Health Coverage

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Too Sick to Care -- The decision by many states not to expand Medicaid has left hundreds of thousands of direct-care workers languishing in the Medicaid “coverage gap,” unable to access affordable health care coverage.

Our Position

Affordable health coverage, along with better wages, is essential to improving the lives of direct-care workers and their families. Moreover, providing access to health insurance has been identified as crucial to workforce recruitment and stability, and ensuring quality care for elders and people with disabilities.

The passage of the Affordable Care Act and its full implementation in 2014 provides an opportunity to significantly expand coverage for direct-care workers.

What We’re Doing

  • Monitoring federal and state implementation of the Affordable Care Act, and the impact on direct-care workers.
  • Advocating for states to accept federal dollars under the ACA to provide Medicaid to all individuals with incomes below 138 percent of the poverty level.
  • Educating long-term care employers and direct-care workers about ACA coverage requirements and assisting employers in making good choices for affordable inclusive coverage.
  • Collaborating with other health and long-term care allies to ensure effective implementation of the ACA, with appropriate consumer protections.


Although part of our health care system, many direct-care workers do not have access to health care themselves. One in every four nursing home workers and a third of home care workers lack health insurance coverage. And access to health insurance is particularly problematic for the 43 percent of direct-care workers who work less than full-time.

Direct-care workers can find themselves uninsured for a number of reasons: they are not offered coverage by their employers; they are ineligible for health benefits because they are part-time or new hires; or due to low pay they cannot afford to participate in their employer’s health insurance plan or, for those who are self-employed, buy coverage on their own. In addition, direct-care workers tend to experience high injury rates and are more likely to be living with chronic health conditions. This makes their insurance coverage more expensive and less affordable to both workers and their employers.

The Affordable Care Act ends many of the barriers that have prevented direct-care workers from accessing coverage in the past. PHI estimates that, if states accept federal dollars to expand insurance for individuals with incomes below 138 percent of the poverty level, over 350,000 direct-care workers would gain coverage. Additionally, workers who have higher incomes, but still cannot afford employer-based coverage, will be able to buy subsidized insurance through newly created state and/or federal exchanges.

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