Could Professionalizing the Caregiving Workforce Have Impact?

The people who make a living caring for older adults — primarily women, typically women of color, often immigrants — are critical to the smooth operation of the health care system. Yet home health aides and other direct-care providers are among the lowest-paid and least respected workers in the U.S.

The problem will only worsen if the jobs don't improve, advocates say. The solution? Better pay, more training and options for career advancement. Since immigrants make up a large portion of the direct-care workforce, immigration policy also needs to be addressed, some say. 

"We have essentially added another generation onto our lifespan without adapting policies" to account for increasing longevity, said Ai-Jen Poo, president of the National Domestic Workers Alliance and executive director of Caring Across Generations, a coalition that advocates for caregivers. 

"It's been about 20 years since our safety net was put into place," she told journalists at Columbia University's Age Boom Academy. Caregiving is "among the fastest growing occupations," and one that can't be outsourced or automated, said Poo, a Next Avenue Influencer in Aging. 

"We know these are going to be a huge part of the jobs of the future. We simply have to make them good jobs."

"There's no way to meet the demand in this country without a strong immigrant workforce," said Poo. She said that a path to citizenship would help immigrants and the workforce. "Home care workers enable tens of millions of families to go to work; it really is the foundation of all other work."

The bottom line is wages, said Nicole Jorwic, chief of campaigns and advocacy for Caring Across America. According to coalition data, home health aides make minimum wage or less in most states. "The reality is these are jobs that are skilled jobs," Jorwic said in an interview. 

However, she said that even in states that use their American Rescue Plan funds to raise direct care workers' wages, people can still earn more at big-box stores. "Even states recognizing the importance of this workforce are still struggling with turnover and vacancy rate because of competition and decades of lack of investment," Jorwic said.

"Covid really brought home the inadequacies of the current system," John Beard, a University of New South Wales professor, told journalists at Columbia University's Age Boom Academy. "Caregivers are really badly prepared. Caregiving is not an easy task."

According to Beard, former director of aging and life course at the World Health Organization, "the stress is exacerbated by the fact that they've had inadequate training."

Israel, South Korea, Germany, Japan and the Netherlands have universal long-term care insurance, "structures that create jobs for younger people" in addition to a "care economy," he added.

Providing training to paid and unpaid caregivers alike, perhaps by "linking" family caregivers with professional caregivers, and providing adequate time off are supports that would make caregiving less of a burden, said Beard.

The direct-care workforce is more significant than any other single occupation, with 1.2 million new jobs expected between 2020 and 2030, said Kezia Scales, vice president of research and evaluation at policy and advocacy firm PHI.

"A combination of strategies" across the spectrum will be needed to ensure these jobs are filled, Scales said in an interview. For example, better pay is "one part of a broader strategy," she said.

"Another key aspect of the challenge we're facing with recruitment and retention is around training and career development," Scales said. "The training landscape for direct care workers is very fragmented" and often inadequate for the job's complexity.

"There are very limited opportunities for people to progress beyond these entry-level positions," Scales explained, adding that leads people to leave for other, more lucrative industries.

Many long-term care providers are investing in training, but "it's not consistent across the board," said Scales. And some states are targeting training with American Rescue Plan funds for home- and community-based services.

"A number of states are investing some of that enhanced funding in their training infrastructure to think about a system that provides good, solid, recognized entry-level training that includes additional potential credentials and career progression," she noted. 

Wisconsin, for example, is launching a program for training and certifying direct care professionals to teach them skills they can take from one employer to another without retraining. 

The state says the program, which aims to certify at least 10,000 new workers, will "professionalize the career" as employers officially recognize workers' skills and workers have a "career ladder" to climb.

Researchers say that direct-care jobs are physically and mentally taxing and can hurt workers' health. Scales studied these workers' health care experiences compared with those of other health care workers and found that direct care workers were less likely to have health insurance — cost was cited as a primary reason — and more likely to have health problems.

"These are low-wage jobs, and they are filled primarily by women, people of color, and immigrants who face structural barriers" to accessing health care, Scales said. "The work itself is very physically and emotionally demanding," and "it's stressful." 

In addition, in-home work can be isolating, and nursing home jobs often come with crushing caseloads, she said. As a result, PHI has published a set of guidelines, "The 5 Pillars of Direct Care Job Quality," laying out elements that would help the direct-care workforce, including wages, training and support.

With immigrants making up one in four direct-care workers, the federal government may have to step up. Changes to immigration policy are still necessary to meet the growing demand for direct care, said Daniel Kosten, assistant vice president of policy and advocacy at the National Immigration Forum. 

"I believe things are progressively getting worse," said Kosten, who published a report two years ago highlighting the shortage of direct-care workers and immigrants' vital role in filling the gap.

Limiting immigration has hurt the market in Britain, Beard noted. "With Brexit, it became a lot harder to access the sorts of people who often fill caregiving roles," a situation that's been exacerbated by the current economic situation.

"Immigration into the U.S. the last several years, especially during the Trump administration but also going into the Biden administration, hasn't improved a whole lot," Kosten said. "There are a lot of backlogs in terms of people waiting for their visas, and also in terms of just processing."

Kosten's group is part of a coalition planning to lobby the Labor Department to expand its list of Schedule A jobs — hiring foreign workers would not hurt U.S. workers' wages or working conditions — to include positions like home health aides. 

Outgoing Labor Secretary Marty Walsh, Kosten noted, has spoken out in favor of immigration reform to address a worker shortage. Though the coalition hasn't yet engaged with the administration, "we think we have an open audience at DOL on this particular issue."

Trade associations are becoming more vocal about the issue, "recognizing the fact that the demand is so large they cannot meet it with native-born Americans," he said.

Editor's Note: This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations, and The Commonwealth Fund.

Nora Macaluso is a freelance writer based in Philadelphia. Read More