PHI Releases Policy Roadmap to Strengthen the Direct Care Workforce—and Reimagine Care

At an inflection point for the U.S. long-term care system, PHI, the nation’s leading authority on the direct care workforce, today released a policy brief outlining both comprehensive responses for current challenges, and proactive solutions to reimagine care and build a better future for older adults, people with disabilities, and all whose lives intersect with our nation’s care systems.

PHI’s report, The Path Forward: Preserving, Strengthening, and Reimagining Care in the United States, comes at a critical juncture for the nearly 5.4 million direct care workers who support older adults, people with disabilities, and those with serious illness across the country.

The report details how recent administration and congressional actions—including unprecedented Medicaid cuts, harsh immigration enforcement, delays to nursing home staffing standards, and proposed elimination of minimum wage and overtime protections for home care workers—are actively undermining the livelihoods of these essential workers—and destabilizing care for millions of families.

“Our nation’s long-term care system—and specifically our direct-care workforce—have long needed investment,” said PHI’s President and CEO, Jodi M. Sturgeon. “That reality hasn’t changed—and growing demand for care is only placing further pressure on the system. We need to  take action today, to build the future Americans deserve.”

Immediate Protective Actions Needed

The direct care workforce—85% women, 64% people of color, and 28% immigrants—earns a median wage of just $17.36 per hour. Nearly half rely on public assistance to survive. Current policy changes threaten to strip health coverage from the one-third of workers who depend on Medicaid, while harsh immigration enforcement is already causing workforce disruptions, with particularly severe impacts in states where immigrants comprise up to 60% of the care workforce.

The report identifies five critical areas requiring immediate action to preserve the existing care infrastructure:

• Restore Medicaid: Congress should act to reverse the damaging changes to Medicaid made by the 2025 budget reconciliation bill (OBBBA).
• Implement Critical Rules: Federal policymakers must reverse course and ensure the Nursing Home Staffing rule goes forward to improve job quality and care. Congress must also ensure the full and timely implementation of the Medicaid Access Rule.
• Protect Immigrant Direct Care Workers: The administration should moderate its approach to immigration and issue expedited work authorization renewals for immigrant direct care workers (28% of the workforce). Congress should also advance bipartisan legislation such as The Dignity Act of 2025.
• Sustain Labor Protections: The U.S. Department of Labor must uphold the Home Care Final Rule, which secures basic minimum wage and overtime protections for home care workers. Failing that, states should codify minimum wage and overtime protections for home care workers and align Medicaid reimbursement rates accordingly.
• Rebuild Federal Infrastructure: Congress and the administration should halt the elimination of essential federal programs and restore trusted leadership to the U.S. Bureau of Labor Statistics to ensure the accuracy of labor data.

A Vision for Transformation—and Reimagining Care

Building  on these responsive measures, our report charts an ambitious path forward, centering on PHI’s Universal Direct Care Workforce Initiative™ launched in July 2025. This groundbreaking effort aims to transform training, career pathways, and compensation for direct care workers through:

• Universal entry-level competencies enabling seamless movement across care settings.
• Stackable, portable credentialing supporting wage progression and economic stability.
• Integrated career pathways balancing accessibility with meaningful specialization.
• Accessible training infrastructure in multiple languages and formats.

Together, these efforts seek to transform the quality of direct care jobs at every level—strengthening workforce recruitment and retention, ensuring that these jobs offer significant opportunities for career mobility, and empowering this workforce to improve care for people and families across the country.

With 9.7 million direct care job openings projected between 2024 and 2034—more than any other occupation—the report emphasizes that workforce investments are not optional but essential to meeting America’s care needs.

“Together, we can empower this workforce to meet our nation’s care and support needs for decades ahead,” added Sturgeon. “State and federal policymakers must act now to ensure that direct care workers have the training, compensation, support, and career development opportunities needed to deliver high-quality care and strengthen the foundation of our long-term care system.”

The full report is available at https://www.phinational.org/resource/the-path-forward-preserving-strengthening-and-reimagining-care-in-the-united-states/