FAQ
WHAT IS THE DIRECT CARE WORKFORCE STATE INDEX?
Created and led by PHI—the nation’s leading expert on direct care workers—the Direct Care Workforce State Index offers a data-driven picture of how states’ public policies support direct care workers and direct care workers’ economic experiences and outcomes. This online interactive tool enables users to rank and compare states based on two composite measures: the range of policies states have enacted to support these and other low-income workers and the economic status of direct care workers.
WHAT DATA DOES THIS INDEX INCLUDE?
The data that informs this tool is drawn from PHI’s existing resources, including analysis for the Workforce Data Center and other PHI publications, and from external resources, including reports and websites, state administrative and legislative documents, and other sources. Most data were collected, compiled, updated, and/or published in 2024, with some exceptions. Please see the Methodology section for an explanation of each indicator included in the index, along with its source and date.
WHY DID PHI CREATE THIS TOOL?
In response to deep-rooted, large-scale challenges facing direct care workers and the individuals they support, a growing number of states in recent years have prioritized measures to improve these workers’ jobs, strengthen this workforce, and improve recruitment and retention in this sector. However, the workforce shortage in direct care continues to intensify, and states must do much more to address it. This online tool aims to help a range of stakeholders understand how states are supporting their direct care workers, where they can improve, and how they compare to other states.
WHO ARE THE PRIMARY AUDIENCES FOR THE INDEX?
This index is primarily intended for state policymakers and advocates, who can use the information to inspire and inform policies that strengthen this workforce. Other audiences include public and private funders, researchers, industry leaders, long-term care employers, journalists, and more.
WHAT ARE THE HIGHEST-RANKING STATES, ACCORDING TO THIS INDEX?
According to the index, the top 5 states for direct care workers are: Washington State (1), Rhode Island (2), Oregon (3), Maine (4), and New Jersey (5). The states with the most opportunity for improvement regarding direct care workers are: Texas (51), Mississippi (50), Alabama (49), Louisiana (48), and Tennessee (47).
ARE THESE RANKINGS DEFINITIVE?
No. While these scores and rankings provide an important lens on the policy realities shaping direct care jobs across different states, they certainly do not capture the complexity and nuance of each state. Therefore, caution should be used when comparing states on the basis of these overall scores and rankings.
WHEN WAS THIS TOOL LAUNCHED?
PHI launched the index on January 10, 2023.
WHEN WAS THIS TOOL UPDATED?
PHI updated the state index in 2024 and released a research report detailing findings.
Methodology
The Direct Care Workforce State Index centralizes a range of information and analysis about direct care workforce policies and outcomes across all 50 states and the District of Columbia. The data that informs this tool is drawn from PHI’s existing resources, including analysis for the Workforce Data Center and other PHI publications, and from external resources, including reports and websites, state administrative and legislative documents, and other sources.
As well as offering comparable statistics on the size, demographics, and expected growth of the direct care workforce in each state, the Direct Care Workforce State Index provides a composite score for each state based on two sub-indexes: the “Worker Supportive Policy Index” and the “Direct Care Workforce Economic Index.” The indicators that compose each of these sub-indexes are described below, along with the data source and year (meaning the year the data were collected, compiled, updated, or published, depending on the source).
WORKER SUPPORTIVE POLICY INDEX
For the Worker Supportive Policy Index, states are ranked according to a composite score reflecting both direct care workforce policies and universal labor policies. Each state’s total Worker Supportive Policy score is based on an average of two averages, i.e., the average scores for all direct care workforce policies and for all universal labor policies.
Direct Care Workforce Policies
Direct care workforce policies are defined as state policies that are intended to improve direct care worker compensation, training, and/or access to employment. Each of these policy indicators are equally weighted in the sub-index based on standardized scores (as shown in brackets for each indicator below).
Personal Care Aide Training Standards Key Provisions
This indicator comprises the following 10 personal care aide training provisions. For this indicator, states received up to 10 points for each provision (for a possible total of 100):
- Consistent Requirements Across Medicaid
- Private-Pay Training Requirements
- Requirements in Consumer-Directed Programs
- Any Training Hours Specified
- Any Competency Assessment Specified
- Portable Credentials
- Central Training Registry
- Requirements for Instructor Qualifications
- State-Sponsored Curriculum
- Continuing Education Requirements in Place
Source: PHI analysis of PCA training standards resources (please contact info@PHInational.org for more details); compiled 2024.
Home Health Aide Training Standards Exceed Federal Minimum
Federal regulations require that home health aides employed by Medicare- or Medicaid-certified home health agencies complete 75 hours of training and 12 hours of continuing education. For this indicator, states are scored on whether they have set a higher minimum training hours standard for home health aides (100=yes, 0=no).
Source: https://www.phinational.org/advocacy/home-health-aide-training-requirements-state-2016/; updated 2016
Nursing Assistant Training Standards Exceed Federal Minimum
Federal regulations require that nursing assistants employed by Medicare- or Medicaid-certified nursing homes complete 75 hours of training and 12 hours of continuing education. For this indicator, states were scored on whether they have set a higher minimum training hours standard for nursing assistants in nursing homes, based on PHI’s review of state training regulations (100=yes, 0=no).
Source: https://www.phinational.org/advocacy/nurse-aide-training-requirements-state-2016/; updated 2016
Dollar-Amount Wage-Pass Through Policy (Current)
A dollar-amount wage pass-through is a state policy that requires Medicaid-funded employers to pay direct care workers a specified base wage or increase direct care worker wages and/or other compensation by a specified dollar amount. This indicator only includes wage pass-throughs that were current in 2024, not historical wage pass-through policies (100=yes, 0=no).
Source: PHI review of wage pass-through resources (please contact info@PHInational.org for more details); compiled 2024
Percentage Wage-Pass Through Policy (Current)
A percentage wage pass-through is a state policy that requires Medicaid-funded employers to spend a specified proportion of their Medicaid reimbursements on direct care worker wages and/or other compensation. This indicator only includes wage pass-throughs that were current in 2024, not historical wage pass-through policies (50=yes, 0=no).
Source: PHI review of wage pass-through resources (please email us at info@PHInational.org for more details); compiled 2024
State-Funded Matching Service Registry
Matching service registries are online platforms that facilitate matching between self-directing home care consumers (and other employers, in some cases) and direct care workers. These registries may have state-wide or regional coverage. For this indicator, states were scored on whether they have a state-funded registry in place (100=statewide matching service registry, 50 = regional matching service registry, 0=no state-funded matching service registry).
Source: https://www.phinational.org/advocacy/matching-service-registries/; updated 2023
Universal Labor Policies
Universal Labor Policies are defined as state policies that are intended to support all workers’ abilities to access health insurance, take paid time off, collectively bargain, achieve greater economic stability, and access and maintain employment without discrimination. Each of these policy indicators is equally weighted in the sub-index based on standardized scores (as shown in brackets for each indicator below).
Minimum Wage Exceeds Federal Minimum Wage
The federal minimum hourly wage in 2024 is $7.25. For this indicator, states were scored on whether they have set a higher minimum wage at the state level (100=yes, 0=no).
Source: https://www.dol.gov/agencies/whd/mw-consolidated/; published 2024
Medicaid Expansion
Under the Affordable Care Act, states have the option to access additional federal funding to expand Medicaid eligibility for all adults to 138 percent of the federal poverty level. For this indicator, states were scored on whether they have opted to expand Medicaid (100=yes, 0=no).
Source: https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/; published 2023
Paid Sick Leave
Paid sick leave policies allow workers to accrue a specified number of paid hours off to address their own or a family members’ health needs. For this indicator, states were scored on whether they have a paid sick leave law in place (100=yes, 0=no).
Source: https://github.com/Shift-HKS/Labor-Policy-Database/tree/main/Individual-policies-data; data from 2022, and additional PHI review of state paid sick leave policies (please contact info@PHInational.org for more details); compiled 2024
Paid Family and Medical Leave
Paid family and medical leave laws allow workers who meet certain requirements to take extended paid time off for their own medical needs, to bond with a new child, to care for a family member, or (in some cases) for other covered reasons. For this indicator, states were scored on whether they have a paid family and medical leave law in place (100=yes, 0=no).
Source: https://github.com/Shift-HKS/Labor-Policy-Database/tree/main/Individual-policies-data and PHI review of administrative and legislative resources (email us at info@PHInational.org for more details); And additional PHI review of state paid family and medical leave policies (please contact info@PHInational.org for more details); compiled 2024.
Union-Supportive Legal Environments
So-called “right to work” laws create barriers to unionization by prohibiting unions from collecting dues from non-members who are covered by a union contract in those states. In practice, these laws hinder efforts to organize workers and collectively bargain on their behalf. Conversely, states that have not enacted such barriers offer more supportive environments for unionization. States were scored positively (100) if they do not have a law weakening unions and therefore have a more supportive environment for unions and workers. If a state has a law weakening unions, it was scored as 0.
Source: https://www.ncsl.org/labor-and-employment/right-to-work-resources; published 2023
Protections for LGBTQ+ Workers
State-level protections for LGBTQ+ workers prohibit employment discrimination based on workers’ sexual orientation and/or gender identity. For this indicator, states were scored on whether they have enacted protections against employment discrimination based on sexual orientation and/or gender identity in public and/or private sector employment. If a state had a law protecting against employment discrimination on the basis of sexual orientation and/or gender identity in the public and/or private sector, they were scored as 100 (100=yes, 0=no). If they had no laws protecting against employment discrimination on the basis of sexual orientation and/or gender identity, they were scored as 0.
Source: https://www.hrc.org/resources/state-scorecards; published 2023 and SHIFT project, https://github.com/Shift-HKS/Labor-Policy-Database/tree/main/Individual-policies-data
Refundable State Earned Income Tax Credits
State Earned Income Tax Credit (EITC) programs reduce the tax burden for low- to middle- income taxpayers. When the EITC is refundable, taxpayers may receive a refund if their credit exceeds their state income tax bill (i.e., the amount of tax owed). For this indicator, states were scored on whether they have a refundable EITC program in place (100=yes, 0=no).
Source: https://www.urban.org/policy-centers/cross-center-initiatives/state-and-local-finance-initiative/state-and-local-backgrounders/state-earned-income-tax-credits#eitc/; published 2023
Non-Refundable State Earned Income Tax Credits
State Earned Income Tax Credit (EITC) programs reduce the tax burden for low- to middle- income taxpayers. When the EITC is non-refundable, the credit cannot exceed the taxpayer’s state income tax bill (i.e., the amount of tax owed). For this indicator, states were scored on whether they have a non-refundable EITC program in place (50=no, 0=yes).
Source: https://www.urban.org/policy-centers/cross-center-initiatives/state-and-local-finance-initiative/state-and-local-backgrounders/state-earned-income-tax-credits#eitc/; published 2023
DIRECT CARE WORKFORCE ECONOMIC INDEX
For the Direct Care Workforce Economic Index, states are ranked according to a composite score reflecting several indicators of direct care workers’ compensation and economic stability. The total score for each state is an average of the standardized scores for the component indicators, which are all equally weighted. Indicators with missing values are not counted in the total.
Median Wage
The median wage for direct care workers in each state is calculated as a weighted average of the median wages for personal care aides, home health aides, and nursing assistants, then standardized to 100.
Source: PHI analysis of Bureau of Labor Statistics (BLS) Occupational Employment and Wage Statistics (OEWS) Program, May 2022 State Occupational Employment and Wage Estimates.
Wage Competitiveness
The values for the wage competitiveness indicator reflect the difference between direct care worker median wages and median wages for occupations with similar or lower entry-level requirements, standardized to 100. These comparative occupations fall into Job Zone 1 (“Little or No Preparation Needed”) and Job Zone 2 (“Some Preparation Needed”) as defined by the Occupational Information Network (O*NET), which is maintained by the North Carolina Department of Commerce with funding from the U.S. Department of Labor.
Source: PHI analysis of Bureau of Labor Statistics (BLS) Occupational Employment and Wage Statistics (OEWS) program, May 2022 State Occupational Employment and Wage Estimates and the O*NET 28.0 Database.
Median Personal Earnings
Median annual personal earnings for direct care workers are calculated as a weighted average of median annual personal earnings for personal care aides, home health aides, and nursing assistants, then standardized to 100.
Source: PHI analysis of 2018-2022 5-Year Public Use Microdata Sample (PUMS) from the American Community Survey (ACS).
Low-Income Household
For this indicator, states were scored according to the percentage of direct care workers in the state living in households below 200 percent of the federal poverty level.
Source: PHI analysis of 2018-2022 5-Year Public Use Microdata Sample (PUMS) from the American Community Survey (ACS).
Lacks Affordable Housing
For this indicator, states were scored according to the percentage of direct care workers in the state who lack affordable housing or are housing cost-burdened, meaning their housing costs exceed 30 percent of their household’s total income.
Source: PHI analysis of 2018-2022 5-Year Public Use Microdata Sample (PUMS) from the American Community Survey (ACS).
Uninsured
For this indicator, states were scored according to the percentage of direct care workers in the state who do not hold any form of health insurance, including through their own or a family member’s employer or union; through Medicare, Medicaid, or another public program; or through the health insurance marketplace.
Source: PHI analysis of 2018-2022 5-Year Public Use Microdata Sample (PUMS) from the American Community Survey (ACS).
For additional information on the methodology, please email us at info@PHInational.org.
