Letter to President Trump: Executive Leadership to Strengthen the Direct Care Workforce

Editor’s Note: The following text was originally sent as a letter to President Trump on January 21, 2025.

Dear President Trump,

As you embark on a second term as President, we urge you to take the opportunity to strengthen the direct care workforce—those who provide essential care for millions of Americans and represent an essential part of our nation’s economy. Across the United States, more than five million direct care workers ensure that older adults, people with disabilities and complex medical conditions—and entire families—have the care and support they need.

The direct care workforce represents our nation’s largest occupation, with the most anticipated job growth. However, direct care jobs are so poor in quality that we have a workforce crisis: employers and individuals are unable to recruit and retain enough workers. Underpaid and without significant training or career opportunities, direct care workers themselves must rely upon public benefit programs to survive, or else leave the profession.  At the same time, people struggle to access needed care and working adults are forced to leave their employment to care for their loved ones. This non-partisan challenge affects families and the economy in every state.

At the heart of your campaign was the recognition that we need to build a strong, successful economy while improving affordability for American families. The direct care workforce crisis sits precisely at this intersection, where poor quality jobs fail to provide opportunities for direct care workers while older Americans and people with disabilities and serious illnesses, cannot afford the long-term services and supports they need.  Investing in the direct care workforce and the services they provide will achieve the twin goals of a stronger economy and more affordable care. It is time for transformational change: It is time to fix a system that lacks stability and efficiency, leaves far too many Americans mired in poverty, and strands far too many more without access to the care they need.

PHI stands ready to help your Administration solve the direct care workforce crisis. As the nation’s leading authority on the direct care workforce, we promote quality direct care jobs as the foundation for quality care. For more than 30 years, PHI has brought a 360-degree perspective on the long-term care sector to our evidence-informed strategies. We produce robust research and analysis, advocate for effective and sustainable public policies that positively impact all Americans, and design groundbreaking workforce interventions that demonstrate return on investment—including cost savings to the system as well as care quality improvements.

Today, poor job quality and limited training and advancement opportunities are pushing potential and existing direct care workers into jobs in other fields that offer better pay and other benefits, like fast food and retail—causing a major recruitment and retention crisis. Indeed, when accounting for occupational turnover and labor force exits along with expected job growth, the United States will need to fill an estimated 8.9 million total direct care job openings from 2022 to 2032—more job openings than in any other occupation. Yet employers are already struggling to fill open direct care positions and ensure that everyone who needs care can receive it. At the heart of this workforce and caregiving crisis is a lack of recognition of the enormous value of direct care workers for our health and long-term care systems and our economy overall.

Your Administration can take strides to solve this problem by leveraging  a whole-of-government approach that includes a broad range of actions to improve economic stability for direct care workers, enhance access to and affordability of care for older adults and people with disabilities and serious illnesses, support long-term care employers and family caregivers, and strengthen our economy. You can leverage your authority to develop national standards and principles that support state-level investments in training, credentialing, wages, and benefits in ways that support quality care, lead to quality jobs, and offer career advancement opportunities for direct care workers.

Transforming direct care work so that that these essential caregivers are valued as professionals, and are trained and paid accordingly, is directly aligned with promoting thriving local, state, and national economies. Through federal leadership and collaboration with states, a national effort to establish consistent standards for core competencies, high-quality training, and portable credentials would go a long way toward improving direct care worker stability, job quality, and career advancement while also strengthening the care infrastructure for those who depend on it.

Solving the care crisis will also mean investing in Medicaid, which provides the majority of funding for direct care services and jobs. Numerous Congressional Republicans have indicated they will be pursuing significant cuts to the Medicaid program. Yet, the only way for your Administration to ensure it fulfills the Republican platform’s crucial pledge to protect at-home care for older adults and address the shortage of direct care workers is by ensuring Medicaid is adequately funded.

Cuts to the Medicaid program will bring significant disruption to care in the United States, and have a profound negative impact on older adults, people with disabilities, and direct care workers. More family caregivers will be forced to choose between working and providing care and support for loved ones. This will force greater reliance on institutional care, at greater expense to both families and to our nation’s care systems. The struggle to recruit and retain direct care workers will only worsen. In other words, whatever short-term cost savings may be achieved through Medicaid cuts, if any, will be vastly outweighed by the economic and caregiving challenges that such cuts will bring for millions of families across our nation.

Strengthening care in our country also requires ensuring the 28 percent of all direct care workers who are immigrants can continue providing the vital services millions of Americans need. You have indicated—and the enforcement operations planned for this first day of your presidency underscore—that your Administration will seek to deport many immigrants currently residing in the U.S., while also limiting incoming immigration. Yet immigrant direct care workers make substantial and significant contributions to our larger economy and Americans’ ability to access high-quality care.

Studies have found that local increases in immigration lead to higher quality care and that immigrant workers remain in direct care positions longer than U.S.-born workers, providing vital stability. Conversely, harsher restrictions on immigrant workers directly correlate with reduced staffing levels in care settings. Deporting immigrant direct care workers will inevitably lead to Americans having even greater difficulty accessing the care services they need and increasing our already unsustainable reliance on unpaid family caregivers to fill the gaps. We urge you to reconsider your plans to carry out “the largest domestic deportation operation in U.S. history” while there is still time to do so.

The connections between your goal of improving Americans’ economic wellbeing and the need to strengthen the direct care workforce are clear. We hope to have the opportunity to brief key members of your Administration on our recommendations for strengthening the direct care workforce, and to identify ways we can move this important work forward together.