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Direct-Care Workforce Projected to be Nation's Largest by 2020, New PHI Analysis Finds

May 10, 2012

Workforce Expected to Add 1.6 Million New Jobs to the Economy, Job Quality Continues to Worsen

Bronx, NY — By 2020, the direct-care workforce — nursing assistants, home health aides, and personal care aides — is projected to be the nation's largest workforce at 5 million workers, according to a new PHI analysis available in PHI FACTS 3: America's Direct-Care Workforce (pdf).

Direct-care occupations are expected to add an additional 1.6 million jobs to the economy over the decade from 2010-2020. Yet the wages for these jobs continue to decline and the number of the workers without health care coverage has increased.

"It's quite striking that probably the largest workforce ever produced by our economy is largely made up of women who struggle with inadequate conditions of employment as they try to make ends meet," said PHI Policy Research Director Dorie Seavey, who conducted the analysis with Policy Research Analyst Abby Marquand.

Home care jobs — both home health aide and personal care aide positions — are the nation's fastest-growing jobs, projected to increase over the decade from 2010-2020 at an astounding 69 and 71 percent, respectively.

Home health aides and personal care aides rank third and fourth, respectively, on the list of occupations expected to generate the most new jobs to the economy over this period.

Direct-care workers far outnumber other health care practitioners, including physicians, nurses, and therapists, comprising nearly a third (30.6 percent) of the entire U.S. health care workforce in 2011. These workers also outnumber, by nearly three to one, all those employed in allied health occupations, such as medical and dental assistants, and physical therapy assistants and aides.

Shift Toward Home and Community-Based Settings

The PHI analysis found that in 2011 there were at least 4 million direct-care workers, with the majority employed in home and community-based settings. By 2020, the workers employed in these settings are expected to outnumber facility workers by more than two to one.

PHI researchers estimate that there are at least 800,000 independent providers who provide personal care services for consumers enrolled in Medicaid-funded programs. These workers, employed directly by consumers and their families in home and community-based settings, are not tracked by the U.S. Bureau of Labor Statistics. Consequently, independent providers have been heavily undercounted in government surveys, the researchers explain.

"There are two basic models for delivering in-home services and supports in the U.S. today: an agency model and an independent provider model," Marquand notes. "The latter has two broad variants: private and public. The size of the private strand is extremely difficult to measure since so many private arrangements are not reported, but publicly funded arrangements can and should be accounted for — substantial numbers of workers and consumers are involved in this sector."

Wages and Benefits Worsen

The median wage of $10.59 in 2011 for all direct-care workers is far below the median wage for all U.S. workers that year ($16.57). Moreover, adjusted for inflation, wages for all three direct-care occupations have declined over the last decade.

Personal care aides and home health aides earned a median wage of $9.49 and $9.91 per hour, respectively. The wages for these home care occupations are significantly less than the median hourly wages of $11.63 for nursing aides, orderlies, and attendants.

The number of direct-care workers without health care coverage in 2010 increased to 950,000, up from 900,000 the previous year.

More than one third of aides employed by home care agencies and one in four nursing home aides lacked health care coverage in 2011.

Poverty Increases

With wages declining, an increasing number of direct-care workers live below the poverty line or just above it. Since 2008, the proportion of direct-care workers living in households with incomes below 200 percent of the federal poverty line has increased from 44 to 47 percent.

At current income levels, nearly half of these workers are eligible for — and rely on — public benefits such as Medicaid and food stamps to support their families.

Demographic Characteristics

The PHI researchers also identified these demographic characteristics of direct-care workers in 2010:

  • Gender: 88 percent women; 12 percent men.
  • Average age: all direct-care workers, 42; employed in nursing care facilities, 39; employed in home health care, 43; and self-employed or working directly for private households, 49.
  • Immigration Status: 80 percent born in the U.S.; 20 percent foreign-born.
  • Education: 46 percent some college or advanced degree; 54 percent high school or less.

"Carework in America is at a crossroads," Seavey said. "We can continue the status quo, adding direct-care positions that are poorly supported and poorly compensated, and then backfill them with public assistance. Or we can acknowledge this workforce as a key underutilized asset in our healthcare system and exploit its enormous potential as one of the strongest job engines that our economy has to offer."

For more information on the direct-care workforce, see PHI FACTS 3: America's Direct-Care Workforce (pdf), and also visit PolicyWorks and the Chart Gallery on the PHI website. For state-by-state data on the direct-care workforce, visit the PHI State Data Center.

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PHI, the Paraprofessional Healthcare Institute (, works to transform eldercare and disability services, fostering dignity, respect, and independence -– for all who receive care, and all who provide it. The nation's leading authority on the direct-care workforce, PHI promotes quality direct-care jobs as the foundation for quality care.

Deane Beebe

PHI Media Relations Director

718-928-2033; 646-285-1039 (cell)

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