Sign Up to Receive PHI Alerts

Is It Time for a Direct Care Workforce Vaccine Mandate? Maybe.

August 4, 2021

As the COVID-19 pandemic persists and vaccination rates remain dangerously low, vaccine mandates are becoming increasingly common in American life. From Google to the Broadway League and countless others, companies in the public and private sector are increasingly adopting policies that require proof of vaccination to enter and work in their environments. Recent guidance and legal rulings enable this trend—with caveats and resistance—and many hope vaccine mandates will finally turn the tide on this unprecedented health crisis.

In this context, health and long-term care settings are an obvious focus for vaccine mandate considerations—and major companies have begun moving in this direction. Each of us should be assured of safely receiving quality care in any setting, yet the ongoing numbers of unvaccinated workers threatens that ideal—and our lives. Nearly 60 national organizations in health and long-term care—including the American Medical Association, the American Nurses Association, LeadingAge, and others—recently issued a statement calling “for all health care and long-term care employers to require their employees to be vaccinated against COVID-19.” This statement encompasses direct care workers who have been on the frontline of this pandemic.

Assertive interventions such as vaccine mandates are needed to ensure that this pandemic doesn’t continue indefinitely—or worsen due to new variants, as many epidemiologists warn. Vaccines are safe, well-tested, and becoming widely available in this country, though access barriers remain and vaccination data should be stronger. Further, vaccines protect our individual health, but they also safeguard the public health; our decisions to vaccinate ourselves determine whether this pandemic will continue or finally resolve. Given these conditions, employer-based vaccine mandates make sense, particularly within a polarized political climate brimming with vaccine misinformation and anti-science attitudes.

Yet entrenched societal problems require multi-faceted responses, and a vaccine mandate, especially for direct care workers, should be handled sensitively and methodically. Before implementing such a mandate, long-term care employers should make every possible effort to encourage and enable their workers to become vaccinated, informed by the ideas offered in a February 2020 report from the COVID-19 Vaccination Uptake Behavioral Science Task Force. Key strategies include fostering vaccine champions within the organization and overcoming remaining barriers to vaccination, such as a lack of trust in government and scientific research, the proliferation of misinformation or insufficient information, logistical access challenges, and language and cultural barriers. While these measures may be limited in effectively moving staunch vaccine refusers, they may still persuade many hesitant workers to make the right decision to vaccinate themselves.

Why should a long-term care employer first explore every possible strategy to increase vaccine uptake before issuing a vaccine mandate? For starters, vaccine mandates risk perpetuating the disempowerment—produced by structural racism, sexism, and paternalism—that direct care workers experience as a mainly female, people of color workforce. Therefore, such policies must only be introduced after workers have had a reasonable amount of time and autonomy to make free and informed choices about their health, along with sufficient access to the vaccine.

Another reason is that a vaccine mandate—without other preemptive or complementary measures—could backfire among workers who have other employment options. Direct care workers have been leaving this sector too soon for years—primarily because of poor-quality jobs but also due to a culture that devalues their worth both as workers and as marginalized people. During the first few months of this pandemic, more than 280,000 direct care workers left the direct care workforce.

Though direct care employment figures have improved since then, turnover in this job sector remains a profound problem. In a labor market where direct care workers can find modestly better-paying and/or less arduous jobs in retail and fast food—or move into a similar job with a different long-term care employer—they may choose to leave rather than comply with an employment requirement that challenges their vaccination concerns. Employers are already struggling to fill vacant direct care positions, which means that this mandate could leave older adults and people with disabilities without workers—the opposite of the intended effect of a vaccine mandate.

If a long-term care employer decides to institute a vaccine mandate, they should consider a few important questions. To what extent will the employer engage employees in arriving at and communicating this decision—and what are the best frames and messages for responding to concerns about vaccines and vaccine mandates? What are the legal and practical implications of implementing a vaccine mandate? If a significant number of workers were to leave their jobs because of this mandate (an estimate that could be generated with a staff survey), how will the employer replace those positions to ensure care continuity for their clients or residents? How will the employer monitor the impact of vaccine requirements on recruitment, turnover, and retention rates, as well as other outcomes? And for employers that do not implement a mandate, what risk mitigation strategies should they carry through, including mandatory weekly testing and enhanced personal protective equipment requirements for unvaccinated staff? These are only a few critical issues that employers will need to address related to these mandates.

As with other aspects of the COVID-19 pandemic, the elephant in the room is poor job quality for direct care workers, which puts both workers and their clients at continual risk, exacerbates the workforce shortage in this sector, and hinders the effectiveness of any pandemic-related strategy, including a vaccine mandate. To get through this crisis and prevent the next one, federal and state leaders must improve the quality of these jobs by increasing compensation, strengthening training and advancement opportunities, and enacting many other reforms, as described for federal leaders in our new federal priorities report. Overall, we need a complete transformation of the direct care workforce. A vaccine mandate that raises its fist without raising the floor for these jobs will eventually fall flat.

Specific to COVID-19, we need more robust and targeted education on the vaccine’s safety and efficacy, especially as the virus and our scientific understanding evolve. We need a “lessons learned” analysis on the direct care workforce and COVID-19, as well as more research on the factors shaping vaccine acceptance among direct care workers and best practices in increasing vaccine uptake. We need stronger data collection and reporting on COVID-19 across long-term care settings and the workforce, which would provide a clearer picture of the pandemic’s impact, including how vaccine mandates and other strategies affect workers and their clients.

Direct care workers make every effort to ensure our health and wellbeing, and their work takes patience and skill. When crafting vaccine mandates and strategies to increase vaccine acceptance, we must adopt the same approach.

All our lives depend on it.


Contributing Authors

Caring for the Future

Our new policy report takes an extensive look at today's direct care workforce—in five installments.

Workforce Data Center

From wages to employment statistics, find the latest data on the direct care workforce.