Twenty one years, 35 percent, and the gap that ate the workforce

In 2021 a provider association in Kansas put two numbers next to each other in testimony to a legislative committee, and I have not been able to stop thinking about them since. Over the previous twenty one years, provider rates for intellectual and developmental disability services had increased 35.20 percent. Over the identical twenty one years, the Consumer Price Index had increased 63.86 percent. That is it. That is the entire workforce crisis, expressed as one subtraction problem that a legislature could have run any year it wanted to and did not.

Kansas is not an outlier. Kansas is the state that bothered to write it down. Every state in this country has some version of that gap, and almost none of them have published it, which is why we spend our advocacy energy arguing about whether providers are managing money well instead of arguing about whether they were ever handed enough of it.

What a 29 point gap actually destroys

Start with what a rate is supposed to cover. A community living supports hourly rate has to pay the direct support professional’s wage, plus payroll taxes, plus whatever benefits exist, plus supervision, plus training, plus scheduling and administration, plus insurance, plus the cost of the vehicle and the fuel and the phone.

Now compress that by 29 percent of purchasing power over two decades and watch what an operator does. Nobody starts by cutting wages, because you cannot staff a shift at all if you do. They start with the invisible parts.

Training goes first, because training is a line item nobody outside the building sees. Then supervision ratios stretch, one supervisor covering two homes instead of one. Then the full time nurse becomes a consultant. Then overtime replaces hiring, because overtime is cheaper than benefits, until burnout makes it expensive in a different currency.

Then wages fall behind the warehouse down the road and the whole thing accelerates, because turnover has its own cost and every dollar spent recruiting a replacement is a dollar not spent serving anyone.

Alan’s list

Alan has run a six home agency for twenty two years. When I asked him about rate increases, he did the thing every long tenured provider does, which is recite them from memory with the years attached, the way other people recite their kids’ birthdays.

Then he recited the other list, which is the one that matters. Paid training discontinued in 2009. Full time nurse position eliminated in 2014, converted to a contracted consultant who visits. The supervisor who used to cover two houses cut in 2019, responsibilities absorbed by a manager now covering six.

His agency is still open. His licenses are current. His compliance record is clean. And what he sells in 2026 is measurably not what he sold in 2004, because three specific capacities were removed from it, one recession and one budget cycle at a time.

When a state auditor examines quality outcomes at Alan’s homes and finds them worse than they were fifteen years ago, that finding will be reported as a provider performance issue. It is a rate issue wearing a provider performance costume.

The Michigan version

Michigan’s numbers tell the same story in a shorter window. The direct care worker minimum in Oakland County sat flat at $16.10 an hour from January 2023 forward, until a twenty cent adjustment brought it to $16.30, an increase of roughly 1.2 percent. Nothing a direct support professional buys rose 1.2 percent over that period. Not rent, not gas, not groceries, not childcare.

And this is in Oakland County, one of the best resourced counties in the state, which now reports waiting lists across vocational services, community living supports, respite, and residential placement where it previously had none.

Meanwhile Michigan spent years constructing a direct care wage increase, layer by layer, reaching $3.40 an hour above the March 2020 base. That was real advocacy and real money and I do not want to diminish it. But a wage add-on layered on top of an eroded base rate is a patch on a structure, and in the FY26 budget cycle the state came within a conference committee of cutting agency rates by $4.56 an hour while leaving the wage mandate intact, which would have made the base problem catastrophically worse.

The fix, which is boring and would work

Index the rates.

That is the whole recommendation. Tie the reimbursement rate to a defined benchmark that moves on its own: a percentage of area median wage, a defined multiple of state minimum wage, a health care cost index, an annual CPI adjustment written into statute. Whatever the mechanism, the point is that purchasing power holds without requiring a coalition to fight for it every single year.

Every year that rates require an active fight is a year they can lose one, and losing is the default because inflation does not need anyone to advocate for it. It just happens. Rate increases require a bill, a hearing, a coalition, a sympathetic subcommittee chair, and a state revenue picture that cooperates. Inflation requires nothing at all.

That asymmetry is why the gap only ever runs in one direction. Twenty one years, 35 percent against 64 percent, and not one villain in the story.

What to do with this

Get the rate study. Email your PIHP and ask for the most recent rate study or cost model supporting current CLS and residential rates, with its date. If the honest answer is that rates derive from historical precedent rather than from any current cost analysis, that is the finding. Get it in writing.

Do the subtraction yourself. Take the cumulative rate change your provider has received over the last ten or twenty years and put it next to CPI for the same period using the Bureau of Labor Statistics calculator. It takes ten minutes. The resulting number is more persuasive than any story you can tell, because nobody can argue with it.

Ask your provider what they stopped funding. Alan’s list is the single most powerful advocacy document I have encountered in this space, and every long tenured provider in Michigan has one. They will tell you if you ask. Most families never ask, because we have been trained to see providers as adversaries rather than as the people holding the other end of the same broken rope.

Ask for the Michigan analysis. Kansas produced its numbers because a legislative committee asked for them. Michigan has never published a comparable twenty year rate adequacy analysis. Ask your state representative to request one from the House Fiscal Agency. It is a small, cheap, specific request, and the resulting document would reframe every rate conversation in this state for a decade.

Nobody voted to cut. That is exactly the problem, and it is why this keeps happening. Make somebody do the subtraction out loud.