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Direct Care Workers (DCW) provide support to older adults and people with disabilities in leading the lives they want. According to a report from PHI released in February, there are 4.5 million direct care workers in the United States; experts project there will be over 1 million new jobs added by 2029. The report also shared findings that highlight extensive racial, ethnic, and gender-based disparities among DCW, how these disparities are related to financial status, and how this may impact the quality of home and community-based services.
Despite the high demand for DCW, jobs in the field often pay poverty-level wages and provide little opportunity for advancement. Further, racial and gender-based disparities in wages are well documented. The median hourly wage is $13.00 for women of color, white women, men of color, Black/African American workers, and Hispanic/Latino workers in the direct care workforce. However, the median hourly wage is $13.50 for white men and $14.75 for Asian/Pacific Islander workers. According to the report, “women of color are more likely than their male and white female counterparts to live in or near poverty, need public assistance, and lack access to affordable housing.” These and other factors have contributed to nationwide shortages in DCW.
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The report further details where these disparities persist within the direct care workforce. From 2009 to 2019, “the number of people of color in the direct care workforce grew from 1.7 million workers (52%) to 2.8 million workers (61%),” PHI reported. Furthermore, 43% of men of color and 40% of women of color in the direct care workforce are immigrants. Low wages and entry-level job requirements may be one reason that minorities and immigrants, who often lack resources to pursue college-level education, have been increasingly filling these roles. And according to The National Health Law Program, the marginalized workers filling DCW positions often have less time and access to resources to push for better working conditions.
Researchers have taken careful note of this data and are trying to understand why the solutions may be more complex than simply increasing wages. For example, Dr. Chanee Fabius, assistant professor at Johns Hopkins Bloomberg School of Public Health, says it is statistics like these that should propel states to study the best ways to support both family caregivers and paid DCW. She emphasizes the importance of federal policies that improve infrastructure in home and community-based services, and believes there must be renewed attention for national, paid family leave for the care of family members. She says there is often a “lack of understanding of what’s available” under Medicare and Medicaid. When a needed service is not covered, family members often step in to fill the gaps in care. By doing so, they sometimes risk loss of pay, or even termination. “You wouldn’t have to risk losing your job,” if national, paid family leave policies were in place, she says. “That’s really important, because we know that people who are typically the most vulnerable, in low-income jobs, (including) people who are doing direct care work, are not often receiving those sorts of protections when they take time off.”
That’s really important, because we know that people who are typically the most vulnerable, in low-income jobs, (including) people who are doing direct care work, are not often receiving those sorts of protections when they take time off.
Dr. Chanee Fabius, assistant professor at Johns Hopkins Bloomberg School of Public Health
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These protections for the direct care workforce were further threatened by the COVID-19 pandemic. Karyn Harvey, psychologist at The Park Avenue Group in Baltimore, said, “There has been such a depletion in the workforce because these are not highly-respected jobs in our culture, and they’re low-wage jobs.” During the quarantine phase of the pandemic, these stressors were too much, and “many people just quit.” The high rate of attrition can have a profound impact on availability and quality of services. “The direct support professional workforce, the quality and stability of that workforce, is of utmost importance, because all of the values and priorities that a state service system is trying to put forth are dependent on that quality workforce,” says Dorothy Hiersteiner, co-director of National Core Indicators (NCI) at Human Services Research Institute (HSRI). “Person-centeredness, self-direction, those are all really contingent on a quality workforce.”
Fabius and Hiersteiner would like to see a pipeline for advancement and respect for the job, so that being a DCW can be viewed as a career. “You really have to like your job to be able to do it,” Fabius says. “It’s not easy work. But (the workers) enjoy what they do. They care about the people they serve. Being able to compensate them adequately is important, along with creating some sort of pathway for them to advance in their careers, whether that’s additional certification or additional training. These are methods that can be taken up to build and sustain a better and stronger workforce.”
The direct support professional workforce, the quality and stability of that workforce, is of utmost importance, because all of the values and priorities that a state service system is trying to put forth are dependent on that quality workforce.
Dorothy Hiersteiner, co-director of National Core Indicators (NCI) at Human Services Research Institute (HSRI)
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Enacting policy changes to enhance the workforce and addressing these concerns is on the legislative agenda for many states. In the Strengthening the Direct Care Workforce: Scan of State Strategies report, 11 states are working to address the workforce crisis. For example, Colorado’s legislature passed a bill in 2019 that set minimum wages of $12.41 for DCW. Indiana raised DSP wages to $15 per hour and increased the cap on the Family Support Waiver to offset the cost to individuals and families in 2021. And Massachusetts “created an online, ten-module, 37-hour training format to certify home care aids. The training curriculum provides trainees with the entry-level position of ‘homemaker,’ which can then be built upon to translate to home health aide through additional training.” Minnesota partnered with The University of Minnesota and Elsevier to make many opportunities for continuing education free for the direct care workforce. The work being done to increase wages and improve training opportunities will address some contributors to disparities found in the PHI report, yet more work needs to be done to make significant progress.
Fabius says American society is up against a deadline with these aspirational goals as the population ages. “We have an aging population that, at the same time, is becoming more diverse,” she said. “Over the next couple of decades, we will see fewer older white adults and more (individuals) from racial and ethnic minority groups (as the population we serve through HCBS programming.) There’s going to have to be a lot of attention put into addressing their needs. That includes the needs of older adults and their family caregivers.” As the HCBS population ages and diversifies, more innovative solutions will be needed to address the growing disparities in the direct care workforce.
Sources:
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Fabius, Chanee. Personal interview. 17 Feb. 2022.
Hiersteiner, Dorothy. Personal interview. 8 Feb. 2022.
Machledt, David. “Disability, Race, and Structural Inequity: COVID-19 and the Long-Term Care Workforce.” National Health Law Program, 29 Apr. 2020, https://healthlaw.org/disability-race-and-structural-inequity-covid-19-and-the-long-term-care-workforce/.
McCall, Stephen, and Kezia Scales. “Direct Care Worker Disparities: Key Trends and Challenges.” PHI, 8 Feb. 2022, http://www.phinational.org/resource/direct-care-worker-disparities-key-trends-and-challenges/.
Ward, Hannah, et al. “Strengthening the Direct Care Workforce: Scan of State Strategies.” Center for Health Care Strategies, Dec. 2021, https://www.chcs.org/resource/str