Transforming Care Work

What is care work and why is it essential?

As we journey through life, the need for care touches us all, whether it’s nurturing our children, supporting aging parents or disabled loved ones, or ensuring we are able to age with dignity in our own homes. Care work is work done in the service of others, can be paid or unpaid, and encompasses a variety of roles from family caregivers to home care workers to childcare providers to nannies and more. Care work is, and has always been, essential because it makes all other work possible.

Despite its pivotal importance, care work faces significant challenges — including low wages, poor conditions, and widespread exploitation — resulting in workforce shortages. With the demand for care expected to soar in coming years, addressing these issues has become more urgent than ever to ensure a sustainable and equitable future both for those providing care and those who need care.

What is the Care Crisis?

Families can’t afford care, care workers aren’t paid enough to feed their families, and our most vulnerable loved ones — children, aging parents and family members with disabilities — can’t get access to the care they need to thrive. Simply put, our country is facing a care crisis.

Low wages

For direct care workers and childcare providers, low wages and poor job quality are leading to high turnover and worker shortages.

Direct care workers provide essential services and care to older adults, people with disabilities, and children with complex medical needs in various settings. They might be called Home Health Aides, Personal Care Aides, Homemakers, or Direct Service Professionals, depending on where they work and who they help. Home care workers are a type of direct care worker who assist people at home or in their communities, not in places like nursing homes.

Despite their essential role, direct care workers struggle to earn a living wage – exacerbating the inequities already faced by women, people of color, and immigrants. Home care workers earned a median hourly wage of just $14.50 in 2022 and annual income of $20,599.

Similarly, childcare workers earn an average hourly wage of just $13.42, with an annual wage of $27,920. In 2022, there were only five occupations with median wages lower than those of child care workers. As childcare wages remain low and wages increase across other occupations, it has become more difficult to hire and retain childcare workers.

Poor job quality

Beyond low wages, direct care jobs are physically and emotionally demanding and often characterized by heavy workloads, scheduling challenges, inadequate supervision, and limited training and career advancement prospects. Additionally, many home care workers work only part-time (less than 35 hours per week) due to both personal reasons and economic conditions at their workplaces. All of these challenges contribute to high poverty rates among home care workers, with 15% living below the federal poverty level. Over half of home care workers rely on public assistance due to low incomes, while housing costs burden 37% of them. Furthermore, 15% lack health insurance, and 43% rely on public coverage, primarily Medicaid, underscoring the financial strains and vulnerabilities they face.

Similarly, childcare workers are faced with many challenges that affect the sector and that result in high turnover and workforce shortages. In addition to low wages, childcare workers experience limited access to essential benefits like health care and retirement plans, with twice as many lacking health insurance compared to the general workforce, and only a fraction receiving retirement benefits. The workforce is predominantly female and disproportionately comprised of women of color, who face substantial wage disparities. Union membership among childcare workers is low, impacting their collective bargaining power. The job itself is demanding, both physically and emotionally, with high rates of depression reported. Despite the importance of professional development, childcare workers often bear the costs themselves, exacerbating financial strain from already low wages.

Lack of access to care for families

For families who need care for a loved one in their home, direct care worker shortages mean that almost 692,000 Americans are on waitlists, waiting an average of over 3 years, to receive home services through Medicaid. By 2060, the number of people 65 and older will nearly double, and the number of adults 85 and older will nearly triple – exponentially increasing the need for quality care and care workers in the US. States already struggle to recruit and retain enough direct care workers to meet escalating demand, and it is estimated that from 2020 to 2030 the home care sector will have 4.7 million total job openings.

For families who need childcare in order to go to work and earn a living, burdensome childcare prices coupled with a lack of providers has made access to childcare even more difficult. Child care can cost more than $15,000 a year with prices ranging between 8 – 19.3 percent of median family income per child, which is well above the Health and Human Services’ recommended 7% of income benchmark for affordable childcare.

Additionally, childcare demands skilled workers to ensure safe and quality care, particularly in programs for infants and toddlers with strict safety standards. However, providing high-quality childcare is costly. Without state or federal funding to supplement their expenses, childcare workers and providers often incur the cost of maintaining operations through reduced wages, hours, or services, which adversely impact program quality.

Why prioritize care?

Our population is growing exponentially and aging.

Due to an exploding growth in our aging population and increasing demand for childcare, we are seeing an exponential increase in the need for quality care and care workers in the US. However, our country’s current approach to care fails to adequately value care work or address the cultural and policy changes needed to meet these escalating needs, which means the care crisis will only get worse.

We must act now to prioritize care, recognizing its indispensable role in supporting families, and ensure that dedicated caregivers get the dignity, respect, fair wages and benefits they deserve. By investing in care and care workers, we can make care jobs good jobs and ensure that families across the country can access the care they need.

What is needed to solve the Care Crisis?

We need investments in our care systems that include comprehensive support and services for care workers. AND, we need policies, resources, and services necessary to help families meet their caregiving needs.

Families are already overburdened with increasing home care and childcare costs. That is why we must prioritize investments in our care systems. By adequately funding care systems, we can ensure that caregivers receive fair wages, benefits, and working conditions, while also making care services more accessible and affordable for families in need. Investing in care not only supports caregivers but also promotes economic stability, social equity, and the overall well-being of our communities. It’s time to prioritize care as a fundamental aspect of our society and invest in its sustainable future.

How is NDWA addressing the Care Crisis?

At NDWA, we are working to tackle the home care crisis by:

• Fighting for bold and unprecedented investment in our nation’s care systems including Home and Community-Based Services (HCBS), early education programs, and more
• Raising care worker wages
• Strengthening protections for care workers

Our strategies to grow funding for care systems such as home and community-based services and childcare will allow more care recipients access to independence and critical care supports as well as increase wages for care workers, helping to stabilize the workforce and lead to better quality of care. Through our organizing and advocacy work, we are building a future in which every family has access to quality care.

Our Impact

In 2023 and 2024, we hit major milestones towards transforming the way this country treats care and caregivers.

The Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers (EO)

In 2023, the Biden-Harris Administration announced executive actions to improve care, which were the most comprehensive set of actions in the history of the United States. The executive order includes more than 50 directives to federal agencies to utilize existing funding to expand access to quality, affordable care, and provide support to family caregivers and care workers, including domestic workers.

These executive actions recognize the critical importance of care work, including paid and unpaid responsibilities such as child care, elder care, and disability care. It acknowledges the challenges care workers face, who are often undervalued and underpaid, and aims to improve their wages, benefits, and working conditions. Learn more about the impact of this historic Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers.

Proclamation on Care Workers Recognition Month

In 2023 and 2024, the White House proclaimed April as Care Workers Recognition Month, highlighting the Administration’s continued commitment to strengthening the care economy and marking a critical step forward for direct care workers, caregivers, early childhood educators, and child care workers to live and work with the respect and recognition they deserve. In 2024, the Biden-Harris Administration also announced that April will also serve as a “Month of Action on Care” to make caring for families more affordable and accessible.

This proclamation represents a turning point in our country – public recognition of work often invisibilized and undervalued, made possible by the women of color who have organized for decades to achieve transformational change in the care industry.

Every April, join us as we celebrate Care Workers Recognition Month and honor the millions of Black, Brown, Latinx, and immigrant care workers who support our families and communities every day!

“Ensuring Access to Medicaid Services” Rule

On April 22, 2024, the Center for Medicare and Medicaid Services (CMS) released the final “Ensuring Access to Medicaid Services” rule,” which marks a crucial step towards improving access to home-based care and better wages and working conditions for home care workers. In defining access to Medicaid, CMS recognizes the inextricable link between quality of Home and Community Based Services (HCBS) & the wages of Direct Care Workers, noting that low wages has led to direct care workforce shortages, which jeopardize access to long-term care.  Improving wages and working conditions to stabilize the workforce will ensure access to higher quality and continuous care.  

The Payment Adequacy provision of the rule applicable to Medicaid’s Home and Community Based Services, establishes a national standard for State Medicaid agencies to require home care providers dedicate at least 80% of all Medicaid payments of home care services towards the compensation for direct care workers.*  Medicaid  is the largest payor of long-term home care, (these services are not provided by Medicare) and HCBS beneficiaries include the aging and individuals with disabilities, who otherwise may be institutionalized in a nursing home.  Direct care workers assist these consumers of care with Activities of Daily Living (ADLS), such as mobility, personal hygiene, and eating and Instrumental Activities of Daily Living, such as cooking, grocery shopping, and managing finances. The rule also requires States to form an Interested Parties Advisory Group, which must include direct care workers to convene to analyze adequacy of existing Medicaid Payment rates and provide public recommendations to the State to raise rates in order to stabilize the workforce.  

In it published response to comments made on during the public notice process, CMS acknowledged the voices of many direct care workers who submitted “personal examples of the hardships caused by financial strain due to inadequate pay, including having to work long hours at multiple jobs to earn extra income, missing time with their own families, struggling to pay bills, risking exposure to (or contracting) COVID-19, and experiencing burnout and  psychological stress.” They stated how the stories of direct care workers showed that low wages impact worker retention and their proposal was critical because direct care workers have been paid low wages for a long time. 

While this standard will ensure home care workers get a fair share of the payments from the government for services they provide and agencies must responsibly manage public monies- NDWA is still campaigning at state and federal levels to dedicate more public dollars to increasing wages.  Thank you to everyone who submitted comments in favor of this rule last year and hope you will continue to participate in our campaigns to improve wages and benefits for the direct care workforce! We rely on our members and supporters to ensure States implement these rules in a timely manner, and solicit the support of state and federal legislators to pledge greater investment in Medicaid HCBS to ensure everyone who needs home care is able to access it and that these care jobs are quality and high-paid jobs.  

*There are flexibilities to state rules.

As we strive to address the challenges faced by caregivers and ensure a brighter future for all, staying informed and connected is crucial. Sign up for NDWA’s email list today to receive updates on our ongoing efforts, opportunities for action, and ways to get involved in advocating for caregivers and those they support. Together, we can build a more equitable and compassionate society where care is valued and accessible for all. Join us in making a difference!

Sources

Key Numbers

¹ Direct Care Workers in the United States: Key Facts 2023, PHI

² Bureau of Labor Statistics

³ A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2023, KKF

Graphics

1 in 6 home care workers live in poverty.

64% turnover rate in home care.

692,000 Americans are on waitlists, waiting an average of over 3 years to receive home services through Medicaid.

Projected Population Growth by Age Group, 2020 to 2060