Pennsylvania’s home care industry is in crisis, with low pay and unfilled shifts driving it toward collapse

Six days a week — including two overnight shifts — Cynthia Melton takes the bus to Marlene Williams’ home in Olney.

Melton, 63, has been a certified nurse’s aide for 40 years, the majority of which she spent working in nursing homes. She switched over to become a home health aide for agency Ameribest eight years ago, going from 16 to 18 patients at a time in the nursing home to focusing on just one: Williams, 62, who has multiple sclerosis and requires nearly round-the-clock care.

Melton cares for Williams like her own family, just as she would have wanted someone to care for her late mother. If that means staying several extra hours for little-to-no overtime pay on already low wages or covering another aide’s shift, so be it.

“I tell [Williams], ‘I’m taking care of you,’” Melton, of East Germantown, said just before she began a shift last month. “We have to work together. You’re putting your life on me.”

The work is strenuous. When Melton comes in for a morning shift, she helps Williams get out of bed, wash up, and dress before getting her set up in her wheelchair for the day. She prepares her meals, and assists Williams with whatever she needs throughout the day.

Melton is one of Pennsylvania’s more than 270,000 home care workers, who on average are paid $16.50 an hour on the state’s $20.63 Medicaid reimbursement rate, earning about the same for the physically demanding care they provide as what their local convenience store or fast food chain pays workers. Pennsylvania lags behind all of its neighboring states by nearly $5 per hour in Medicaid reimbursements, translating to lower wages and increased employee turnover.

It’s a disparity that has festered for years. But now, the association representing home care agencies has put out a dire warning: If Pennsylvania state lawmakers don’t invest $550 million more to increase Medicaid reimbursements for home care workers this year, the crisis for home care will only worsen and endanger Pennsylvania’s growing aging population, as more than a third of the state’s population will be at retirement age by 2030. Seniors who want to stay in their homes, rather than moving into skilled nursing facilities when they can no longer care for themselves, make up a large portion of home care clients.

Gov. Josh Shapiro, a Democrat, proposed as part of his $51.5 billion budget pitch last month that the state invest an additional $21 million to raise wages and cover vacation time of 8,500 non-agency home care workers, who make up only 6% of the total home care workforce. He did not propose any rate increase for agency home care workers, who represent the majority of home care workers, working for organizations like Ameribest, Bayada, or locally owned agencies.

Shapiro’s Department of Human Services released a rate study after his budget address that acknowledged that Pennsylvania’s home care agencies need a reimbursement increase by 23% to $25.42 per hour so that agencies can offer competitive wages above the current $16.50 average.

Mia Haney, the CEO of the Pennsylvania Homecare Association, said that due to low pay and worker turnover, 112,000 home care worker shifts go unfilled in Pennsylvania each month.

“That’s 112,000 times that somebody is waiting for somebody to arrive, and no one is coming,” Haney said. “That scenario is only going to worsen.”

More than 3 million Pennsylvanians use the state’s Medicaid program — eligible groups include seniors, children, and people with disabilities who meet specific income guidelines, among others — and can receive in-home care through the state’s insurance. However, the state is only willing to reimburse up to $20.63 per hour for work by a home care agency. That payment is then mostly passed on to the direct care worker — on average, $16.50 an hour — with the agency keeping some of the pay for administering the health-care program.

A spokesperson for Shapiro said in a statement that the governor’s home care proposal was targeted to the specific subset of the home care field that has fewer resources than agency workers, as part of his efforts to address larger workforce challenges across the state.

“As the governor made clear in his budget address, we have to be there for home care workers and individuals receiving home care services all across Pennsylvania, and his administration will continue working to bring people together to deliver results on these key issues,” said Manuel Bonder, Shapiro’s press secretary.

Home care agencies see the $550 million investment as both necessary and as a long-term cost-savings for the state. The cost of living in a residential facility — which, on average, can exceed $10,000 a month — is more than double the average cost of remaining in one’s home. People who stay in their homes, or “age in place,” also report better quality of life and health outcomes, Haney added.

Lawmakers and Shapiro will begin negotiating the state’s annual budget this summer, though the challenges in the home care industry was not a core concern among legislators during budget hearings in the state House and Senate earlier this month.

» READ MORE: Balancing a national profile and a new Trump term, Gov. Josh Shapiro’s budget pitch toes the line

Shapiro’s budget proposal makes major investments in other parts of the health-care continuum, including a $2.5 billion increase in Medicare payments after underestimating how much costs would rise in the 2024-25 budget year.

But Haney and agency leaders say they can’t wait any longer for a Medicaid reimbursement rate increase for agency home care workers, which rose by only about $2 over the last decade — most of which occurred during the COVID-19 pandemic. More than 80% of direct care workers employed by home care agencies in Pennsylvania are women and 46% are people of color, Haney added, which means the low wages disproportionately affect them.

“We can’t sit back and say, ‘We’re OK if you skip us,’” Haney said. “We’ve been skipped for multiple years. It’s scary, and we are genuinely concerned. We want to protect our patients, and we want to protect our direct care workers.”

Home care is not only necessary for senior or physically disabled adults. The industry also plays a critical role in helping pediatric patients transition from a hospital setting to their homes.

Andrea Smith’s now 3-year-old son Drew was born 100 days early and spent the first nine months of his life in a Philly hospital. He was chosen for a Bayada initiative called the HICU — Home Intensive Care Unit — specifically designed for medically fragile children who are likely to be hospitalized again within 30 days.

But once Drew graduated from the HICU, Smith struggled to find reliable nursing staff to care for her son, who until November had a tracheostomy tube to help him breathe and still requires care during the day and evening. At one point, Smith said she lost her job as a teacher’s assistant at a Philadelphia charter school, after having to call out of work to take Drew to appointments or when she was unable to find care for him.

“Some days my nights were covered, but my mornings weren’t,” Smith said. “He was literally on a trach. He couldn’t be disconnected from the trach all day, and he had to be watched around the clock. You can’t even take a shower without someone watching him.”

Smith, who lives in North Philadelphia, has gone through approximately 15 nurses in her son’s short life so far, including one who was afraid of touching his trach. She remembers the best of them, though, and was heartbroken to see some of her favorite nurses leave the home care field for better pay in local hospital systems, she said. Direct care workers are paid by the agencies they work for, and that pay is determined by a state’s reimbursement rate.

“They become family once they come in your house,” Smith said. “When I look back at my cameras, I see them singing to him, reading to him … The majority of my nurses that cover me, I wish I could’ve done something or had the money to keep them. They were good nurses, but they couldn’t just work for Drew and make it enough to take care of their livelihoods.”

Shea Boland, who handled Drew’s case and is the director of Bayada’s local pediatric home care program, said nurses will often choose to work in home care because they like the flexibility of creating their own schedule and caring for one specific patient. But the low reimbursement rates prevent agencies from increasing their hourly rates, and therefore, the highest-quality Philadelphia-area nurses often look for higher-paying jobs at local hospital systems, or in neighboring New Jersey, where hourly rates top $25.16.

“It’s incredibly competitive, the market in Philadelphia,” Boland said. “The fact they can cross a bridge and make more money has a negative impact.”

For Melton, the longtime CNA, she knows she could go back to school if she wanted to, or get a higher-paying job. But she doesn’t want to at this point in her life.

“This is my life. I love what I do,” Melton said. “We there for them like their own kids. The kids [are] not there for them, so we need to take care of them.”