PORTLAND, Maine — Until this summer, Rob Moran thought Community Living Association, a nonprofit that helps adults with intellectual disabilities, had dodged a bullet.

While his southern Maine counterparts struggled with staffing in a tight labor market, Moran never had more than five simultaneous job openings for the agency that used to employ 200 workers in Houlton, in southeast Aroostook County.

“It has been rare when we didn’t have any positions open, but I would have never called it a workforce crisis prior to the pandemic,” he said.

Now, there’s no other way to describe the situation. Moran is struggling to fill 20 open jobs and expects another 15 people to leave when the state starts enforcing a vaccine mandate for health care workers at the end of October.

For Moran and others like him, the principal reason hiring is such a challenge comes down to money. His agency relies on reimbursement from MaineCare, the state’s version of Medicaid, to pay wages. MaineCare reimbursement rates are fixed — Moran can’t simply “raise prices” like many other competing employers can to boost wages. And jobs at many of those competing employers are far less difficult and stressful.

Because it doesn’t have enough staff, Community Living will be closing a group home where five people live, and Moran plans to personally work vacant shifts with clients. He estimates up to 20 rooms for people with intellectual disabilities soon will close across Aroostook County because of the staffing shortage.

“This is the worst it has ever been,” Moran said. “People can job-hop here now — it is a really, really competitive labor market.”

Dozens of nonprofit agencies offer crucial services to Maine’s most vulnerable residents. More than 25,000 front-line workers across the state aid adults and children with disabilities and provide elderly care, according to Maine Department of Labor.

But those employers have struggled to offer competitive wages as the state’s labor market has tightened in recent years. Since the coronavirus pandemic began, what started as a staffing challenge has become a full-blown emergency.

Many place responsibility for the care industry’s low wages on the Medicaid reimbursement system, which provides fixed hourly reimbursement rates to providers for eligible services. Those rates are expected to cover the agency’s costs, but some have not increased in years.

As a result, many workers providing critical, emotionally and physically draining work are also among the lowest paid in the state. Despite injections of emergency cash and a new law to boost wages, advocates worry their industry can’t compete with for-profit business that can offer more attractive pay, benefits and working conditions.

“When we can’t even compete with Walmart and (providing care) is more intensive work, we are at a disadvantage,” said Malory Shaughnessy, executive director of the Maine Alliance for Addiction and Mental Health Services.

High effort, low pay

In recent memory, social services jobs were stable, rewarding and offered good benefits and pay. That’s no longer the case, Shaughnessy said.

“There used to be a time when it was not as hard to keep people — it could be a career ladder,” she said. “That has been broken as (Medicaid) rates have not increased. Increasing benefits and wages would be a huge step in stopping turnover.”

While other worker-starved businesses have adjusted by offering better pay, sign-on bonuses and benefits — or by cutting services — social services agencies are forced to do more with less.

Hundreds of long-term care workers — often called direct support professionals — in testimony before the Maine Legislature this year and in 2020 described stressful, 60- to 80-hour workweeks with hourly pay hovering just above Maine’s $12.15 hourly minimum wage. Conditions lead to burnout, with annual staff turnover rates in long-term care agencies of 55 percent to 70 percent, according to a 2020 report by Maine’s Commission to Study Long-Term Care Workforce Issues.

“Despite having 25 years of experience in the field, I am still paid less than an entry-level worker at a fast-food restaurant,” said Johanna Gilly, a worker for Portland-based Spurwink Services, in testimony provided to the Legislature’s Health and Human Services Committee. “The message sent to us as (care workers) is clear: The work we do and the people we serve are not of value.”

Thousands of Mainers working in the field are a “hidden industry,” said Ellis Baum, regional director of Residential Resources, a disability services agency in Westbrook.

Many positions — even those offering low wages — carry huge responsibilities and require 60 hours or more of initial training and certification. Workers administer medication, keep clients safe and comfortable, attend to their personal care and fulfill a range of other roles, often with minimal supervision. Jobs involve stressful encounters with clients and family members, and in some roles, exposure to violence.

With all that responsibility, it is no surprise that employers struggle to hire and retain good workers. Even though wages at Residential Resources start at $15 to $17 per hour, close to the current market standard, Baum said it still isn’t enough.

“When you look at the work and the responsibility of direct-care staff, that is where you start to see a big disparity with other jobs that pay the same,” he said. “These people are responsible for taking care of human beings.”

Devastating turnover

The consequences of a shallow labor pool for this sector are more serious than long waits for a restaurant table, lines at a retail store or trouble reaching a plumber or electrician.

Waban, a Sanford agency for adults and children with intellectual and developmental disabilities, will close a six-bed group home because of inadequate staffing.

The home’s four residents will move to new places in Waban’s network, but the closure is indicative of a frayed system. Without new staff, Waban can’t take on more clients or expand its preschool programs. That makes it even harder for the thousands of Mainers stuck on state waiting lists to access services, said Waban Executive Director Jennifer Putnam.

“Right now we are in emergency staffing mode, and I am confident we will be in this mode for quite a few months to come,” Putnam said. “I think as a state we have to look at how we are going to provide services for our most vulnerable adults and children in the coming decades, and we need to create a long-term, sustainable solution for that.”

Kate Riordan, a 41-year-old with cerebral palsy, has seen 86 different workers filter through her group home in Brunswick in the past four years, said her mother, Debbie Dionne.

It is a setback for Kate every time a staff member leaves and another new face arrives. When a caregiver who worked there for 13 years left this year, the effect was even worse.

“She was very despondent when this latest person left — she has known them forever,” Dionne said. “The people who work in her home and throughout the agency, they have this incredible gift — I could never do it. It is just amazing to see when it works well, (but) when they leave it is huge loss — Kate loses skills, she becomes despondent and kind of shuts down. It is hard.”

Dionne, a member of the board of directors for the Independence Association, which manages the Brunswick group home, advocated for an increase in caregiver pay and testified in favor of a successful bill this year to raise reimbursement rates to cover 125 percent of the minimum wage.

Dionne worries even a pay increase won’t be enough to attract more people to the field and retain those who are in the workforce now.

“Caregiving is infrastructure. It should be a profession, it should be revered and it should be paid accordingly,” she said. “The general perception is that anyone can do this, but it is a really hard job and it needs to be cultivated at an early age.”

Caregivers undervalued

Last year, the median hourly wage for home health and personal care jobs in Maine was $13.80 an hour, about the same as for retail salespeople, child care workers, short-order cooks, tire repairers and floral designers. The hourly wage was well below $19.45, the statewide median hourly wage, according to the Maine Department of Labor.

State policymakers have not ignored the problem, but immediate solutions are scarce. Last year, lawmakers approved a measure to increase reimbursement rates for direct support professionals, personal care assistants and nursing assistants to 125 percent of the state’s minimum wage. When the law goes into effect next year, those jobs will pay almost $16 an hour and will increase gradually every year.

Policymakers are also in the midst of a comprehensive review of the state’s Medicaid reimbursement system. So far, that review shows a “fragmented and outdated” system for dozens of reimbursable services where some rates get annual reviews and increases, while at least 40 percent have not been updated since 2015.

The coronavirus pandemic made challenges in the field even worse, with workers struggling to reach clients, deadly outbreaks in long-term care homes and pressures that shrank the labor pool further.

Maine Gov. Janet Mills plans to use tens of millions of dollars from federal coronavirus relief to put stopgaps in the programs. An administration plan to invest $229 million of state and federal money into home- and community-based services is being reviewed by the Centers for Medicare & Medicaid Services. It includes $126 million in one-time retention and hiring bonuses for direct support workers and tens of millions of dollars for health workforce initiatives, creating a direct support worker council and establishing a universal worker credential.

“The planned payment of bonuses to new and existing direct support workers and supervisors recognizes the urgent need for investment in the home- and community-based services workforce,” said Maine Department of Health and Human Services spokeswoman Jackie Farwell. “It aims to address both the acute health care worker shortages and the need to increase historically low pay.”

In addition, the administration added $146 million in the state budget for workforce development in nursing homes, hospitals and care homes, awarded $25 million in federal relief funds to recovering health care organizations and increased reimbursement rates for substance abuse treatment and child care providers by as much as 84 percent.

But some in the industry worry that just keeping up with the state’s wage trends won’t be enough to solve the problem years down the road.

“If the rate structure is that everybody will be paid $16 an hour, but $16 an hour is the high average everywhere else, that is just going to be a Band-Aid,” said Catherine Thibedeau, executive director of Independence Advocates of Maine. Her agency serves about 50 clients with a staff of 100. The agency has about 20 open positions and has to offer overtime to cover about 40 percent of the direct care shifts.

“If these positions are so important to society, why is it structured so that people have to work 60 to 80 hours a week just to take care of their family?” Thibedeau said. “These positions need to be valued. If you asked the average person on the street, ‘Do you think this is a minimum-wage job?’ they would say no.”

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