and 5-year retention rates. Kennedy et al. compared retention rates for direct care workers in assisted living and nursing homes using an Ohio data set. Their results showed comparable retention rates across settings, but predictors of retention differed. Retention strategies should take into account context, including work settings and their attendant resources and regulation. Although long-term care workforce policy is often associated with standardized quality indicators, these are only indirectly associated with resident quality of life. Using a novel, hermeneutic approach to policy analysis, Hande et al. (2021) examined the connections between decentralized Canadian long-term care regulations and resident quality of life. They found that newer regulations tended to provide more flexibility for staff to promote resident quality of life. Despite the overall tendency of regulations to be rigid and safety-oriented, the findings offer some optimism that more flexible regulations might support the goal of empowering staff to emphasize quality of life for residents. Whereas the aforementioned articles approached the direct care workforce from a policy and large data set perspective, three qualitative papers privilege the perspectives of those workers. Douglas et al. (2021) explored the pressures associated with mealtime assistance, a burdensome task that is often an “extra” duty for nursing assistants. Their findings show the importance of training for this task, emphasizing the importance of verbal and nonverbal communication skills to this intimate social interaction. Cooke and Baumbusch (2021) further examined the interpersonal climate of the care facility in their critical ethnographic study of two Canadian nursing homes. This work documents power dynamics among nursing home staff, showing how incivility and bullying relate to team collaboration, and how these dynamics affect care delivery. Cooke and Baumbusch conclude that, although increasing staffing numbers may alleviate some care burdens and improve quality of care, considering who is working and how they interact may be equally important. Themes of managing time pressures cut across these qualitative analyses and are the focus of a study of Swedish nursing assistants (Lundin et al., 2021). The workers’ accounts depict nursing assistants as a collective “we,” facing, on the one hand, the “they” of residents, largely drawn as passive recipients of care, and, on the other hand, the “they” of administrators who impose burdens that are not always related to direct care of residents. This paper explored how workers prioritize their time among these demands, the values that they use for prioritizing, and how those values are compromised. Together these three qualitative studies enrich our understanding of the day-to-day experiences of direct care workers and emphasize how institutional contexts may affect the link between workers and quality of care. The challenges faced by direct care workers are compounded by an external environment that devalues this work. The systematic review by Machha et al. (2021) found that work in aging care remains highly stigmatized. This review applied a linguistic framework to English-language articles addressing stigma in aging care. The analysis demonstrates how the work of caring for older people and the workers who do this work are stigmatized, although the nature of that stigmatization depends on the social position of the people studied. Unsurprisingly, such stigma affects recruitment, job satisfaction, and worker well-being. The joint import of support and training connects the quantitative and qualitative work in this collection; enhancing the direct care workforce involves increasing numbers and increasing their skills. A key skill needed in all long-term care settings is the ability to work with people living with dementia. McKay et al. (2021) address training directly in their comparison of a traditional skills training approach to an approach based on an occupational adaptation (OA) framework. Although both groups improved in skills mastery, the OA-based group showed greater gains, developing more cooperative approaches to solving the complex problems typical in dementia care. This exploratory study suggests that OA-based training has the potential to address climate and skills issues that challenge worker satisfaction and effectiveness in long-term care settings. As Foley and Luz (2021) point out, the increasing acuity of nursing home residents demands changing models of medical care delivery. Katz et al. (2021) review current models, noting that shortages of geriatricians have led to greater proportions of care delivered by nurse practitioners, physician assistants, and skilled nursing facility specialists. At the patient care level, involvement of these nonphysician professionals may lead to higher quality of care, but Katz et al. argue that there is insufficient research to determine which models of care are ideal. They call for rigorously testing these models in the future. As a start, Wagner et al. (2021) regressed Nursing Home Compare quality measures onto provider and institutional characteristics. They found that having a staff physician was associated with fewer emergency room admissions, but greater use of antipsychotic medication for long-stay residents. Their findings suggest that policies that favor a particular model may not yield unambiguously positive outcomes. Further research is needed to compare different care models directly to one another. McGilton et al. (2021) demonstrated how, during the COVID-19 crisis, nurse practitioners in rural and urban Canadian nursing homes took on the burdens of containing the spread of the virus, stepping in to cover gaps across the workforce spectrum from nursing to medical care, providing support for staff and families, and creating linkages across health care systems such as emergency medicine and psychiatry. Nurse practitioners in this qualitative study demonstrated flexibility in being able to span the complex needs of postacute care systems, supporting McGilton et al.’s call for increasing the formal involvement of nurse practitioners in these systems. Clearly, administrative structures, workplace climate, training, and support are important factors in creating a thriving workforce for long-term care. Missing thus far in the articles discussed is a focus on the individuals with the most administrative power within these settings: administrators and directors of nursing. A scoping review by Siegel and Young (2021) reveals important gaps in our knowledge about these key players. They found no studies of how administrators and directors of nursing work together to navigate the complexity of demands they face, although anecdotal evidence suggests that this relationship is critical. This review suggests that there is a great need for theory-based studies of the organizational process to understand how to improve important workplace characteristics to make long-term care jobs more appealing. Overall, this collection of articles spans the long-term care workforce from the front line to the back office, from rigid hierarchies to flexible models that promote creativity. When we started on the path to producing this collection, we knew that the way forward would have to negotiate a complex and changing landscape. If the shared goal is that long-term care should provide both high-quality care and the opportunity for a good life, the resulting articles lay out many of the challenges faced by policymakers, practitioners, and providers. At the same time, new models of care and new ways of thinking about and defining “work” have perhaps moved us a few steps down the path. The COVID-19 pandemic has laid bare the need to reinvest in the long-term care workforce, and we hope that this collection will provide positive guidance for future research and policy.

Eric R. Kingson, Molly W. Checksfield

White House Conferences on Aging, held roughly every 10 years since 1961, have “generated ideas and momentum prompting the establishment of and/or key improvements in … programs that represent America’s commitment to older Americans” (The White House, 2015a). In terms of economic security, notably, the 1961 conference gave a push to the enactment of Medicare by recommending the provision of medical care for the aged through Social Security (Senate Special Committee on Aging, 1961). In 1971, President Nixon advocated inflation-proofing Social Security benefits, saying “It does not make sense to have … benefits constantly behind inflation” (Nixon, 1971), language backed-up when he signed the 1972 amendments to the Social Security Act implementing automatic cost of living adjustments (the “COLA”). While unlikely that this year’s conference will see the fruits of its labor enacted into sweeping policy change in the near term, it could play an important agenda-setting role for future congresses and presidents if conference planners and delegates: Explicitly reject the “entitlement crisis frame” and language; Advance the intergenerational understanding of Social Security; Highlight economic insecurity among today’s seniors Sound the alarm on the looming retirement income crisis; Consider benefit increases in Social Security as a critical option Once a neutral budget term, “entitlement” has taken on new meaning in policy, media and even everyday discourse—one that diminishes the dignity of the old and contributes to the mis-framing of policy discussions about the economic consequences of the aging of America. Conference planners and participants should reject “entitlements” language and urge politicians and the press to do likewise. Here’s why. Americans properly understand Social Security and Medicare as benefits they have earned through lifelong contributions from their (or a family member’s) earnings, not as a “hand-out.” Medicaid, in turn, ensures that the poor as well as many very sick Americans obtain needed health care. Subtle or not, “entitlement” terminology implies that somehow such benefit protections are not deserved. Intended or not, the language chips away at the self-esteem and reinforces negative stereotypes that somehow the old—like spoiled, overly entitled children or adults—are demanding and taking more than they deserve (Altman & Kingson, 2015). The terminology of entitlement is functional for those wanting to scale-back or otherwise radically change—Social Security, Medicare, and Medicaid. Rather than frontally attacking these popular programs, it allows them to obfuscate their intentions by attacking “entitlements.” Lumping these programs together as a “unified entitlement problem” provides a convenient frame for advancing and reinforcing the claim that entitlement spending is the largest cause of federal deficits and the national debt, and that left unchecked this spending will bankrupt the nation. As William Greider writes in The Nation, the political consequences of this shift in meaning are not benign: For many years, the smug elites of Wall Street have peddled “entitlement reform” as a sly euphemism for cutting Social Security. And Washington’s political elites, including President Obama, bought into the propaganda. Social Security, not to mention Medicare and Medicaid, was driving the nation into ruinous debt if government did not act to curb this venerable New Deal program. Think tanks and editorial writers, political reporters and TV talkers, witlessly embraced the big lie and promoted it as indisputable truth (Greider, 2014). Equally problematic, the terminology of “entitlement,” “entitlement problem,” and “entitlement crisis” distracts attention from tax spending sprees (e.g., profligate tax cuts and expenditures primarily benefitting well-off constituencies), two wars paid for with credit cards, financial mismanagement leading to the near collapse of our economy, and widening inequalities of income and wealth. Whatever the problem, this frame offers cuts to spending on Social Security, Medicare, and Medicaid as solution. At any one point in time Social Security serves all age groups and, over time, all generations. Princeton economist J. Douglas Brown, an architect of the Social Security Act, spoke eloquently of Social Security as a covenant reaching across generations and arising from a commitment to mutual responsibility that undergirds civilization. This covenant “underlies the fundamental obligation of the government and citizens of one time and the government and citizens of another time to maintain a contributory social insurance system” (Brown, 1977, 31–32). The most important source of income for retirees, Social Security is also working American’s most reliable disability insurance and the nation’s largest children’s program. Indeed, 3.4 million dependent young children and one million dependent adults disabled before age 22 receive benefits each month. The most significant source of income flowing into the homes of 7.4 million children being raised by grandparents or other older relatives, Social Security is also the most important life and disability insurance working parents have, protecting nearly all of the nation’s 74 million children. As important as Social Security is for today’s old, it is likely to be even more so for today’s young- and middle-aged workers. Indeed, it is they who have more at stake if benefits are cut or expanded (Altman & Kingson, 2015). Unfortunately, in policy discourse Social Security is often presented—by both friends and foes—as if it is only a program for the old. And, the prime sponsor of this year’s WHCOA contributes to this mischaracterization. The President’s 2007–2008 presidential primaries and general election campaigns and the White House website provide case in point. Unionists, women, religious groups, environmentalist, and the like were listed among the 25 or so groups providing special support for candidate Obama (e.g., “_____ for Obama”). “Seniors for Obama” was nowhere to be found on this list. Instead, seniors were assigned to the “Issues” section of the website under “Seniors and Social Security.” The problem here is that “Seniors” are not issues, and, “Social Security” benefits and policy concerns everyone, not just seniors. A one-time occurrence would be of little concern. But in spite of requests by supporters engaged in the campaign and followed by similar requests at White House meetings, “Seniors” and “Social Security” remain joined under the “Issues” tab on The White House (2015b) website (see Figure 1). Seniors are not issues. Like the contemporary use of the word “entitlement,” intended or not, defining seniors as “an issue” is, at best, inaccurate, and, at worst, disrespectful. And presenting Social Security narrowly as an issue primarily of concern to the old misframes policy discussions. So, it is time for the White House to push the “reset” button… Language frames issues and conveys attitudes. Like the contemporary use of the word “entitlement,” intended or not, defining seniors as “an issue” is, at best, inaccurate, and, at worst, disrespectful. And presenting Social Security narrowly as an issue primarily of concern to the old misframes policy discussions. So, it is time for the White House to push the “reset” button with regard to how it talks about older Americans and Social Security. Failing this, the WHCOA delegates could perform an important service by raising such concerns. By virtually any measure, the economic status of the old has, on average, improved since the 1950s, with, for example, poverty rates declining under the official poverty measure from roughly 35% in 1959 to 9% today (15% when the Census Bureau’s new Supplemental Poverty measure is used). But contrary to stereotypes, most seniors are not living on easy street. A small percentage is wealthy, while many more live in poverty or near the margin of economic insufficiency. Indeed 48% of seniors are economically vulnerable when 200% of the New Supplemental Poverty Measure is used as the standard. Others—including many among the one out of four senior households with annual incomes in excess of $50,000—are comfortable but often only one shock away from serious financial problems (Altman & Kingson, 2015). Monthly Social Security benefits for seniors are modest, averaging just $1,328 in January 2015. Yet, two thirds of beneficiaries, 65 and over, receive at least half of their income from Social Security (U.S. Social Security Administration, 2014). While the struggle to make ends meet is a burden many seniors face, this pattern of economic stress is generally more pronounced among particular demographic groups—notably Latinos, African Americans, unmarried women, and the oldest old—who are very much at risk for living in poverty based on their limited access to resources and societal limitations that have prevented many from accumulating wealth over their lifetimes. Also, a large numbers of older workers, with health limitations and/or little opportunity to work, accept Social Security retired worker benefits at early ages (e.g., 62), thus sustaining large, permanent reductions in their monthly benefits. Social Security has helped maintain a standard of living for many families of color in America that may otherwise not be possible. People of color rely more heavily on survivor and disability benefits, reflecting lower educational attainment and higher incidence of poverty and morbidity (Martin, 2007). While non-Hispanic whites are more likely to possess wealth outside of their Social Security retirement benefits, many people of color rely solely on what they earned from Social Security for financial stability (Rockeymoore & Lui, 2011). Many people of color have also been unable to obtain wealth through their lifetimes due to past racial discrimination in American policies, yielding a disproportionate reliance on Social Security benefits to ensure that they are able to meet basic monthly expenses. While acknowledging the heterogeneity of economic circumstance among today’s old, the 2015 WHCOA provides opportunity to highlight the very real financial insecurities facing the majority of seniors today, especially those who are most vulnerable. American workers face a looming retirement income crisis, where far too many will find themselves unable to maintain their standards of living when they grow old. Allianz Life Insurance Company reported, from its 2010 survey of 3,257 people, that “an overwhelming 92%” answered that they absolutely (44%) or somewhat (48%) believe that the nation faces a retirement income crisis, with “more than half (54%)” of persons ages 44–49 saying they are “totally unprepared” for retirement (Allianz Life Insurance Company, 2010). In their 2013 retirement confidence survey, the Employee Benefit Research Institute found that only “13 percent are very confident they will have enough money to live comfortably in retirement,” the lowest ever reported in the 23 years of conducting this annual survey. This lack of confidence is not surprising as the past 35 years have not been good to most American workers. Only the top 10% of the income distribution have seen aggregate gains in household income (Picketty, 2014). From 1979 until the eve of the Great Recession in 2007, almost two fifths of all gains in household income were received by the top 1% (Hacker & Pierson, 2010), while men in the bottom 60% saw their real wages decline (Economic Policy Institute, 2012). Further, traditional private sector defined benefits are rapidly disappearing, public sector plans under political attack, and 401K and related retirement vehicles primarily benefit the well-off. And changes enacted in the 1983 (e.g., raising retirement ages, taxing benefits) have reduced benefits by roughly 24% for persons born after 1959 (Altman & Kingson, 2015). The economic crash furthered the deterioration of retirement prospects for countless individuals. Since 2008, many people in their 40s and 50s have been balancing substantial losses of 401(k), IRA and other savings, pension protection, housing equity, and job security with the rising cost of health care and college tuitions. The median income of households headed by persons 55–64 dropped from $61,700 in 2009 to $58,626 in 2012 (Kingson, 2013). Post-crash in 2013—after the stock market increased and housing prices improved—52% of households were on a glide path to an inadequate retirement income (Munnell, Hou, & Webb, 2014), presumably as much as two thirds more if health and long-term-care costs were included in this risk assessment (Altman & Kingson, 2015). According to the Pension Rights Center there is a $6.6 trillion deficit between what Americans have saved for retirement and what they should have saved in order to maintain their current standard of living. According to the National Institute on Retirement Security 38.3 million working-age households (45%) do not have any retirement account assets (National Institute on Retirement Security, 2013). Even among working households with retirement savings, “Four out of five working households have … less than one times their annual income” (National Institute on Retirement Security, 2013, 11). Thus, the WHCOA has an important opportunity to sound the alarm on the retirement income crisis. … the WHCOA has an important opportunity to sound the alarm on the retirement income crisis. Responding to the looming retirement income crisis of today’s workforce and tenuous economic circumstances of many among today’s retirees, legislative proposals are being advanced which increase Social Security’s modest, though vital, protections while simultaneously strengthening program financing. These proposals include revenue measures such as lifting the payroll contribution ceiling, gradually increasing the contribution rate over 20 years, and diversifying trust fund investments. With respect to today’s and tomorrow’s retirees, on the benefit side, they include such proposals as modest across the board increase in benefits, larger minimum benefit payments for low wage-workers, caregiver credits, and use of the Consumer Price Index for the Elderly (CPI-E) to calculate COLAs. A poll by the National Academy of Social Insurance (NASI) indicates that our Social Security system is supported across all political groups; self-reported Democrats, Republicans, and Tea-Partiers alike agree that Social Security benefits should be expanded because they understand the importance of the system to their families and communities (Tucker, Reno, & Bethell, 2013). Americans favor having millionaires and billionaires pay the same rate by raising the payroll contribution cap, currently set at $118,500 for 2015 (U.S. Social Security Administration, 2015). Of course, many disagree with the proposition that it is time to expand Social Security, but that should not stop the WHCOA from recommending that very serious consideration be given to such proposals. Whatever the outcome, the nation will benefit from a full and open debate and the WHCOA can serve as vehicle to facilitate such debate. The 2015 White House Conference on Aging has the opportunity to delve into diverse issues affecting older Americans, their families, and caregivers. As 2015 begins, we look forward to the 80th Anniversary of the Social Security Act as well as the 50th Anniversaries of Medicare and Medicaid—institutions that have reduced poverty, helped families sustain their standard of living and strengthened the national community. Addressing the retirement income crisis and significant income problems of today’s retirees in a way that recognizes the importance of intergenerational commitments and supports the expansion of the nation’s most successful and popular domestic policy will resonate most effectively with the American people. E. Kingson, Professor of Social Work at Syracuse University is Founding Co-director, Social Security Works and Co-chair of the Strengthen Social Security Coalition. M. Checksfield is Legislative Director of Social Security Works and the Strengthen Social Security Coalition. Partial support for the writing of this article was provided from a grant received by Social Security Works from The Atlantic Philanthropies.

Per Johansson, Martin Nilsson

Sweden has obligatory sickness and disability insurance which is both financed (from payroll taxes) and administrated by the government. In order to receive sickness benefits, insured individuals must have certificates issued by a medical doctor. Since health care is administrated at the county level, this means that monitoring is, to some extent, decentralized at a lower jurisdictional level than the funding and governance of the insurance. This paper studies one consequence of such decentralization: the effet on individual sickness absence when such certificates are not approved be the Sickness Insurance Agency (SIA) and are instead re-remitted to the doctor completion and, potential, reapproval by the SIA. We find that this re-remission increases the length of sickness absence spells by an average of 30 percent. A suggestive test of the reason for the observed effect indicates that it is due to a decrease in health caused by increased stress related to the uncertainty about entitlement and future sickness benefits. Given that added resorces improve the quality of the patients' medical certificates, directed intergovernmental grants from the state to the counties would be cost saving.

David E. Bloom, Ajay Mahal, Larry Rosenberg, Jaypee Sevilla

Abstract The rapid ageing of India's population, in conjunction with migration out of rural areas and the continued concentration of the working population in the informal sector, has highlighted the need for better economic security arrangements for the elderly. Traditional family ties that have been key to ensuring a modicum of such security are beginning to fray, and increased longevity is making care of the elderly more expensive. As a result, the elderly are at increased risk of being poor or falling into poverty. In parallel with its efforts to address this issue, the Government of India and some of the Indian states have initiated an array of programmes for providing some level of access to health care or health insurance to the great majority of Indians who lack sufficient access. Formal‐sector workers have greater social security than those in the informal sector, but they only represent a small share of the workforce. Women are particularly vulnerable to economic insecurity. India's experience offers some lessons for other countries. Although there is space for private initiatives in the social security arena, it is clear that most such efforts will need to be tax‐financed. The role that private providers can play is substantial, even when most funding comes from public sources, but such activity will face greater challenges as more individuals seek benefits. India has also shown that implementation can often be carried out well by states using central government funds, with a set of advantages and disadvantages that such decentralization brings. Finally, India's experience with implementation can offer guidance on issues such as targeting, the use of information technology in social security systems, and human resource management.