The Invisible Caregiving Workforce
Who are the essential workers paid to care for America’s aged in their homes and in residential and nursing care facilities?
The past year-and-a-half has put an unprecedented spotlight on the care received by America's aging population. There's been a renewed focus on the essential workers who do the hard, uncelebrated labor of tending to their daily, even hourly, personal, physical, emotional and social needs.
This direct care workforce of certified nursing assistants (CNAs) and personal care aides who work in care facilities or private homes numbers approximately 4 million. They provide critical support to older or disabled people, often without hazard pay, paid sick leave or adequate support and training; many work with marginal or nonexistent benefits.
Who are the people who are brushing your grandmother's teeth? Helping your aunt transfer to her wheelchair? Changing your father's sheets and clothes when they're soiled? The answer can be found in both the statistics that track this workforce and also in the experiences shared by the people doing the hands-on work.
According to the U.S. Bureau of Labor Statistics, this workforce is 86% female, with most of them women of color; one-quarter are immigrants and refugees.
"I love my seniors, but we who do this are invisible, sad to say. I work with all my heart. I do extra. But I get stuck on the same payment for years."
Compensation for their labor is low and their pay has remained stagnant even as hundreds of thousands of families have come to depend on them and the demand for their work continues to expand.
Federal data released in 2020 said that these paid caregivers earned a median wage of $13 an hour. That number swings higher in large metropolitan areas and lower in less populated regions; the hourly mean wage in San Francisco is $16.57, while caregivers in small Texas communities in the Rio Grande Valley earn $9.54 an hour.
"These wages are not livable or competitive; forty-five percent of these workers live in low-income households," said Robert Espinoza, vice president of policy for PHI, an organization focused on strengthening the direct care workforce (who is a Next Avenue Influencer in Aging). "Many leave for better paying jobs with more stable schedules in retail or fast food. Direct-care jobs are often misrepresented as low- or no-skilled work, but because of the responsibility they assume and the emotional component they bring, that's just wrong."
Maria: Doing Extra
While the rest of the world is waking up, Maria Marrero is on the job.
A certified home health aide for low-income older clients in New Jersey, her first stop is in the home of a man with dementia. She helps him out of bed, bathes and dresses him and prepares and feeds him breakfast. When his family caregiver relieves her midmorning, Marrero goes up a floor to client No. 2, a patient with Parkinson's disease, and performs many of the same tasks.
It's early afternoon when she arrives at the home of a married couple in their eighties. The husband is slowed by congestive heart disease and his frail wife has osteoporosis. Marrero tends to their personal needs, does their laundry, cleans, reminds them to take their medications, cooks and keeps them company.
"Sometimes my people say, 'Don't do nothing today, just sit and talk.' This is how lonely they feel," said Marrero. "I bring the lady in the wheelchair in the kitchen with me while I make the lunch and do the dishes. She wants the companionship, but I have work to do."
Marrero began taking care of older people at age 11, helping a neighbor in her native Puerto Rico. Later, after marrying, arriving in New Jersey and giving birth to three daughters, she began working through a home health agency, a job she's performed for 18 years.
"My husband drives a truck and I could not afford to do this if he didn't have a good job," she said. "I love my seniors, but we who do this are invisible, sad to say. I work with all my heart. I do extra. But I get stuck on the same payment for years."
Unfair Share of the Burden
In 2019, before the coronavirus arrived, the federal government had issued a 10-year projection that anticipated that the demand for direct-care workers would surge, with 1.3 million new jobs added by 2029.
Attracting adequate numbers of workers to take those jobs was already challenging, but the pandemic made efforts to recruit and retain direct care staff far trickier.
"Shortages went through the roof. A lot of nursing homes were already not staffed at levels we think are sufficient to meet the needs of their vulnerable residents, and the pandemic exacerbated that," said Lori Smetanka, executive director of The National Consumer Voice, which advocates for policy to improve long-term care for patients, their families and the direct-care workforce.
"It's a great field. You can grow and learn. But I've had people make fun of me, they say I wipe butts for a living, like it's the lowest job you could have, and that frustrates me."
When co-workers called in sick, extra shifts and stress levels rose sharply among direct-care staff. Smetanka believes they've continued to shoulder an unfair share of the burden brought on by the virus.
"Their workload increased tremendously. They have concerns about their own well-being and that of their families. They were dealing with inadequate supplies as the virus came through the door. Many of them got sick and some died," said Smetanka.
She tracks legislation pending in a few states that would require upgraded staffing levels and Congressional action that would dedicate money to staff compensation, actions that could edge working conditions in the right direction.
"When people come to his job, we hear them say it's their calling. They like the close relationships with residents. We want to encourage that, but we need to improve pay and benefits so these are quality jobs that people want to keep," Smetanka said.
She predicts a steep climb to fill the gap of unfilled caregiving jobs without significant policy changes.
"We keep asking them to do more and don't give them the supports they need," Smetanka sighed. "Unfortunately, there's not the will to address these issues in a meaningful way."
Venecia: A Reason to Stay Put
Venecia Bradley is proud of her recent promotion to overnight shift lead at a long-term care facility in Tallahassee, Fla. Those hours allow this single parent to work as a CNA while her sister is with her four sleeping children; Bradley sleeps while they're at school and day care.
More to the point, the new position raised her pay to $15 an hour.
"I'm making the most money of my career, but I am not there just for the check," Bradley said. "It's not like that."
Eight years ago, as she began working with older people, Bradley earned $10 an hour and pieced together jobs in two residential facilities "to make ends meet."
"It was stressful on me to get off one job and go to the next," she said. "Sometimes we're not treated like what we do is valuable."
The skimpy paychecks, erratic scheduling, demanding hours and strenuous working conditions have given Bradley a first-hand view of the reasons behind the high turnover that plagues the industry. A recent published report calculated the median annual turnover among nursing assistants in nursing homes at an astonishing 99%.
"People who make ten dollars or twelve dollars an hour have to make a lot of hard choices. This is a problem our country has designed and it entrenches people in poverty."
Bradley herself has jumped several times, landing with her current employer two years ago. Now she plans to stay put, in part because the facility offered a rare benefit: a chance for advancement.
"The work environment is better here. I can say they do value me. It makes me eager to come to my job," she said.
Bradley dreams of becoming a registered nurse, which would double her wages and expand the scope of her responsibilities with older residents.
"It's a great field. You can grow and learn. But I've had people make fun of me, they say I wipe butts for a living, like it's the lowest job you could have, and that frustrates me. They should think about how they may need someone like me someday for their mother or their grandma. Or even themself."
Disincentives to Work
Many direct-care jobs are paid through Medicaid, which funds health care (including home health) for some 80 million low-income people. Employers who run programs funded through the federal/state program often complain that they don't receive adequate reimbursement and must keep labor costs low to sustain the system.
"The people who form the foundation of the system are low-wage workers and low-income older adults," said Espinoza.
He explained that many direct-care workers are so poorly paid that they and their families are eligible for public assistance programs. A PHI report found that 36% of nursing assistants working in nursing homes require public assistance, relying on housing subsidies, food assistance through SNAP (Supplemental Nutrition Assistance Program) and Medicaid for health care to stay solvent.
"Care workers don't receive the regular benefits that other workers do — insurance, family leave. But we survive."
In some cases, though, when they work more, they experience a cut, or even a loss, in their benefits, a situation PHI documented in a 2017 case study that analyzed what happened when hourly wages went up in New York.
"In reality, the system is designed so that their public benefits decrease in a greater amount than what they could earn if you took an extra shift. Working past a certain number of hours is a disincentive for low-income workers," Espinoza said.
He finds the current refrain that "people don't want to work" while direct-care jobs go unfilled to be simplistic and unfair.
"People who make ten dollars or twelve dollars an hour have to make a lot of hard choices," Espinoza said. "This is a problem our country has designed, and it entrenches people in poverty."
Allen: 'Reciprocity in Our Spirit'
Allen Galeon's work caring for older people in their homes was pared down as the coronavirus arrived.
"Pre-pandemic, I took care of multiple clients. But a year ago, I chose to drop to only one to minimize the potential for transmission," he said.
Now Galeon works multiple 12-hour shifts every week, part of a team that provides round-the-clock care for a 91-year-old woman in suburban Los Angeles.
"The social distancing is hard. This is intimate work, so I'm nervous every moment. The reality is, if our client has the virus, we will have it. If we get it, she will have it. Thank goodness we all stayed well and thank goodness for the vaccine," said Galeon.
He was a child when his mother "went looking for greener pastures" and left their home in the Philippines for southern California. She was undocumented when she began working at a long-term care facility. After becoming a permanent resident in 2008, she arranged for Allen and his siblings to come to the U.S. Since arriving, he has provided direct care to older members of some 30 families.
"In our family, we all do this work. We look at taking care of elderly people as how our mother supported us back home and as what brought us to this life. There is some kind of reciprocity in our spirit for this," he said.
A single father, Galeon sometimes feels isolated and stigmatized as the rare man doing hands-on caregiving — of the 1.9 million certified nursing assistants working in the US, only 13.2% are male.
"Care workers don't receive the regular benefits that other workers do — insurance, family leave. But we survive," said Galeon. "We contribute to the public good. Do we all need to become kings and queens in this lifetime? I don't think so."
Editor’s note: This story is part of The Future of Elder Care, a Next Avenue initiative with support from The John A. Hartford Foundation.