Direct care workers are an essential part of the care infrastructure in the United States. These workers—primarily comprising personal care aides, home health aides, and nursing assistants—help older adults and individuals with disabilities with everyday tasks such as eating and dressing, and some perform clinical medical tasks as well, such as administering medications and assessing vital signs. They work in private homes, nursing homes, hospitals, and residential care facilities.1
The demand for direct care workers2 is high and is only expected to increase, due to an aging U.S. population and an increase in the use of home-based care.3 In 2022, 1,361,300 people were employed as nursing assistants and 3,715,500 people worked as personal care assistants or home health aides.4 According to the National Center for Health Workforce Analysis, demand is expected to rise for nursing assistants by 48 percent, for personal care aides by 43 percent, and for home health aides by 42 percent between 2020 and 2035.5 (see Figure 1)
In the face of such high demand, this country is grappling with a severe shortage in direct care workers. This was only exacerbated by the COVID-19 pandemic, during which about two-thirds of U.S. states saw a Medicaid home- and community-based care provider—including adult day health programs, providers of home-based services, and group homes—permanently close due to staffing shortages; these events revealed weaknesses in the long-term care system.6 Exacerbating this dire worker shortage is the fact that direct care workers face poor working conditions, with extremely low wages and little access to vital employment benefits.
Exacerbating this dire shortage is the fact that direct care workers face poor working conditions, with extremely low wages and little access to vital employment benefits.
This issue brief examines the low wages and inadequate benefits faced by the direct care workforce and why the workforce disproportionately comprises women of color. It then highlights the need for policymakers to take steps to address these severe shortages and improve working conditions in order to meet the country’s needs, such as increasing Medicaid reimbursement rates and ensuring those funds go to workers, as well as promoting unionization.
Direct care workers earn low wages and have inadequate access to benefits
Along with orderlies and psychiatric aides, direct care workers earn the fifth-lowest average hourly wage among U.S. occupational groups. (see Table 1) In May 2022, this group made an average of $15.60 per hour, or $32,440 per year. This is below the 2022 national average living wage for an adult employed full time with no children, which was $36,311 annually.7
Compounding these low wages, direct care workers also often lack access to vital employer benefits such as health insurance and retirement savings plans. At almost 14 percent, the proportion of direct care workers who lack any health insurance is only slightly higher than the average for the U.S. labor force of about 11 percent; however, more than half (about 53 percent) of direct care workers lack access to employer- or union-provided health insurance specifically, compared with just more than 32 percent of the general labor force. (see Figure 2) Like other low-wage workers, many direct care workers also lack access to paid sick time—nationwide, most workers in the lowest 10 percent of income earners have no paid sick time.8
Lack of access to a retirement savings plan is common among the U.S. labor force at large, with about 68 percent of the labor force reporting that they were not included in a retirement or pension plan at work in 2022.9 (see Figure 2) However, this number is significantly higher for direct care workers at about 82 percent, meaning many of these workers lack access to tools that could help them accumulate savings for their futures.
In addition to this lack of access to wages and benefits, direct care workers report health issues at slightly higher rates than the general U.S. labor force. (see Figure 3) These workers perform highly demanding jobs, including physically assisting adults and often working during the night, which is associated with negative health effects.10
Despite such demanding work, training requirements for direct care workers vary widely across states, and while some states have or are developing training programs, workers in many areas receive very little training.11 Without adequate training, workers are more likely to suffer from back injuries, muscle strains, and infectious diseases such as COVID-19;12 in fact, direct care workers face “some of the highest rates of occupational injury and on-the-job violence” in the United States.13
Compared with the entire labor force, more direct care workers report that they have a disability that limits or prevents them from completing their work, and just more than 13 percent of the direct care workforce reports that their health status is only fair or poor, compared with about 7 percent of the general labor force. (see Figure 3) These workers both experience health issues and lack the benefits and wages that could help them address them.
Low pay and poor working conditions: History and current state of play
It is no accident that direct care workers receive low pay and benefits, even though they are in demand and their jobs involve skilled work. The quality of these jobs has been shaped by policy at both the federal and state levels. The 1938 Fair Labor Standards Act (FLSA), which first set federal minimum wage and overtime pay, and the 1935 National Labor Relations Act (NLRA), which guaranteed workers collective representation and bargaining rights, excluded many of these workers.14 Similar to today, a disproportionate number of U.S. direct care workers at the time were Black women and other women of color.15 To gain support for these bills from Southern Democrats, lawmakers excluded many occupations in which Black workers were overrepresented—for instance, by exempting workers doing “domestic service.”16 These laws also excluded public sector workers, and many direct care workers work for the government either directly or indirectly.17
Today, Medicaid is the largest funder for both institutional and home- and community-based care, so direct care worker pay is largely determined by Medicaid funding and the rates at which Medicaid reimburses providers for direct care services.18 These rates are low relative to the real costs of direct care overhead, administration, and labor, and they vary considerably between states. Furthermore, some states set a maximum for the amount that can be paid to direct care workers or restrict worker overtime pay.19 Given that reimbursement rates are set through policy, they are also slow to respond to changes in overhead costs and supply and demand.20
Low direct care worker wages also stem from forces beyond reimbursement rates, including the historic devaluing of the skills of direct care workers in the medical field and institutional restrictions on the tasks they are allowed to perform.21 Due to these forces, direct care worker pay is likely to remain low without policies dictating the amount that must be paid to the workforce and facilitating collective bargaining and training.
Marginalized populations are overrepresented among direct care workers
As with other care occupations—including child care and domestic work—women, Black or African American workers, and immigrant populations are overrepresented in the direct care workforce,22 with women being particularly overrepresented. Care work has historically been presented as work performed by women, and consequently very few men work in these jobs: Compared with just more than 47 percent of the general labor force, women make up about 86 percent of the direct care workforce. (see Figure 4)
This is part of a larger trend of occupational segregation in the U.S. labor market, in which women and marginalized racial and ethnic groups are relegated to poor-quality jobs that have clear social benefits but are economically devalued. Care work has historically been portrayed as women’s work and as a job for women of color.23 This pattern of occupational segregation, along with undervaluing of vital service occupations, deepens the gender and racial wage gaps in the United States.24
The myth of unskilled care work
Beyond the overrepresentation of people of color and women in the direct care field, the low value attributed to this sector is also connected to a false perception that this work is unskilled. Contrary to this view, direct care workers perform taxing physical labor to help clients with activities of daily life, including helping them to the bathroom and about the home, assisting them with eating and bathing, helping them get dressed, and cleaning their houses.25 These workers also manage client schedules, including medical needs, while acting as advocates for their clients with other medical providers.
Furthermore, their jobs require complex interpersonal skills to ensure the health and well-being of their clients.26 Care work requires the worker to perform emotional labor, to be adept at ensuring that their clients feel their health needs are understood, and to be in tune with their clients’ moods to ensure their basic needs are being met.27 Beyond requiring emotional skills, direct care work can entail negative emotional experiences, such as isolation and discrimination or abuse from clients or client families.28
Given these job requirements, there is a mismatch between the importance of this work and how these workers are compensated.
The trend of occupational segregation is also clear when looking at the proportions of racial and ethnic groups that make up the direct care workforce: Black or African American workers are especially overrepresented, constituting about 12 percent of the general labor force but about 29 percent of the direct care workforce, while white workers are underrepresented, making up 59 percent of the general labor force but only 38 percent of the direct care workforce. (see Figure 5)
Black or African American workers in these occupations are also likely to live in particularly precarious economic situations. While Black or African American direct care workers have the highest personal median annual income among racial or ethnic groups at $25,000, they have the lowest family median annual income at $41,700.29 They are also the most likely of racial and ethnic groups to live at or below the federal poverty threshold (46 percent) and to receive benefits from the Supplemental Nutrition Assistance Program (34 percent).30 While less overrepresented than Black workers, Hispanic or Latino direct care workers make by far the lowest personal median annual incomes among racial or ethnic groups at $22,200.31 (see Figure 6)
Women of color are vastly overrepresented in the direct care workforce, constituting only about 20 percent of the general labor force but about 53 percent of the direct care workforce. (see Figure 7) About 44 percent of women of color in the direct care workforce live at or below the federal poverty threshold, and about 40 percent are immigrants, which may make them especially vulnerable to employer exploitation.32
The direct care workforce also comprises a disproportionate number of immigrants. About 27 percent of all direct care workers are immigrants, compared with about 17 percent of the general labor force.33 Especially large proportions of Asian or Pacific Islander (84 percent) and Hispanic or Latino (45 percent) direct care workers are immigrants.34
Direct care workers are especially vulnerable to being exploited, especially in cases where they work in private homes, both because they are isolated and because enforcement of employment regulations requires that workers file a complaint about their employer.35 Fears of retaliation for reporting employers may be especially high for immigrant workers, and if they are undocumented, these workers may fear that their employer may report them to immigration authorities.36Consequently, immigrant direct care workers may be especially vulnerable to poor working conditions and wage theft.37
Improving job quality for care workers
Fortunately, worker advocates and progressive policymakers have made some gains to support direct care workers. Reforms to the FLSA under the Obama administration in 2015 extended minimum wage and overtime protections to most direct care workers.38 Some states have passed reforms to require an increased base pay for direct care workers.39 Meanwhile, other states have used funds from the American Rescue Plan Act to require increases to direct care worker base pay for Medicaid home- and community-based care—Colorado, for instance, has raised base pay to $15 per hour for direct care workers—but it is unclear if these changes will continue into the long term.40 Some states have also established direct care worker training and certification programs to raise both job quality and care quality.41
Similarly, progressive action in some states has led to an increase in collective bargaining and representation rights for direct care workers, though many still lack bargaining rights. Only about 10 percent of direct care workers were covered by unions in 2022.42 Eleven states currently allow direct care workers paid through Medicaid to organize and collectively bargain with the state or local government as their employer.43Unionized direct care workers earn about 13 percent higher hourly wages than comparable nonunion direct care workers.44 This is consistent with the union wage premium enjoyed by all workers throughout the economy, and unionized workers are also much more likely to have health benefits, as well as a retirement plan.45 Union collective bargaining is also critical to closing gender and racial pay gaps, as well as to improving conditions for workers with disabilities.
The Biden administration has also focused on increasing job quality for direct care workers. While the administration’s proposed American Jobs Plan included an increase in funding toward Medicaid intended to bolster direct care worker pay, this provision was ultimately not enacted.46 In the absence of congressional action on the issue, a rule proposed by the Biden administration in May 2023 would require that at least 80 percent of Medicaid payments for care services go to direct care workers.47 Still, in order to meet demand and raise standards across the board for workers, large-scale federal intervention, including congressional action, is needed.
Direct care workers are skilled and in high demand but unfairly compensated, with low pay and inadequate access to benefits. Despite performing jobs that require technical knowledge, emotional skill, and physical labor, their work has been undervalued by the market due to a historical lack of protection by labor regulations, limits dictated by health policy and the medical field, and broader social patterns of gendered and racial occupational segregation.48
Despite performing jobs that require technical knowledge, emotional skill, and physical labor, the work of direct care workers has been undervalued by the market.
The nature of direct care work means that these workers are especially vulnerable to workplace injury, harassment, discrimination, and exploitation.49 They are also likely be from marginalized social groups, including women, Black or African American workers, and immigrants.50 Since addressing workplace harms usually involves standing up to an employer or government authority, marginalized social groups may hesitate to seek enforcement of their rights for fear of retaliation or a lack of confidence in the enforcement system.51 Compounding this, few direct care workers are represented by unions, which can help support workers’ rights.52
While lawmakers in some states have made strides toward improvements through wage and collective bargaining legislation, policymakers at the national level need to act to guarantee higher job quality for all direct care workers. It’s past time that this critical workforce receive benefits and compensation that reflect the importance of their work.