Academic journal article Generations

Direct-Care Healthcare Workers: You Get What You Pay For

Academic journal article Generations

Direct-Care Healthcare Workers: You Get What You Pay For

Article excerpt

An unnecessary crisis in long-term care?

Just don't get sick ... and don't grow old either. -advice of a home health aide

The long-term-care system in the United State long ago structured itself on the presumption of a seemingly endless supply of low-income individuals (usually women, and disproportionately women of color) willing to work as certified nurse's aides, home health aides, and personal care attendants. Both providers and consumers presumed that these workers would always be available to offer care and companionship in long-term-care settings-- despite low-quality jobs that kept them working, but poor.

Now, however, direct-care staffing vacancies are spreading throughout nursing homes and home care agencies across the country (Paraprofessional Healthcare Institute, 2000). The very future of the industry now rests on an ability to attract direct-care workers within an increasingly competitive environment.

Of course, given that paraprofessionals in long-term care are paid primarily by American taxpayers, it could reasonably be argued that our long-term-care system simply has an obligation to create healthcare jobs that provide a livable wage, that our publicly funded healthcare system has a responsibility, at the very least, to guarantee its own workers health insurance. Yet, historically, moral suasion alone has failed to forge significant improvements in the quality of direct-care jobs. Perhaps the new economic imperative will provide a more effective impetus.

Below, we argue that in order to survive, let alone provide high-quality care, the long-termcare system must restructure and must significantly improve the quality of paraprofessional employment.


Today, the long-term-care industry faces a profoundly changed labor market. Nationwide, the pool of likely entry-level healthcare workers -women in the civilian workforce aged 25 to 44 -is projected to decline by 1.4. percent during the next eight years (Fullerton, 1999). This particular population cohort is crucial, since it is the labor pool that has typically provided fresh recruits for the long-term-care industry.

Note in Figure i that the likely decline of this cohort of women in the civilian workforce follows three decades of significant expansion-- nearly tripling from 1968 through 1998.

Two interacting factors have caused the expansion of this female cohort during the past three decades: the increasing number of women from the baby boom generation coming of adult age and the increasing percentage of those women participating in the workforce (45 percent in 1968, rising to 76.7 percent in 1998). Now, however, the baby boom workforce has passed through this age range, leaving a smaller workforce to follow. Moreover, the rate of increase of participation of women in the workforce has slowed considerably, rising to only 79.5 percent for 2008, according to projections (Fullerton, 1999).

Because our long-term-care system developed during three decades of unprecedented labor expansion, it is little wonder that today, as traditional labor pools start to shrink, the industry is dazed and uncertain as to how to proceed. Although the nation's full-employment economy certainly exacerbates the situation-low-income women now have many more employment alternatives outside of healthcare-the hot economy is primarily a cyclical phenomenon that hides the deeper truth of the structural demographic shifts now occurring in the country's workforce.

In short, labor is becoming a scarce resource and will likely remain so even when the economy begins to cool (Judy, 2000). Therefore, the decades-old presumption of an endless supply of low-income women to feed, bathe, and comfort those in need of care is no longer valid. The system must change if it is to compete successfully with other employers.


The low-income, direct-care worker stands at the intersection of three public policy worlds: healthcare policies designed to deliver long-- term-care services, labor policies designed to improve employment prospects for all U. …

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