mittee is proposing to strengthen—the methods for training and certifying personal- and home-care aides are much more inconsistent from state to state, with no formal system in existence. The committee’s recommendation with regards to these workers is intended to create a basic framework for further requirements that may be implemented by states and the federal government in the future, especially as the knowledge base about the education and training of all types of direct-care workers develops.

As described previously, wages for direct-care workers are low and do not appear to adequately support the recruitment and retention of these workers. In a classic economic model of a labor shortage, wages, benefits, and other job attributes would simply improve until enough workers were willing to fill the positions, and the shortage would no longer exist. However, given that Medicaid and Medicare are responsible for about 70 percent of all long-term care dollars spent (Komisar and Thompson, 2007), there is little room for the market to adjust without the government’s being willing to commit additional funds.

Evidence shows that higher wages do in fact lead to lower rates of turnover among all types of direct-care workers (Howes, 2005, 2006; Sherard, 2002). In seeking to find ways to increase wages for direct care workers in this environment, several mechanisms have been employed, including: setting a minimum service rate percentage that must to be passed through to direct-care labor costs; creating rate enhancements for providers that compensate their workers at a higher level; establishing automatic cost-of-living-adjustments to be passed through to direct-care labor costs; and establishing procurement and contracting standards that specify