Pennsylvania’s funding structure for homecare for older and disabled adults puts the commonwealth at a disadvantage with neighboring states, while leaving many vulnerable residents with inconsistent care — or no care at all. While Gov. Josh Shapiro has proposed a modest new investment in the system in this year’s budget, it would only boost pay for direct care workers who provide about 6% of home-based care in the state.

The problem is that so many aspects of the state’s Department of Human Services are underfunded — such as the state’s system of care for people with intellectual disabilities and autism (ID/A), which the Editorial Board has frequently observed. This forces organizations representing different kinds of caregivers to fight for pieces of a toosmall pie. This is a long-term problem caused by Harrisburg’s failure to invest in largely invisible care for vulnerable people who don’t have powerful lobbyists advocating on their behalf.

That means it’ll take a long time to fix the problem: incremental increases in funding, with a firm goal to ensure everyone who is owed care can receive that care. That requires giving all direct homecare workers (DCWs) the same wage boost currently being offered to a small subset of workers.

COMPLEX SYSTEM If you are a Pennsylvania resident who meets certain income eligibility limits and is over 18 and disabled, or over 60 and facing health problems that can be treated at home, you can apply for a Medicaid homecare waiver. Once approved, there are three ways you could receive your care.

The first option is called “participant- directed” care, which involves you selecting an individual care worker, who is essentially a free agent. You are responsible for working with your DCW to manage scheduling, and if your care worker can’t make a shift, you’re probably out of luck. Some people prefer the independence and flexibility of this model, which accounts for about 6% of homecare in Pennsylvania.

The second option is working through an agency. These organizations — some nonprofit, some for-profit — handle all the administrative duties, and can try to find a replacement if your usual DCW can’t make it. Most people prefer this more traditional model of care.

The third option is managed care organizations (MCOs). If you’re enrolled in an MCO — such as the Community HealthChoices options offered by UPMC Health Plan, PA Health & Wellness (a division of Centene) — that organization will work with agencies on your behalf. MCOs are reimbursed by Medicaid on a per-member/per-month scheme, which means they have a fixed amount to spend on all types of Medicaid-funded services, including homecare. This is meant to control costs, but it also introduces a profit incentive to deny care — a topic for another time.

INCONSISTENT CARE Just receiving a waiver is not a guarantee that a DCW will be immediately available. According to the Pennsylvania Homecare Association, which represents agencies, the state “support coordinator” assigned to your case is likely to have to call over a dozen agencies to find a single available DCW. Further, the state doesn’t track how long it takes to find a worker, which means we don’t know how long the average Medicaidapproved patient has to wait for care he or she is entitled to.

What we do know is that in a system that cares for about 140,000 Pennsylvanians, about 112,000 care worker shifts are missed each month.

These lapses are largely due — as they are across the state’s systems of care — to low reimbursement rates. These are the per-hour amounts the state pays agencies for the labor DCWs provide, as well as associated administrative costs. And they’re far too low.

Since 2012, despite a period of high inflation, the key rate has only increased about $2 an hour, to an average of $20.63. Further, the state is divided into quadrants, and the southwest quadrant has the lowest rate, $19.32, along with the lowest reliability for care.

In the same period, the amount agencies are actually paying has gone up nearly $5 an hour, because the only way to remain remotely competitive is to outpace the state reimbursement rate. This means they’re absorbing more and more costs while struggling to be able to attract workers; meanwhile late rate are leading to agencies closing, reducing healthy competition.

It’s all the more difficult when every neighboring state has reimbursement rates 25% to 75% higher than Pennsylvania’s. Many DCWs live here, but work across the border.

SHORING UP THE SYSTEM In his 2025 budget address, Mr. Shapiro touted a major investment in homecare DCWs — but under the hood there’s not much to it. The funding boost is $21 million, and accounts for a 10% increase in the reimbursement rate for DCWs only in the participant- directed care system, which accounts for a very small part of the overall system.

The Homecare Association estimates that spreading that increase across the entire system, including the subsequent increase to the MCO per-member/per-month rate, would be $370 million. That won’t be easy to find in a state still running a structural deficit — but allowing vulnerable Pennsylvanians to go without care, or with inconsistent care, isn’t an option.

One structural fix would be to require regular reviews of reimbursement rates. This already occurs within the Department of Developmental Programs, where ID/A programs live, but not in the Office of Long-Term Living, where homecare services live. Ideally, these rates would be pegged to an annual measure of inflation. But barring that, regular reviews — say, every three years — would ensure they don’t depend on the legislative for paltry boosts, which only happen when legislators’ extremely divided attention can be captured.

Ultimately, the goal must be to ensure homecare rates are competitive with other states. But a 25% increase would cost over $800 million, which is unrealistic in a single budget cycle. Harrisburg leaders should commit, however, to reaching that competitive level within five years.

A community is judged on how it treats its most vulnerable members. Pennsylvania must do better.

— Pittsburgh Post-Gazette via TNS