Our New Data Show It’s Time to Improve Direct Care Jobs

PHI’s new annual research report describes a pivotal moment for the direct care workforce (which includes home care workers, residential care aides, and nursing assistants).

Our analysis reveals that longstanding challenges for this workforce persist: despite high demand, wages remain low, and many direct care workers live in or near poverty and rely on public assistance. Furthermore, this poor job quality is misaligned with their skill-intensive responsibilities, their critical roles in the health and long-term care systems, and the danger they have faced during the COVID-19 pandemic. In this context, the recent heightened attention on these challenges could finally pave the way for desperately needed transformative reforms for this workforce.

High Demand, Low Wages

Our new data show that demand for the direct care workforce overall continues to rise as our population grows older. From 2010 to 2020, the workforce added 1.5 million new jobs, bringing the total number of workers to 4.6 million.

Despite the high demand for their services, direct care workers continue to earn poverty-level wages. The median wage for home care workers, who constitute the largest and fastest-growing segment of the direct care workforce, was just $12.98 in 2020. Median wages were only slightly higher for residential care aides ($13.35) and nursing assistants in nursing homes ($14.48).

There is one bright spot: wages have ticked upward slightly in recent years, from $12.53 in 2010 to $13.56 in 2020 (adjusted for inflation). However, this small increase has not significantly improved workers’ economic stability. Our new research shows that 44 percent of direct care workers live in low-income households (below 200 percent of the federal poverty level) and 45 percent rely on public assistance (most often Medicaid and nutrition assistance). Direct care workers’ compensation still far from guarantees their ability to afford basic living expenses.

Our new data also shows that high demand coupled with poor job quality will create a staggering number of direct care job openings in coming years. From 2019 to 2029, the direct care workforce is projected to add 1.3 million new jobs, more new jobs than any other U.S. occupation. Over the same period, another 6.1 million job openings will need filling—to replace workers who leave the labor force or transfer to new occupations, often in search of higher wages or safer working conditions.

The COVID-19 Pandemic

The low wages received by direct care workers fail to reflect the value of their work—or the intensified challenges they have faced during the COVID-19 pandemic. As one example, 582,000 nursing home staff (including nursing assistants) had contracted COVID-19 and 1,700 had died as of July 2021, according to our analysis of nursing home data from the Centers for Medicaid & Medicare Services (CMS). Home care workers and residential care aides have been acutely impacted by the pandemic as well, but reliable data on their infection and illness rates are woefully lacking.

As the Delta variant spreads across the country, direct care workers remain at high risk, especially because many are unvaccinated. Just 47 percent of nursing assistants were fully vaccinated as of July 4, 2021, compared to 58 percent of all U.S. adults. Reports from the field suggest similar challenges in the home care and residential care industries.

To ensure the safety of direct care workers, long-term care consumers, and the public, boosting vaccination rates among direct care workers should be a national public health priority. Effective strategies include community-informed vaccination campaigns and peer-led vaccination conversations, and the vaccine mandates recently implemented in nursing homes may also be required across long-term care settings, though they should be implemented with caution.

New Recruitment Challenges

As well as directly impacting workers’ health and lives, the COVID-19 crisis has also made it more difficult to recruit new direct care workers. From January 2020 to March 2021, workers who were laid off or furloughed due to COVID-19 from direct care jobs and other occupations may have earned more through unemployment benefits than in a new direct care job, which highlights how unattractive direct care jobs are to jobseekers—and underscores the inadequacy of direct care worker wages in meeting jobseekers’ most basic financial needs.

As enhanced unemployment programs have expired, vaccines have become more widely available, and the economy has begun to re-open, long-term care employers have continued struggling to attract workers. Industries like fast food and hospitality have faced similar challenges. However, they were able to raise wages to attract workers displaced by COVID-19 because these industries could shoulder profit losses and price increases, unlike the long-term care sector, which relies heavily on public programs with less forgiving reimbursement rates. It’s true that some long-term care employers have been able to leverage federal relief funds (e.g., from the Coronavirus Aid, Relief, and Economic Security Act or the American Rescue Plan Act) to boost wages for their workers, but only temporarily. To implement sustained wage growth for direct care workers, more permanent financing solutions will be needed.

Time for Change

Year after year, PHI’s annual research reports have described the pressing need to address direct care job quality, but this year is different.

Direct care workers have demonstrated their importance throughout the pandemic, and the mismatch between their challenging roles and their compensation has been thrown into stark relief. If there was ever a time to transform direct care jobs and stabilize this critical workforce, it is now.

Concerted effort from policymakers, employers, workforce development experts, and others is critically needed to provide direct care workers with good, safe jobs—and help ensure stable care for the long-term care consumers they support.