Will Congress Finally Transform the Direct Care Job?

As COVID-19 has reinforced, home care workers and nursing assistants are critical to the lives of older adults and people with disabilities, ensuring they can thrive in their private homes, nursing homes and various residential care settings. They are the paid frontline of long-term care and spend more time with clients and residents than any other paid professional.

The size of this workforce speaks in part to its enormous value. At 4.6 million, this workforce is larger than any other single occupation in the United States. Furthermore, demand for these workers will continue to grow exponentially; between 2019 and 2029, long-term care employers will need to fill 7.4 million job openings in direct care, including 1.3 million new jobs and 6.9 million openings caused by workers who move to other occupations or exit the labor force altogether.

For many people, this crisis also has shed light on the profound, long-standing challenges facing these "essential" workers: inadequate compensation, limited training and advancement opportunities and a general lack of recognition and support, among other challenges. When jobs are poor in quality, everyone in this system suffers: workers lack economic security, employers struggle to recruit and retain workers and consumers receive poor-quality care. Yet the reverse also holds true: quality jobs improve employment, care and cost outcomes—as job satisfaction and care quality improve, consumers spend more, public assistance rates drop and costly health outcomes (such as unnecessary emergency department visits) go down.

A wave of new federal bills and actions signal an important shift in federal recognition of this workforce. As detailed below, President Biden and congressional leaders have recently unveiled an unprecedented number of federal bills that aim to address the top challenges facing this workforce, from financing and compensation to training and other workforce interventions to data collection, equity and COVID-19 relief and recovery.

These developments are exciting—and should serve as a clarion call to finally ensure that these workers receive the federal recognition and high-quality jobs they deserve.

Financing and Compensation

Of all the recent federal proposals impacting direct care workers, President Biden's massive, two-part infrastructure investment has received the most attention. The American Jobs Plan, the first part, would invest $400 billion in expanding access to home- and community-based services and improving wages for home care workers, while also funding a range of workforce development programs that could benefit these high-demand workers.

The American Families Plan serves as the second part of this investment, providing affordable childcare, universal preschool, expanded higher education access, individual and family tax credits and comprehensive paid leave to millions of people, including direct care workers.

‘A three-part package of bills would bolster the training infrastructure for direct care workers.’

While they have not yet been introduced, two other federal bills up for discussion would also bolster funding for long-term care and this workforce. The Well-Being Insurance for Seniors to be at Home (WISH) Act would create a federal social insurance program to finance long-term care and could be designed to also strengthen direct care jobs, and the Home and Community-Based Services (HCBS) Access Act would fund states to strengthen their HCBS infrastructure and further invest in the home care workforce. Inadequate financing prevents many state officials and employers from improving these jobs—these two bills could help address this problem.

Training and Other Workforce Interventions

A three-part package of bills would bolster the training infrastructure for direct care workers: the Direct Support Worker Training Reimbursement Act, which would increase federal matching payments for training programs focused on the direct care workforce; the Mollie Baldwin Upskilling of Personal and Home Care Aides Act, which would fund competency-based upskilling models in direct care; and the Career Advancement for Direct Support Aid Workers Act, which would fund direct care workforce interventions focused on education, training and advancement, with an emphasis on workers in rural areas and from communities of color (among other vulnerable populations).

Additionally, the Direct Creation, Advancement, and Retention of Employment (CARE) Opportunity Act would invest more than $1 billion in workforce interventions that improve training, recruitment, retention and advancement opportunities in the direct care workforce. All these measures would help professionalize this workforce and elevate their roles in care delivery, among other benefits.

Data Collection, Equity and COVID-19

Federal leaders also have drawn attention to other urgent needs of this workforce. The Recognizing the Role of Direct Support Professionals Act would establish a Standard Occupational Classification for direct support professionals who assist people with intellectual and developmental disabilities. This policy change would allow for more data and a better understanding of this segment of the direct care workforce.

The Domestic Workers Bill of Rights Act would extend numerous rights and protections for domestic workers (home care workers, housekeepers and childcare workers) related to wages and benefits, discrimination, health and safety and more. Because the direct care workforce is predominantly female, largely people of color and increasingly composed of immigrants, such legal safeguards would help these marginalized workers navigate a fractured, biased labor market.

Finally, to help direct care workers through the COVID-19 crisis, the American Rescue Plan, signed into law this March, presents numerous opportunities for states to invest this boost in COVID-19-related funding in the direct care workforce.

The early part of 2021 has been exciting for direct care workers and their advocates—and could begin altering the landscape for one of the most valuable yet neglected workforces in the country. Moreover, when jobs improve, the quality of care improves—and we all win.

It's time to do right by these workers.

Robert Espinoza is the vice president of Policy at PHI, where he directs a national policy advocacy and research program focused on the direct care workforce. He also serves as a member of the board of directors for the American Society on Aging and the National Academy of Social Insurance.