Restore, Support, Defend: PHI Midterm Policy Brief Series Maps What’s at Stake for the Direct Care Workforce
Direct care workers—5.4 million personal care aides, home health aides, nursing assistants, and direct support professionals—provide essential daily support to millions of older adults, people with disabilities, and families across the United States. Yet this workforce is facing three unprecedented federal policy changes at once: deep cuts to Medicaid, sweeping changes to immigration policy, and the rollback of basic labor protections. To help policymakers, advocates, and others understand the full ramifications of these policy changes and their interconnected impacts on care as the country enters a consequential election season, PHI has released a three-part policy brief series: Restore Medicaid, Support Immigrants, and Defend Labor Rights.
Stabilize the Program That Care Depends On
Restore Medicaid assesses the changing landscape of the Medicaid program, the primary payer of long-term services and supports in the United States. Cutbacks to this vital program doubly impact direct care workers, as providers of Medicaid-funded services and as Medicaid beneficiaries themselves, with nearly one in three relying on the program for their own health coverage. The brief documents how states are responding to the 2025 budget reconciliation act—estimated to cut $1 trillion from Medicaid over the next decade—with changes to coverage, benefits, and provider payments that leave home and community-based services especially vulnerable. PHI calls on federal and state leaders to prevent further erosion of Medicaid, minimize burdensome Medicaid requirements, and proactively seek sustainable funding solutions for our nation’s long-term care infrastructure.
Support the Immigrant Workers Who Anchor Care
Immigrants represent more than one in four direct care workers across the United States—over half in some states and localities—and research has shown their outsized contribution to care stability, continuity, and quality. Support Immigrants describes how federal immigration policies and enforcement actions threaten these workers’ safety and wellbeing, push them out of the workforce, and erode the pipeline of new workers—even as almost 800,000 new direct care jobs will need to be filled in the decade ahead. PHI urges Congress to halt and reverse punitive immigration policies, create immigration pathways for direct care workers, and strengthen support for immigrants already in the workforce.
Stop the Rollback of Basic Employment Protections
Recent federal actions will strip wage protections from home care workers, weaken safeguards against worker misclassification, eliminate nursing home staffing standards, and reduce federal oversight and workforce data capacity. Defend Labor Rights details these rollbacks and their consequences for jobs already characterized by low wages, unstable hours, and limited benefits—employment conditions that are not inevitable, but the result of policy choices that have historically undervalued care work. PHI calls for the U.S. Department of Labor to withdraw its proposed rollback of Fair Labor Standards Act protections for home care workers, for CMS and Congress to reinstate nursing home staffing standards, and for the Administration to rebuild the labor and data infrastructure that upholds direct care workers’ rights.
One Workforce, Interconnected Impacts
While the seismic policy shifts outlined above are often debated separately, they converge in the daily lives of direct care workers. A home care worker may rely on Medicaid for her own health coverage, work alongside immigrant colleagues who anchor her employer’s staffing, and depend on wage and hour protections to make ends meet on a median hourly wage of $17.36. Policy changes in one area ripple into the others, adding to workforce instability, putting more pressure on family caregivers, and compromising access to care for all who rely on it.
We call on State and Congressional leaders to invest in a national direct care workforce strategy embodied by PHI’s Universal Direct Care Workforce Initiative™, with universal entry-level competencies, stackable and portable credentials, and integrated career pathways, underpinned by financing structures that support wage progression and workforce retention. Today’s policy choices will determine whether the direct care workforce, and the long-term care system it sustains, can meet growing care needs into the future.
We encourage policymakers, advocates, employers, and partners to read the full series and share it with their networks—and to reach out to Amy Robins, Senior Director of Policy, to explore opportunities to collaborate.
