The Direct Care Workforce Crisis: Continued Vigilance for Change is Essential
The United States continues to face an escalating crisis in direct care work, one that threatens the well-being of millions of older adults and people with disabilities who rely on essential care services. Despite being one of the fastest-growing occupations in the country, direct care work is plagued by low wages, poor job quality, and high turnover, creating a workforce shortage that impacts families, employers, and the broader healthcare system. Without immediate intervention, the gap between the demand for care and the supply of workers will only widen, leading to serious economic and social consequences.
The Scope of the Crisis
Direct care workers (DCWs) go by many names depending on state, services, and care setting. Some names include home health aides, personal support service providers, home care aides, long-term care workers, and certified nursing assistants. DCWs play a critical role in long-term services and supports both in the home and in congregate, facility-based care settings. More than 5 million individuals work in these roles, ensuring that older adults, individuals with disabilities, and those with complex medical conditions receive the care they need. However, the profession is characterized by historic systemic inequities which result in high turnover rates, low wages, and minimal career advancement opportunities, making it difficult to attract and retain workers.
Over the next decade, the U.S. will need to fill approximately 8.9 million direct care job openings due to a combination of job growth, retirements, and workforce attrition. Yet, many employers already struggle to find and retain workers, as minimal recognition and respect, low wages, and poor benefits push people into other industries such as retail and food service. This creates a vicious cycle where those who need care have difficulty accessing affordable and consistent services, and family caregivers are forced to step in, often at great personal, emotional, and financial cost. The intervention of family caregivers is often required regardless; but, with undue pressures put on family members and friends, billions of dollars are lost every year as qualified professionals leave the workforce to become unpaid caregivers.
Economic and Policy Implications
The direct care workforce crisis extends beyond individual workers and care recipients—it is an issue that affects the broader economy. As more family caregivers leave the workforce to provide care, businesses experience productivity losses, and the economy suffers from reduced workforce participation. The lack of adequate staffing also increases reliance on costly institutional care settings, which are often more expensive than home- and community-based services.
Medicaid remains the primary funder of direct care services, yet proposed cuts to the program threaten to destabilize the system even further. If Medicaid funding is reduced, wages for direct care workers could stagnate or decline, exacerbating the workforce shortage and making it even harder for families to access care.
Additionally, immigrant workers make up 28% of the direct care workforce, playing a crucial role in filling labor gaps. Policies that limit immigration or increase deportations could further reduce the availability of qualified caregivers, making the crisis even more severe.
PHI’s Call to Action
A recent letter from PHI, a leading organization in direct care workforce research and advocacy, outlines key actions the Trump administration should take to address this crisis. In its letter, PHI urges a “whole-of-government” approach that prioritizes workforce development, job quality improvements, and sustainable funding models for long-term services and supports.
Key Recommendations from PHI:
Enhance Wages and Job Quality: Improve compensation and benefits for direct care workers to attract and retain talent.
Establish National Training Standards: Develop consistent training, credentialing, and career pathways as guidance and support for state-level investments to ensure a stable workforce and improve care quality.
Protect Medicaid Funding: Ensure Medicaid remains adequately funded to support direct care services and prevent further workforce shortages.
Support Immigration Policies That Stabilize the Workforce: Recognize the essential role of immigrant workers in caregiving and avoid policies that exacerbate labor shortages.
Encourage Public-Private Partnerships: Work with states, employers, and advocacy groups to develop sustainable workforce solutions that address long-term care needs. Leverage the open market for innovation and problem-solving.
The Path Forward
Solving the direct care workforce crisis requires a comprehensive, multi-faceted approach that includes policy reform, investment in workforce development, and recognition of the economic value of caregiving. The PHI letter highlights the urgent need for federal leadership, but state and local governments, private employers, and advocacy organizations must also play a role in ensuring that caregivers receive the wages, benefits, and career opportunities they deserve.
Some promising solutions for workforce health and development include
Access and awareness campaigns across industries. For example, vocational training schools and colleges can include guest speakers from long-term and community-based care providers to share the rewarding work and opportunities that exist from entry-level positions and beyond. Pro tip: bring stories of those individuals who have shifted careers into caregiving, or started as caregivers and transformed their career in healthcare.
Non-traditional educational pathways such as upskilling - skills training and certification for workers to increase their acumen, pay, and advancement opportunities. For example, a home care agency can offer a dementia care certification as continuing education for aides. For the aides who complete the program and express interest, explore further upskilling to make them a certified dementia care mentor or trainer. Pro tip: connect with local vocational and community colleges to learn more about job fairs and speaking opportunities to fill your employee pipeline with the next generation of caregivers.
As the demand for long-term services continues to rise, the U.S. must make direct care jobs a viable and attractive career choice. As healthcare professionals and change leaders, we must lead the charge sharing stories and experiences with all stakeholders from our colleagues to legislators and policymakers. Doing so will strengthen the workforce, support family caregivers, and ensure that millions of Americans can access the care they need to live with dignity and independence.
Join the Conversation
What do you think needs to happen to solve the direct care workforce crisis? Share your thoughts in the comments or engage with advocacy organizations pushing for change.
