Updated July 2025

The pandemic exposed multiple flaws in the nation’s healthcare system. Some of those flaws were apparent even before the pandemic began. A nationwide shortage of direct care workers contributed to the impact that the pandemic had on aging Americans.

Direct care workers include home care workers, personal care attendants, and home health aides. They are caregivers who assist older adults. They help with the activities of daily living, such as bathing and getting dressed. They keep track of medication. They run errands. They often prepare meals and perform housekeeping tasks. In short, direct care workers help people do the things that they can no longer do themselves.

Apart from the other tasks they perform, direct care workers provide company for their clients. Lockdowns and quarantines took an emotional toll on everyone, but social isolation was particularly difficult for the nation’s elderly. Without the in-person visits that help people stave off loneliness, older adults suffered from anxiety, depression, poor sleep quality, and health problems that were exacerbated by physical inactivity.

A Growing Need for Direct Care Workers

Most caretakers are unpaid family members who voluntarily help their aging relatives. They often live in the same household. Yet many older people need the assistance of a paid worker. Some are living independently while others reside in an assisted-living or long-term care facility.

The Commonwealth Fund characterizes direct care workers as a “massive invisible workforce.” About half of the nation’s 4.5 million direct care workers provide home-based care. Many recipients of personal care are low-income individuals who qualify for home-based services through Medicaid.

Unfortunately, many direct care workers are not well paid. The Commonwealth Fund reports that 18% of direct care workers live in poverty, while 44% have low incomes. Low earnings make it difficult to attract workers who are willing to perform the exhausting and physically demanding tasks that the job requires. Yet as the U.S. population ages during the next decade, the direct care workforce is projected to be the fastest-growing segment in the labor market.

In fact, the Health Resources and Services Administration expects demand for direct care workers to increase by 45% by 2035. Two-thirds of the workforce providing long-term services and supports to older adults are direct care workers.

An economic stimulus law enacted in 2021 provided state Medicaid programs with enhanced funding to stabilize their direct care workforces. That funding ended in 2025 and reductions in the federal Medicaid budget will preclude similar assistance to states in the near future.

Valuing Direct Care Workers

Why are direct care workers paid so little when their work is so valuable? An analysis by Kezia Scales and Michael LePore emphasizes that Medicaid is the largest payer for direct care services. Efforts to improve funding for direct care, and thus to attract and retain qualified workers, “have ended in political gridlock or inertia.”

The labor market characterizes direct care workers as “unskilled” or “low skilled.” Those labels are used to justify “low pay, minimal training, and overall lack of recognition.” Low pay may also reflect a systemic belief that an occupation disproportionately filled by women, people of color, and immigrants has little value.

Scales and LePore argue that direct care workers are far from unskilled. In addition to developing the “core competencies” required to assist patients with their needs of daily living, “direct care workers must be knowledgeable about cognitive impairment, skilled in managing care to avoid or address behavioral and psychological symptoms, prepared to recognize and report changes in health status that may require clinical intervention, [and] adept at communicating with individuals with cognitive impairment and their unpaid caregivers and interdisciplinary care teams.”

The pandemic has highlighted the essential nature of the work that direct care workers perform. If pay should be commensurate with the importance of a job, direct care workers are obviously undervalued.

Legislative Changes

Scales and LePore point to the need for greater public funding, in Medicaid and other programs, to assure that direct care workers earn a living wage. In the absence of reasonable pay, a “stable and sufficient workforce” to deliver care to older Americans will never be achieved.

Unfortunately, Congress has chosen to devote less funding to Medicaid rather than adding the money that direct care workers need. While President Trump contends that his “Big Beautiful Bill” strengthens Medicaid by eliminating waste, fraud, and abuse, a research professor at the Georgetown University McCourt School of Public Policy argues that claims of waste and abuse in the Medicaid program are “dangerously wrong.” A statistical analysis of Medicaid payments found that only about 5% of Medicaid payments were improper, and most of those were classified as improper because documentation to support the payment was incomplete, not because unnecessary services were provided or because recipients were ineligible for Medicaid.

Scales and LePore also identify state laws that could be used as a model for other states or for federal legislation:

• Washington State enacted the country’s first social-insurance program to pay for long-term care. The state’s taxpayers will be eligible for insurance funds to pay a home health aide to help them with their activities of daily living. While the tax rate and the insurance benefits are both modest, the program is a step in the right direction.
• New York amended its Home Health Care Worker Wage Parity Law to require employers in the New York City area to pay, in addition to a minimum wage, additional wages or benefits that will help direct care workers obtain health insurance.

Scales and LePore also recommend:

• Improving career mobility by creating a uniform credentialing system so that direct care workers can prove they have experience and training.
• Creating and funding entry-level training programs that implement uniform standards of care.
• Developing and funding advanced training for experienced workers.
• Making technology available to care workers that will enhance their ability to deliver services to their clients.

Scales and LePore argue that similar proposals have been made for years by advocates for direct care workers. Yet the pandemic and growing realization that America’s aging population faces an uncertain future may have created the perfect storm to focus attention on assuring the well-being not just of older Americans but of the direct care workers who serve them.

(This article was updated July 2025 since it originally published April 2021.)