By Brianna McGurran

With more people insured under the Affordable Care Act and a surging elderly population, jobs in nursing homes are set to skyrocket. But for nursing assistants on the front lines of the patient boom, high demand hasn’t translated to higher pay.

Health care jobs bucked employment trends throughout the recession and recovery and grew by almost 23 percent from 2003 to 2013, according to a Brookings Institution report. And with the number of adults aged 65 and older doubling in the next 30 years, jobs for certified nursing assistants — who feed, bathe, monitor and reposition nursing home residents — are projected to jump 21 percent by 2022. Yet low pay, high turnover and a lack of opportunities to advance means an overhaul is necessary to make sure there are enough nursing assistants to meet demand, advocates say.

“We’re on a crisis path right now,” said Genevieve Gipson, director of the National Network of Career Nursing Assistants. “We are training a fantastic number of people who don’t stay.”

Annual turnover among CNAs in nursing homes is almost 70 percent, according to a 2011 report by the Department of Health and Human Services. Nursing assistants cited low pay as the No. 1 reason for leaving their current jobs: in 2013, the median hourly wage for a CNA was $11.97 an hour, $4.90 less than the median wage for all occupations. Adjusted for inflation, that’s $0.36 less than a nursing assistant’s average hourly pay in 2002.

Even CNAs who choose to stay in their positions see only middling pay raises and little career mobility. Nursing assistants who’d been working for more than 10 years saw their median hourly pay increase just $2.16 in that time, the Health and Human Services study reported.

Advocates are experimenting with ways to lift wages and keep good nursing assistants on the job. Taking these measures will encourage qualified CNAs to stay longer in their positions and care for aging baby boomers, said Steve Edelstein, national policy director for the Paraprofessional Healthcare Institute.

“The nursing home population is a lot older, frailer, more likely to have cognitive issues than previously,” he said. “Providing those services is more complicated than it was.”

CNAs have the option to become licensed practical nurses or registered nurses, which both carry much higher average salaries. But going back to school isn’t as easy as it sounds, said Betty Beverly, who’s been a nursing assistant at Shady Lane Nursing Home in Clarksboro, N.J. for 26 years.

“I’m a single parent,” she said. “I didn’t think I could afford to go to nursing school. So that’s why I chose to stay where I am.”

Beverly’s plight is a common one, said Rebekah Lashman, senior vice president of the workforce development nonprofit the Commonwealth Corporation. More than 75 percent of CNAs have a high school degree or less, and many are heads of households who can’t easily take on heavy coursework on top of their full-time jobs, said Lashman.

“CNAs typically are cobbling together complicated work schedules and complicated lives and typically need quite a while before they can even be college ready,” she said.

Taking into account all of these limitations, the best and most immediate way to raise nursing assistants’ pay would be to increase the federal minimum wage, said Steve Edelstein of PHI.

“If they are just above it now, raising the floor would hopefully exert the pressure to raise their wages more,” he said.

Last month Senate Republicans voted down a bill to bump up the federal minimum wage from $7.25 an hour to $10.10 an hour. Absent a federal mandate, opening up the CNA workforce to nontraditional candidates could force a pay increase from within the industry, advocates say. It’s not a coincidence that 92 percent of nursing assistants are women, said Edelstein.

“The fact that this is viewed as ‘woman’s work’ has kept wages down and has meant that wages haven’t really been reflective of the value of the service,” he said.

The National Network of Career Nursing Assistants created a task force to recruit more men with the goal of pressuring employers to pay more, said Genevieve Gipson.

“Males will say, ‘That’s not enough for what I’m doing,’” she said. “They’ve got a history of being able to get better wages.”

Some nursing homes are also coming up with their own ways to raise CNAs’ pay. At Loomis House, a nursing home in Holyoke, Mass., nursing assistants can choose to get additional on-the-job training in dementia care, end-of-life care and communication skills. Each level of the career ladder comes with a 30- to 50-cent hourly pay increase, and when an employee reaches the fourth and final level they become peer mentors to new hires.

“We’ve always had a strong belief that investing in our employees is very important,” said Lori Todd, administrator of Loomis House.“The more that we can offer for them, the better they treat the residents.”

Since starting the career ladder program, yearly turnover at Loomis House has dropped to 23 percent, CNAs seem more attentive to their patients and residents’ family members have reported better communication with staff, said Todd. She is also working with a local community college to create an extended training program for incoming nursing assistants, she said, to make sure they’re more prepared when they start. Loomis House is convinced all these investments are worth it, said Todd.

“Look at the bottom line of your retention and your satisfaction and your occupancy,” she said. “There’s a bottom line and then there’s a bottom line.”

But not all nursing homes have the resources to offer better pay, said Rebekah Lashman, whose organization provided Loomis House with an initial grant for its career ladder program.

“Much of the pay in this industry is driven by what either the federal or state government pays to reimburse for services,” said Lashman. Nursing homes make their money from Medicare and Medicaid reimbursements, so without higher fees for health care services there’s little flexibility to raise wages across the board, she said.

It might be up to CNAs to lobby for their own worth, said John Booker, a nursing assistant in Lake Forest, Calif. In 1994, Booker, 58, had been working as a CNA at a nursing home for 10 years when he started raising concerns with the administrator about high CNA turnover. The administrator asked Booker to join the board of directors at the nursing home to help implement some of the changes he recommended.

“That work on that board of directors showed me a different aspect on how nursing assistants can change themselves to hopefully increase our value in their eyes,” he said.

At his nursing home, he pushed for more customer service training for CNAs and more recognition of the professional medical work they do. He has since been elected to advisory positions in national groups like the Direct Care Alliance and the Paraprofessional Healthcare Institute, all while working as a nursing assistant and, most recently, as a home health aide.

To raise pay for CNAs for good, a shift in the way they’re viewed is necessary, Booker said. Nursing assistants in nursing homes shouldn’t be grouped in with domestic service workers or food service workers as part of the campaign to raise the federal minimum wage, he argued.

“We don’t work at McDonalds, we don’t work at Wendy’s, we don’t do hotel work,” he said.“We do work that’s life saving, life giving.”

Booker and other advocates are pushing to raise CNA wages to a base of $15 an hour nationwide. He said he hopes grouping nursing assistants more closely with the medical workforce will force wages up. But it will be a long fight to get there, he said.

“The respect and the lack of it is our biggest obstacle.”