10 Reasons to Advance Equity for Direct Care Workers

In my conversations with aging and long-term care leaders around the country, I'm routinely asked why I speak so explicitly about equity issues among direct care workers.

If this workforce comprises almost entirely women, people of color and immigrants—people will ask—isn’t equity assumed and therefore irrelevant? Also, wouldn't it be more appropriate to focus our efforts entirely on improving the overall direct care job—given its dearth of quality—regardless of workers’ identities?

It's a valid question that unfortunately reveals a variety of misconceptions about “equity” and the realities of direct care workers. First, these comments conflate the diversity of direct care workers with the inequities they face; it's true that this workforce is already diverse (though less so in management positions). But our data also reveals that, in an already marginalized workforce, women, people of color and immigrants generally fare worse in this job sector than do their counterparts, and they experience unique challenges that merit targeted attention.

In a marginalized workforce, women, people of color and immigrants fare worse than do their counterparts.

It is also possible to improve the overall quality of a job and remove the barriers that certain workers face—these ideas are not mutually exclusive. Finally, today’s inequities are historical, longstanding and deeply entrenched—and we must each do our part to tackle them for the betterment of our society.

In this context, PHI recently launched the Direct Care Worker Equity Institute, which aims to address the structural inequities and profound disparities facing direct care workers by compiling resources and publications, producing original studies, developing advocacy tools, designing workforce interventions and convening workforce experts—all with a focus on equity. Through this institute, we will help all direct care workers thrive personally and professionally, delivering the care that millions of older adults and people with disabilities deserve.

Here are 10 reasons for advancing equity for direct care workers:

1. The overwhelming majority of direct care workers are women, people of color, immigrants and poor and low-income people—groups that have long faced a multitude of societal challenges related to discrimination. According to PHI, 87% of direct care workers are women, 61% percent are people of color, 27% are immigrants, and 27% are ages 55 and older. Forty-four percent of direct care workers live in or near poverty.

2. A long history of systemic racism has concentrated people of color into poor-quality, low-paying occupations, including direct care. From slavery to Jim Crow and continuing to this day, a variety of government policies have limited the employment options of people of color, overrepresenting them in critical though grossly underpaid occupations related to food service, agriculture, laundry and dry cleaning services, domestic work and direct care, among others.

3. This egregious history of systemic racism—which has affected distinct communities of color differently—has harmed the health and financial security of people of color. Extensive literature has documented how people of color experience limited employment and educational opportunities, reduced earnings, entrenched poverty and poor health, among other inequities and outcomes. These realities affect people of color within and beyond direct care.

4. Racist government decisions have historically targeted direct care workers and the broader long-term care system. For decades, racist policies have devalued direct care jobs—a notable example being the exclusion of home care workers and other domestic workers from New Deal labor benefits and protections in the 1930s, which impoverished these workers in the decades that followed. Racism also has been a driving force in the gradual erosion of Medicaid, which serves as the primary public payer of long-term care and direct care jobs—and provides health coverage to many direct care and other low-income workers.

5. Throughout history, immigration policy has been fraught with racism, punishing immigrants of color who help sustain job sectors like long-term care. Roughly one in four direct care workers is an immigrant, as noted above, and many of them deal with increased hostility in our culture, face barriers to navigating the immigration system, and struggle with documentation difficulties, among other challenges.

6. Gender injustice also undermines direct care jobs. Specifically, caregiving has historically been defined as “women’s work” and often still is dismissed as a labor of love that requires only minimal compensation, training and support, perpetuating poor job quality in this sector.

7. As a result of systemic racism and gender injustice, women of color fare worse than white men in direct care. According to PHI, the median family income for women of color in direct care is $37,600, compared to $47,100 for their white male counterparts. Additionally, 53 percent of women of color in direct care live in or near poverty, compared to 38 percent of white men in direct care.

8. Many direct care workers also struggle with the heightened challenges of discrimination and bias related to their sexual identities and their age, among other characteristics. Research shows that 5.6 percent of the U.S. population identifies as LGBTQ+, a proportion that is likely represented in the direct care workforce, and roughly one in four direct care workers is ages 55 and older. Discrimination against both groups continues to be widespread.

9. Intersectional race- and gender-explicit approaches are necessary to strengthen and support the direct care workforce. Because specific segments of the workforce experience unique and additional hardships rooted in a long history of systemic inequities, long-term care leaders must elevate equity approaches that support workers and consumers.

10. Creating equity approaches in direct care benefits every worker in this job sector and the millions of people they support. This holistic vision guides PHI's new Direct Care Worker Equity Institute—and should inspire all of us to advance our own equity initiatives.

Robert Espinoza is Vice President of Policy at PHI, in Bronx, NY, and serves on ASA’s Board of Directors.