Menus Subscribe Search

Follow us


Taking Care of the Caregivers

• November 15, 2010 • 5:00 AM

WANTED, Home care providers: flexible hours, good working conditions, low pay, age irrelevant, bring own insurance.

If you’re a “people-person” looking for a job in a field that’s growing not shrinking — and especially if you are an older “people-person” — you might consider the mushrooming field of at-home direct care.

These are not the workers who provide care in nursing homes or hospitals, but those who go to the homes of the elderly, sick or disabled to help them eat, dress, bathe and a number of other tasks. By some estimates, seven of every 10 care workers for the elderly are direct care workers, and the opportunities are growing outside geriatrics: direct home care has been called “the next frontier of pediatric practice.”

The nonprofit PHI, which works to improve the lives of both those who need home care and those who provide it, estimates that between 2008 to 2018, the overall direct care workforce will expand from 3.2 million to 4.3 million. And of that increase, the percentage of workers 55 and older will jump from the current 22 percent to almost 30 percent.

Speaking to the Brookings Institute in January, PHI President Steven L. Dawson outlined the size and shape of this sprawling new industry. “What’s most important to understand is that they are a huge workforce. Of the $160 billion in long-term service support, about half of that — $80 billion — goes to the payment and support of this work force.

“There are about 3 million direct care workers in this country. They are the fastest-growing occupation in the United States.” In the next six years, he said, there will be more direct care workers than kindergarten-to-high-school teachers, fast food workers or registered nurses.

If current trends continue, this burgeoning profession will not be a slice of the American workforce as a whole; it will be overwhelmingly female, increasingly aged and quite likely broke.

At present, 90 percent of direct care workers are women, and PHI expects by 2018 we can conservatively expect employment of “at least 1.2 million older female direct care workers, up from approximately 723,002 today.”

The March Supplement of the Current Population Survey divides the direct care workforce into two categories: “nursing aides, psychiatric aides, and home health aides” and “personal and home care aides.” In the first group, only one-fifth are older than 55, while in the second older workers make up 28.3 percent. In the general population, meanwhile, those 55 and older make up 14 percent of the workforce, with that percentage increasing as the general population ages.

The New York Times related a story earlier this year in which a 68-year-old caregiver who hurt her back was replaced — by a co-worker who was 73.

While direct care may provide job opportunities, its pay and benefits in no way have kept pace with the growth in medical spending.

Dawson describes direct home care as a low-investment, high-turnover, low-return business model. “Over an eight-year period ending in 2007, in real wages adjusted for inflation, per capita spending on health care has increased 30 percent, salaries for doctors and RNs increased 16 percent, and for home care workers, wages decreased 3 percent. And in a bitter irony, even though these workers serve the health care industry, 2 out of 5 home care workers do not have health insurance.”

In July, U.S. Rep. Linda Sanchez (D-Calif.) told her fellow representatives 1 in 3 direct home care workers lived near or below the poverty level, more than 1 in 4 lacked health insurance; and that 2 in 5 live in households that receive one or more public benefits such as food stamps or Medicaid.

According to Cooperative Home Care Associates, a 25-year-old for-profit worker-owned co-op in the South Bronx, “Most home care agencies fill their rosters with as many part-time aides as they can hire, train them to minimum required standards, and assign work with little regard for the aides’ need for full-time hours or other professional treatment. As a result, turnover in the industry is high, care provided is erratic, and both home care aides and home care clients suffer.”

The federal health care overhaul signed into law this spring, and possibly on the ropes in the next Congress, addresses some of these problems. The legislation contains several provisions that will impact long-term care and direct-care workers. For example, Medicaid eligibility will be expanded to those earning 133 percent of the federal poverty level, giving many direct-care workers access to health care for the first time. In addition, training standards are likely to improve as the result of demonstration grants intended to develop and pilot competency-based training curricula for personal and home care aides.

Particularly important is the CLASS Act, a new voluntary long-term care insurance program, which includes in its provisions a Personal Care Attendant Workforce Advisory Panel that will make recommendations on how to sustain a workforce capable of caring for America’s aged population.

This summer, Rep. Sanchez introduced legislation to remove the restrictions that allow employers not to pay direct care workers the minimum wage or overtime. The federal Department of Labor under Barack Obama’s administration has discussed axing those exclusions, but has not taken action. (Meanwhile, Sanchez’s Direct Care Workforce Empowerment Act — which also collects information on the industry and establishes grants to recruit more workers to the field — was in the House’s Subcommittee on Workforce Protections at press time.)

Some states such as Michigan, Vermont, Massachusetts, Illinois, Pennsylvania and Iowa have had programs (or proposed legislation) in this area for some time, but in recent years budgetary constraints, as in California, have taken their toll.

Nonetheless, this fall Michigan announced a new program called Building Training … Building Quality in which the state’s Office of Service to the Aging will partner with PHI on a project to build and operate a “gold standard” training program that would provide education to more than 1,500 new and working personal-care attendants. The pilot program is funded by a three-year, $2.03 million Personal and Home Care Aide State Training Program demonstration grant awarded to the Office of Service to the Aging by the U.S. Department of Health and Human Services. Michigan is one of six states to receive this home care aide funding made available under the health care reform laws signed in March.

On its website, the nonprofit Direct Care Alliance lists three key issues: fair pay, health care and benefits and training. “Too many people perceive direct care work as ‘unskilled labor’ or ‘women’s work,’” the site says. “This lack of respect leads to high turnover and denies workers a seat at the table in efforts to reform our long-term care system.”

PHI’s Dawson argues, “We have to create a very positive argument that, in fact, these workers are of enormous value to the system, but they are really underutilized. We’re paying about $80 billion dollars a year” for direct home health care, and “70 cents of the dollar, of your tax dollar, and we’re really not getting what we could from that value.”

Subscribe to Miller-McCune

John Greenya
John Greenya, a Washington, D.C.-based writer, is the author or co-author of 18 books. His work has appeared in The New York Times, The Washington Post, and The New Republic, among other publications.

More From John Greenya

A weekly roundup of the best of Pacific Standard and PSmag.com, delivered straight to your inbox.

Recent Posts

December 19 • 12:00 PM

Social Scientists Can Do More to Eradicate Racial Oppression

Using our knowledge of social systems, all social scientists—black or white, race scholar or not—have an opportunity to challenge white privilege.


December 19 • 10:17 AM

How Scientists Contribute to Bad Science Reporting

By not taking university press officers and research press releases seriously, scientists are often complicit in the media falsehoods they so often deride.


December 19 • 10:00 AM

Pentecostalism in West Africa: A Boon or Barrier to Disease?

How has Ghana stayed Ebola-free despite being at high risk for infection? A look at their American-style Pentecostalism, a religion that threatens to do more harm than good.


December 19 • 8:00 AM

Don’t Text and Drive—Especially If You’re Old

A new study shows that texting while driving becomes even more dangerous with age.


December 19 • 6:12 AM

All That ‘Call of Duty’ With Your Friends Has Not Made You a More Violent Person

But all that solo Call of Duty has.


December 19 • 4:00 AM

Food for Thought: WIC Works

New research finds participation in the federal WIC program, which subsidizes healthy foods for young children, is linked with stronger cognitive development and higher test scores.


December 18 • 4:00 PM

How I Navigated Life as a Newly Sober Mom

Saying “no” to my kids was harder than saying “no” to alcohol. But for their sake and mine, I had to learn to put myself first sometimes.


December 18 • 2:00 PM

Women in Apocalyptic Fiction Shaving Their Armpits

Because our interest in realism apparently only goes so far.


December 18 • 12:00 PM

The Paradox of Choice, 10 Years Later

Paul Hiebert talks to psychologist Barry Schwartz about how modern trends—social media, FOMO, customer review sites—fit in with arguments he made a decade ago in his highly influential book, The Paradox of Choice: Why More Is Less.


December 18 • 10:00 AM

What It’s Like to Spend a Few Hours in the Church of Scientology

Wrestling with thetans, attempting to unlock a memory bank, and a personality test seemingly aimed at people with depression. This is Scientology’s “dissemination drill” for potential new members.


December 18 • 8:00 AM

Gendering #BlackLivesMatter: A Feminist Perspective

Black men are stereotyped as violent, while black women are rendered invisible. Here’s why the gendering of black lives matters.


December 18 • 7:06 AM

Apparently You Can Bring Your Religion to Work

New research says offices that encourage talk of religion actually make for happier workplaces.


December 18 • 6:00 AM

The Very Weak and Complicated Links Between Mental Illness and Gun Violence

Vanderbilt University’s Jonathan Metzl and Kenneth MacLeish address our anxieties and correct our assumptions.


December 18 • 4:00 AM

Should Movies Be Rated RD for Reckless Driving?

A new study finds a link between watching films featuring reckless driving and engaging in similar behavior years later.


December 17 • 4:00 PM

How to Run a Drug Dealing Network in Prison

People tend not to hear about the prison drug dealing operations that succeed. Substance.com asks a veteran of the game to explain his system.


December 17 • 2:00 PM

Gender Segregation of Toys Is on the Rise

Charting the use of “toys for boys” and “toys for girls” in American English.


December 17 • 12:41 PM

Why the College Football Playoff Is Terrible But Better Than Before

The sample size is still embarrassingly small, but at least there’s less room for the availability cascade.


December 17 • 11:06 AM

Canadian Kids Have a Serious Smoking Problem

Bootleg cigarette sales could be leading Canadian teens to more serious drugs, a recent study finds.


December 17 • 10:37 AM

A Public Lynching in Sproul Plaza

When photographs of lynching victims showed up on a hallowed site of democracy in action, a provocation was issued—but to whom, by whom, and why?


December 17 • 8:00 AM

What Was the Job?

This was the year the job broke, the year we accepted a re-interpretation of its fundamental bargain and bought in to the push to get us to all work for ourselves rather than each other.


December 17 • 6:00 AM

White Kids Will Be Kids

Even the “good” kids—bound for college, upwardly mobile—sometimes break the law. The difference? They don’t have much to fear. A professor of race and social movements reflects on her teenage years and faces some uncomfortable realities.



December 16 • 4:00 PM

How Fear of Occupy Wall Street Undermined the Red Cross’ Sandy Relief Effort

Red Cross responders say there was a ban on working with the widely praised Occupy Sandy relief group because it was seen as politically unpalatable.


December 16 • 3:30 PM

Murder! Mayhem! And That’s Just the Cartoons!

New research suggests deaths are common features of animated features aimed at children.


December 16 • 1:43 PM

In Tragedy, Empathy Still Dependent on Proximity

In spite of an increasingly connected world, in the face of adversity, a personal touch is most effective.


Follow us


Don’t Text and Drive—Especially If You’re Old

A new study shows that texting while driving becomes even more dangerous with age.

Apparently You Can Bring Your Religion to Work

New research says offices that encourage talk of religion actually make for happier workplaces.

Canadian Kids Have a Serious Smoking Problem

Bootleg cigarette sales could be leading Canadian teens to more serious drugs, a recent study finds.

The Hidden Psychology of the Home Ref

That old myth of home field bias isn’t a myth at all; it’s a statistical fact.

The Big One

One in two United States senators and two in five House members who left office between 1998 and 2004 became lobbyists. November/December 2014

Copyright © 2014 by Pacific Standard and The Miller-McCune Center for Research, Media, and Public Policy. All Rights Reserved.