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New Index Ranks States on Direct Care Workforce Policy Supports

January 11, 2023

NEW YORK — PHI today released a new online tool that will help policymakers, advocates, and other leaders in various states understand how they support direct care workers, where they can improve, and how they compare to other states.

Created and led by PHI—the nation’s leading expert on direct care workers—the Direct Care Workforce State Index offers an interactive, data-driven picture of how states’ public policies support direct care workers and how these workers are faring financially.

It enables users to rank and compare states based on two composite measures: the range of policies that states have enacted to support these and other workers, and the economic status of direct care workers.

The latest research shows that about 4.7 million direct care workers—home care workers, residential care aides, and nursing assistants—support older adults and people with disabilities in various long-term care settings. Yet, despite their growing size and enormous value, workers often avoid or leave this field because direct care jobs impoverish workers and suffer from many other dimensions of poor job quality.

However, states can significantly address these hardships and stabilize this essential job sector.

“States are critical actors in job quality for direct care workers, and we hope this new online tool provides state leaders with insightful data and information to improve these jobs for the benefit of workers, consumers, and employers,” said Jodi M. Sturgeon, president & CEO of PHI, a national research, advocacy, and workforce innovations organization based in New York City.


To compel states to create the much-needed policy infrastructure to improve direct care jobs, the Direct Care Workforce State Index scores and ranks all 50 states and the District of Columbia.

This ranking is based on two composite measures: the worker supportive policies measure, which examines policies related to wages, training requirements (with added detail on training standards for personal care aides, the most under-trained segment of the direct care workforce), Medicaid expansion, paid leave, “Right to Work” laws, protections for LGBTQ+ workers, and state-level Earned Income Tax Credits; and the direct care workforce economic measure, which includes variables such as median wage, wage competitiveness, median annual personal earnings, poverty, affordable housing, and health insurance coverage.

According to the index, the top 5 states for direct care workers are Washington State (1), Rhode Island (2), District of Columbia (3), Maine (4), and New Jersey (5).

The states with the most opportunity for improvement regarding direct care workers are Texas (51), Mississippi (50), Louisiana (49), Alabama, (48), and North Carolina (47).

While the index’s scores and rankings provide a critical lens on the policy realities shaping direct care jobs across different states, PHI’s researchers emphasize that these scores and rankings do not capture the complexity and nuance of each state. Therefore, PHI strongly advises that caution be used when comparing states entirely on these overall scores and rankings.

“PHI has always been committed to providing our partners and audiences with reliable research that strengthens their interventions on the direct care workforce—and this new index provides the much-needed analysis that state and national leaders have wanted for years,” said Dr. Kezia Scales, vice president of research and evaluation at PHI.


While the COVID-19 pandemic has underscored the essential contribution of direct care workers to the lives of millions of older adults and people with disabilities, their jobs continue to be rife with challenges that make it difficult for them to make ends meet. From inadequate compensation to limited training and advancement opportunities to a general lack of recognition and support, job quality challenges also force many direct care workers out of this field.

As a result, PHI estimates that between 2020 and 2030, the long-term care sector will need to fill about 7.9 million job openings in direct care. This figure includes jobs that must be filled when existing workers transfer to other occupations or exit the labor force, as well as new jobs created by growing demand, which is largely spurred by the rapid aging of this country.

In response to these challenges, a growing range of states in recent years have prioritized measures to improve direct care workers’ jobs and improve recruitment and retention in this sector. However, the workforce shortage in direct care has intensified, and states must do much more to address it.

“This index is the beginning of a vital state-to-state assessment of direct care workforce policy issues, and we hope to continue evolving it over time to ensure that it benefits everyone,” said Scales.

Visit the Direct Care Workforce State Index here.

This index was made possible by generous funding from the W.K. Kellogg Foundation.



Contributing Authors

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