At the foundation of the long-term care system — below the physicians, nurses, therapists, and administrators who occupy its more visible and better-compensated roles — are the direct care workers: home health aides, personal care attendants, nursing assistants, and certified nursing aides who provide the most hands-on, most intimate care to the most vulnerable people in the healthcare system. They assist people with bathing, dressing, eating, toileting, and mobility. They are present in the moments of greatest physical vulnerability and greatest human need. They are the operational foundation on which the entire long-term care system rests.
They are also among the lowest-paid workers in the American economy.
Median wages for home health aides and nursing assistants remain below $15 per hour in many states. Employer-provided health insurance, paid leave, and retirement benefits are not reliably available. Schedules are frequently part-time or unpredictable. Many direct care workers hold multiple jobs at multiple facilities simultaneously — not by preference but because no single position offers adequate hours or compensation to sustain a household. The work is physically demanding, emotionally intensive, and largely invisible to the policy system that depends on it.
This is not a peripheral workforce. The United States will need an estimated 1.2 million additional direct care workers by 2030 to meet the demand generated by an aging population. The current system cannot recruit or retain the workers it already needs. The gap between what the long-term care system requires and what it is structured to provide is one of the defining demographic challenges of the next two decades.
Who Does This Work
The direct care workforce is disproportionately female, disproportionately Black and Hispanic, and disproportionately immigrant. These demographic patterns are not coincidental. They reflect the historical devaluation of care work — labor that has been associated with women, with people of color, and with domestic service — in ways that have shaped both its compensation and its policy visibility across generations.
Approximately 4.5 million people work as direct care workers in the United States, making it one of the largest occupational categories in the economy. The Bureau of Labor Statistics projects it will be among the fastest-growing occupations over the next decade, driven by the aging of the baby boom generation and the documented preference of older adults for home and community-based care over institutional settings. Demand is growing. Supply is not keeping pace. The reason is straightforward: the jobs do not pay enough, under conditions good enough, to attract and retain the workforce the system needs.
The workforce that is being asked to absorb this demographic surge is already strained past its capacity. Vacancy rates at nursing facilities and home care agencies are elevated across the country. Agencies routinely turn away clients they cannot staff. Nursing facilities operate below their licensed capacity because they cannot hire enough workers to safely operate all their beds. The care that older adults and people with disabilities need is going unprovided — not because the need is unrecognized but because the system is not structured to meet it.
The Wage Problem and Its Source
The direct care workforce crisis is not primarily a labor market failure. It is a financing failure. The wages paid to direct care workers are not determined by competitive labor markets in the ordinary sense — they are determined largely by Medicaid reimbursement rates, which are set by state and federal policy. Medicaid is the primary payer for both nursing facility care and home and community-based services. The reimbursement rates Medicaid pays to nursing facilities and home care agencies set the effective ceiling on what those providers can afford to pay their workers.
Those reimbursement rates have been chronically inadequate. They do not reflect the actual cost of providing care at a quality level that supports competitive wages for the workers delivering it. States set Medicaid rates under budget constraints that create systematic pressure to hold rates below what the care actually costs. The result is a financing system that structurally prevents the wages necessary to attract and retain an adequate direct care workforce — and then attributes the workforce shortage to labor market conditions rather than to the policy decisions that produced it.
The inadequacy of Medicaid reimbursement is not a recent development. It has been documented, flagged, and largely unaddressed for decades. The political economy of Medicaid rate-setting consistently advantages fiscal restraint over workforce adequacy — because the people who bear the cost of inadequate rates are workers and care recipients with limited political voice, while the budget savings from low rates are immediate and visible to legislators facing fiscal pressure.
The Turnover Crisis
Low wages produce high turnover. Annual turnover rates among home health aides and nursing assistants routinely exceed 50 to 60 percent — meaning that the majority of the direct care workforce in any given facility or agency turns over within a year. In some settings turnover rates exceed 100 percent annually, meaning the entire workforce is replaced more than once in a twelve-month period.
Turnover at this scale is both a care quality problem and an organizational cost problem. Continuity of care workers matters significantly for people with cognitive decline, behavioral health needs, and complex care requirements. A person with dementia who has learned to trust a specific aide, who has established routines and communication patterns with that person, experiences genuine harm when that relationship is disrupted — harm that does not appear in any cost accounting but is real to the person experiencing it and to the family members watching it happen. High turnover means that continuity is structurally unavailable as a feature of care for people who need it most.
The organizational cost of high turnover consumes resources that might otherwise improve wages or care quality. Recruiting, hiring, and training a new direct care worker costs an estimated $2,500 to $5,000 per position. Facilities with 60 percent annual turnover across a workforce of 100 direct care workers are spending $150,000 to $300,000 annually on turnover costs alone — resources that are unavailable for wage increases that might reduce the turnover generating those costs. The turnover trap is self-reinforcing: low wages produce turnover, turnover produces costs, costs reduce the resources available to raise wages.
Immigration Policy and the Direct Care Workforce
A substantial share of the direct care workforce consists of immigrants, including workers in visa categories that have been affected by immigration policy changes in recent years. This is not incidental — it reflects both the demographic composition of communities where direct care work is concentrated and the documented willingness of immigrant workers to accept direct care positions that native-born workers increasingly decline at current wage levels.
Enforcement actions, changes to visa categories, and policy uncertainty about immigration status affect the direct care workforce in ways that are consequential for the long-term care system’s operational capacity. Facilities and agencies that depend on immigrant workers for a significant share of their direct care staffing are directly exposed to immigration policy changes in ways that do not appear in immigration policy debates but are felt immediately in staffing levels and care availability.
The relationship between immigration policy and direct care workforce supply is not primarily an immigration debate. It is a long-term care access debate. The older adults and people with disabilities who depend on home health aides and nursing assistants for their daily care are directly affected by policy decisions that reduce the supply of workers willing and able to do this work at current wage levels. Those effects are borne by people who are among the least able to absorb them.
The Unpaid Complement
The paid direct care workforce exists alongside an unpaid complement that dwarfs it in scale. Family caregivers — predominantly women, predominantly middle-aged, frequently employed outside the home simultaneously — provide an estimated $600 billion in unpaid care annually to older relatives and people with disabilities. This unpaid labor is the invisible foundation of the long-term care system: the care that gets provided because a family member provides it rather than because the financing system supports it.
The relationship between the paid direct care workforce and unpaid family caregiving is not simply one of substitution — where family caregivers fill gaps left by an inadequate paid workforce. It is more complex. Family caregivers who lack access to adequate paid care support face the choice of providing care themselves, at cost to their own employment, health, and financial security, or going without care for the person they are responsible for. The inadequacy of the paid direct care workforce is not absorbed by some other system. It is absorbed by family members, disproportionately women, who carry costs that do not appear in healthcare spending statistics but are real and substantial.
The long-term care financing gap documented in this hub — the absence of a coherent public financing system for sustained care — produces both the direct care workforce crisis and the unpaid family caregiver burden simultaneously. They are two faces of the same financing failure.
What Would Change Things
Improving direct care workforce supply and stability requires addressing the financing conditions that produce the wage floor. That means Medicaid reimbursement rates that are adequate to support competitive wages — which requires either increased federal Medicaid funding, state budget commitments that have consistently not materialized under current fiscal conditions, or a fundamental restructuring of how long-term care is financed.
The workforce dimensions of the long-term care crisis are inseparable from the financing dimensions. There is no workforce solution that does not require a financing solution. The policy options for long-term care financing — expanded Medicaid, a new public insurance program, mandatory private insurance, or some hybrid — each have different implications for direct care workforce wages and supply. Understanding the workforce crisis is part of understanding what any serious long-term care financing reform needs to accomplish.
The people best positioned to describe what this workforce crisis looks like in its human and operational detail are the direct care workers themselves — the home health aide who holds three jobs because none pays enough to live on, the nursing assistant who has worked the same unit for fifteen years and watched her colleagues cycle through annually, the personal care attendant who provides essential daily support to someone who would otherwise be institutionalized and who earns less than the person managing the agency’s billing software. That experience belongs in the deliberation this hub is designed to support.
This article was researched and drafted with AI assistance under human review. See our full AI and editorial practices.