The hardest part of Culix Wibonele's first job in long-term care was not getting injured.

Originally from Kenya, Wibonele worked as a certified nursing assistant in Atlanta in 2014. She went to the homes of mostly older clients, helping them with everything from bathing to cooking. Wibonele worked alone and sometimes had to lift clients much bigger than her.

It was demanding work and paid only $9 per hour with no benefits. If not for Wibonele's second job as a babysitter and her husband's income, they would not have made ends meet while supporting their four children.

"My paycheck, you know, was literally just nothing," Wibonele said. "I was kind of shocked, like, the amount of work we (were) expected to do and the pay you get at the end."

Wibonele's experience reflects broader trends in the long-term care workforce. Those who tend to older adults in settings like private homes and assisted living facilities across the U.S. face low wages and risk of injury while the industry struggles with staff shortages, CNHI News and The Associated Press found as part of an examination of the state of America's long-term care.

Meanwhile, demand for these workers is rising as the population ages. By 2030, roughly 20% of the U.S. population will be 65 or older, and that share will continue to grow, according to the U.S. Census Bureau.

"It's a national problem, and it's everywhere," said Dr. Stephen Crystal, director of the Rutgers Center for Health Services Research. "Almost everybody is understaffed."

'NO WORKFORCE COMING IN'

The industry has dealt with labor shortages and high turnover for years, problems that were made more acute during the COVID-19 pandemic.

Nursing care facilities shed employees after the pandemic's onset, and the workforce has not fully recovered, federal data shows. A March survey of hundreds of nursing home providers by the American Health Care Association found almost all have open jobs and difficulty recruiting. And a recent nursing home staffing mandate from the Biden administration has panicked facility administrators who say they're already scraping to fill vacancies.

Turnover is so bad at nursing homes that some see all of their employees leave within a year, said Alice Bonner, director of strategic partnerships for the Center for Innovative Care in Aging at Brown University.

"The people who are left are working much harder, double shifts, overtime and working with agency and temporary workers," Bonner said.

Noelle Kovaleski, administrator of the Carbondale Nursing and Rehabilitation Center in Pennsylvania, said the biggest challenge in hiring is the lack of candidates. One nurse supervisor position at her facility went unanswered after being posted on a leading job site for two years.

"There is no workforce coming in," Kovaleski said. "They're just not out there."

Workers pass on these jobs for many reasons, including poor compensation and a competitive labor market. Nurses, for instance, can earn more working at hospitals than nursing homes, Bonner said.

Experts see looming potential shortages as the industry grows. Overall demand for full-time workers in long-term services and support settings is projected to increase by 42% between 2021 and 2036, according to the federal Health Resources and Services Administration. Demand for direct care workers, who make up the bulk of the workforce, is expected to grow 41%.

LOW WAGES

Direct care workers play vital roles in their clients' lives — a certified nursing assistant bathing an incontinent dementia patient, a home health aide assisting an older widower with his medication, a personal care aide helping residents of a group home eat lunch. These workers are mostly women and people of color, and many are immigrants.

Victoria Gardner, who is tetraplegic after a vehicle accident left her unable to stand or use her hands, sees her at-home caregiver as a lifeline. The caregiver helps the 57-year-old Pennsylvania woman 16 hours each day. Without this care, Gardner couldn't bathe, prepare meals, do laundry or clean her home.

"My circumstance right now, I have one caregiver. That's a very fragile position to be in. I'm not alone in that," Gardner said.

The industry added about 1.5 million new direct care workers between 2012 and 2022, an AP-CNHI analysis of Bureau of Labor Statistics data found. It's expected to add close to 800,000 new direct care jobs through 2032 — which experts say will be hard to fill.

Pay is a big factor.

The average annual salary for home health and personal care aides was $33,380 in May 2023, according to the bureau. These earnings were similar to cafeteria attendants and retail sales workers.

Direct care workers are typically on the low end of pay scale. Roughly half of them rely on public assistance, according to a January Department of Health and Human Services report.

Experts point to funding as a reason wages are low. Medicaid is the primary payer of long-term care services, but many stakeholders argue Medicaid reimbursement rates are insufficient to properly compensate workers.

Some states have made efforts to bolster the workforce, such as requiring a percentage of providers' Medicaid reimbursements go to direct care worker wages. Others have used funding from the 2021 American Rescue Plan Act to boost wages and recruitment efforts. Meanwhile, the Biden administration finalized a rule in April requiring 80% of Medicaid payments for homecare services be used to pay workers.

THE RESPECT FACTOR

Zulma Torres, a long-time home health aide working in New York City, said she used to cry after work because of how people treated her.

For years, she earned $6.25 an hour. Sometimes, clients would treat her like a maid, expecting her to cook for the entire family. In some instances when she had to take her client to the hospital, she felt like the nurses and doctors were judging her.

"Many times you feel like just walking out and be like, you know, this is not for me," Torres said.

Researchers say a lack of respect both inside and outside the industry is another factor driving away long-term care workers.

"There's a general view, I think from the public, that people who work in long-term care are lesser than," said Barbara Bowers, founding director of the Center for Aging Research and Education at the University of Wisconsin-Madison. "I don't think they get anywhere near the respect they deserve for the very hard work they do."

REASONS TO STAY

Culix Wibonele, the certified nursing assistant in Atlanta, now earns $18 hourly at an assisted living facility. But she's had to endure years of low wages, layoffs and lasting migraines from when she was injured by an agitated facility resident. Her pay still doesn't feel like enough.

"I can go to Walmart and make more money than being a CNA," Wibonele said.

Still, Wibonele said she plans to stay in the industry for now. In addition to working as a CNA, she's studying at Georgia State University with the goal of becoming a registered nurse in long-term care.

"I love (the) older generation, their wisdom, their stories. I love knowing that I am doing something while they (are) still here on the earth," Wibonele said. "As much as we don't get paid enough, I won't change it."

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Kelety reported from Phoenix and Scicchitano from Shamokin, Pennsylvania. AP data journalist Nicky Forster in New York contributed.

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The share of the U.S. population older than 65 keeps rising — and will for decades to come. Since nearly half of Americans over 65 will pay for some version of long-term health care, CNHI News and The Associated Press examined the state of long-term care in the series the High Cost of Long-Term Care, looking at adult day cares to high-end assisted living facilities, to understand the challenges in affordability, staffing and equity that exist today and lie ahead.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute's Science and Educational Media Group and the Robert Wood Johnson Foundation.