Posted Oct 8, 2021, 11:35 am
May helped care for her elderly aunt for years. When her aunt died,
May, who is 41, decided to leave her part-time job as a telemarketer and
become a full-time home health aide.
She said the thought of making other people like her aunt more
comfortable felt like a calling. “Just the joy of helping,” May said.
In the 11 years she worked as a home health aide, May estimates she
looked after 100 elderly clients in their homes. Some just needed a
light meal prepared, but others required much more help. “They couldn’t
move at all. I had to change them, feed them, bathe them, everything.”
Tens of millions of older Americans want to age at home. But the
critical shortage of people to take care of them will require more than
the Biden administration’s proposed billions of federal dollars for
home-based long-term health care. It will take a complete and
substantial change in the training system, career pipeline, pay and work
conditions of home health aides, experts and advocates say.
If those things aren’t fixed, the suffering will be felt not only by
the “millions and millions of people [who] work very hard at very
difficult and important jobs and get poverty wages,” said Paul Osterman,
a professor of human resources and management at MIT and author of the
book “Who Will Care for Us?” It will affect everyone who wants to age
at home or has a loved one who does, he said. The burden of caregiving
will fall on unpaid relatives, affecting their financial and mental
“It’s a real problem for society,” Osterman said.
It’s also an example of how job training in the United States is not
well ordered, lacks incentives for people to take on critical work and
often leaves consumers to fend for themselves and spend more money on
their educations than is justified by what they’ll earn.
There are about 54 million Americans over 65, according to the U.S.
Census Bureau. That number is expected to rise to 95 million by 2060.
Older adults have shown a clear preference for remaining in their homes, for the independence but also the comfort and community connections.
Aging in place is typically more cost effective than moving into long-term nursing facilities and proved a far safer option during the Covid-19 pandemic, when more than 184,000 residents and staff died in nursing homes and assisted living.
Key to enabling more older adults to remain at home is expanding the
number of home health aides, workers usually seen as being on the lowest
rung of the health-care ladder. These aides provide day-to-day support
such as feeding and dressing as well as doing shopping and laundry, and a much-needed respite for overwhelmed or absent relatives.
There is already a shortage of health aides, and demand is skyrocketing; one study estimated that 70 percent of adults over 65 are expected to need
some form of basic assistance. But attracting and retaining home health
aides is challenging; it’s exhausting work, with low pay, often no
benefits and little respect and is overwhelmingly done by women of color
and a dwindling number of immigrants.
President Joe Biden wants to increase the supply through an infusion of $400 billion into home- and community-based care for the elderly and people with disabilities over the next eight years, close to doubling what’s being spent now.
The president’s goal of “creating new and better jobs” will mean
overhauling the current system of training, which is disorganized and
overpriced and blocks home health aides from advancing to the next
level, according to Matt Sigelman, CEO of Emsi Burning Glass, a labor
analytics firm. He said training programs are often run by for-profit
players that charge far more than is merited by what the jobs pay.
Most of the time, May loved working with her clients. They talked to
her about trips abroad and gave her relationship advice. One taught her
to sew, another how to make deviled eggs. “They had so much wisdom. They
taught me a lot about life,” she said.
But it was hard to make a living. May started at $7 an hour and
eventually got up to $12, but with no benefits. She and other home
health aides asked that their last names not be used for fear of
retaliation at work or in case they applied for new jobs.
When the pandemic hit, she wasn’t offered “hazard pay,” even though
she was a designated essential worker. Then schools shut down and she
decided to stay home with her children. Now she isn’t sure if she’ll
return to her old job because it doesn’t cover her bills. “I can’t live
on my salary,” she said.
In a Zoom class at a nonprofit training center
for adults, instructor John McIntyre was giving his 17 students a verbal
quiz. The class, at the Opportunities Industrialization Center of D.C.,
or OIC-DC, trains people to be home health aides. It’s 15 weeks long
and is held at 6 p.m. because many of the students have jobs or need to
look after their children during the day.
“When you’re helping a client who has a stroke, on which side should
the home health aide stand — the stronger side or the weaker side?”
Twenty-four-year-old Dashia raised her hand. “The stronger side?”
“Hmm. Think about it for a minute.” Dashia did, and changed her answer.
“That’s good! That’s good!” said McIntyre. “We always assist on the weaker side.”
McIntyre praises his students often. He knows they have overcome
obstacles to be here. The minimum requirement is that they test at the
eighth grade reading level and seventh grade math. Some students who
apply need extra tutoring before they can enroll.
Dashia was laid off from two restaurant jobs during the pandemic.
She’s now working as a teacher’s aide while taking classes in the
evenings to be a home health aide.
“There is such a shortage,” she said. “So I thought, why not take a course?”
Dashia called all seven District of Columbia-approved home health
aide training programs for information. They cost between $1,500 to
$2,100, she said. Dashia would also have to pay for transportation, her
home health aide certification ($105), first aid and CPR certification
($85) and a background check ($25). “I definitely don’t have that
money,” she said.
She ultimately got into the one free program in the district, OIC-DC,
which is subsidized by the district government and private funds.
Otherwise, she said, she wouldn’t have been able to enroll. “My credit
is bad so I can’t get a loan, and my family doesn’t have money, either,”
she said. “Everyone is struggling.”
The cost of training can be prohibitively expensive for students who are among the most vulnerable and poorly paid workers.
“It wouldn’t even be something they consider, because it’s just out
of their range.,” said DyAnne Little, director of training at OIC-DC.
Even though her program is free, Little said, some of the students
have to save for months to be able to afford their scrubs, white Crocs
and watches with a second hand. Advocates say having these students take
out loans or borrow from family members is unjust, unfair and
exploitative, because it’s unlikely they will be able to pay back that
money even after they start working.
Home health aide is the fifth lowest-paying among the 25 lowest-paid
jobs held disproportionately by people of color, according to a 2020 study of workforce equity in the United States. Other jobs near the bottom include dining room attendant and dishwasher.
The median wage for a home health aide is $24,000 a year, said
Sigelman — about $500 more than for a fast-food cook. “So the notion of
taking out a loan and going into debt to get into a job that pays you
the same as you would make in a fast-food restaurant is pretty hard to
Communities across the country are realizing it’s essential to increase the numbers of home health aides. In Washington alone, 16,700 people 65 and over are unable to live independently
without support, a study found. Those numbers are expected to rise by
at least 10 percent every five years, according to the D.C. Coalition on
Long Term Care, which conducted that study.
“It’s a full-fledged crisis,” said Neil Richardson, who works on
aging issues for DC Appleseed Center for Law and Justice, a nonprofit in
This shortage of direct care workers mirrors the national demand,
said Johan Uvin, who was acting assistant secretary for the Office of
Career, Technical and Adult Education under President Barack Obama. That
demand has increased “exponentially” because of Covid, he said. “It’s
exacerbated the shortage that already existed.”
And the need is expected to grow, up by 34 percent between 2019 and 2029,
according to the U.S. Bureau of Labor Statistics, far outpacing the
less than 4 percent projected growth, on average, for other jobs.
For years the U.S. relied on immigrants to fill the roles of
long-term care workers, said Gail Kohn, coordinator of Age-Friendly DC, a
government program. But “what we’re seeing recently, at least in the
last four years, is the reduction in the number of people who immigrate
to this country, which has made it almost impossible to get people into
Almost 40 percent of home health aides are immigrants, according to the Migration Policy Institute, many of them from the Dominican Republic, Mexico and Jamaica.
Being a home health aide can be physically exhausting. Some clients
need to be turned every two hours to prevent bedsores; others have to be
lifted out of their beds to be bathed. Not all private homes are
equipped with devices such as lifts and slings that can help with these
Thalia, who worked for five years as a home health aide before she
stopped because of Covid, said she hurt her foot lifting a client but
didn’t have health insurance to pay for physical therapy. She had to
stop working for months. “You don’t work, you don’t get paid,” she said.
But Thalia considers herself lucky because, with rest, her foot
healed. Her neighbor, also a home health aide, injured her back on the
job and had to stop working because her agency refused to pay for
treatment and she had no insurance.
Aides also have to deal with the irascible nature of some elderly
clients. Many have dementia or are frustrated that they need assistance.
Others, as May put it, “for whatever reason, just don’t like you. They
cuss at you and call you names.” One home health aide said a client
accused her of stealing her glasses and didn’t apologize when she later
found them on a bedside table. Another, an immigrant from Nigeria, said
clients would complain her “food smelled” when she was eating lunch. Yet
another said a client mocked her accent. Then there is the emotional
impact on aides who become close to clients who eventually have to be
taken away and institutionalized or die.
Home health aides also feel disrespected by other medical workers.
Some say they are routinely ignored by nurses when they give updates on
their clients’ health and aren’t seen as part of the health care team.
In general, these positions are “poorly trained, poorly compensated,
disrespected and restricted in their duties,” MIT’s Osterman said.
Osterman argues for expanding the duties of home health aides. In
many states they cannot give a client medication or change a bandage.
Expanding the scope of their jobs would help clients with chronic
illnesses stay healthier and stay out of hospitals. “That would also
save money, by taking over some of the work from much higher-paid
nurses.” Osterman said those savings could go toward better salaries.
Aides are also at the mercy of their staffing agencies for
assignments. Thalia said she has seen family members of clients doing
drugs and has felt unsafe in some houses, but has never reported
anything because she needed the work hours. Working conditions can be
harsh, she said.
“Sometimes,” Thalia said of one client’s home, “the kitchen would be a
disaster, and in order for me to get her meals prepared, I would have
to clean up the mess that was left by family members.” Clients’ families
have also asked her to do their laundry and clean their rooms. Thalia
said she did whatever she was told, for fear the families would ask her
agency to send someone else.
The disrespect affected May’s decision to quit. “No one believes this
is a real job,” May said. She’d like the title “home health aide” to be
“changed to something with ‘medical’ in it,” in the hope of getting
more respect. “We do a lot of work, and we’re not recognized for it.”
When she graduates from her home health aide class, Dashia said, she
wants to continue studying and move up in the health care field. She
hopes she can one day earn a degree. “I want to do something that’s not
just for the moment,” she said.
Experts say showing students such as Dashia a clear career path is
one way to increase the supply of home health aides and make the
profession more desirable. But that doesn’t happen often.
One study Emsi Burning Glass conducted with the nonprofit JFF looked
at health care jobs that didn’t require a college degree and put them in
three buckets. Two allowed people to move up the career ladder. The
third, Sigelman said, were usually “dead-end jobs.“ Home health aides,
he said, fall “squarely in that category.”
Sigelman said home health aides are just a few training courses away
from gaining additional skills to move up and into jobs that pay a
living wage with benefits, such as certified nursing assistant ($31,000), medical assistant ($36,000), health information technician ($44,000) or licensed practical nurse
($49,000). None of these professions requires a college degree. But he
said upward mobility doesn’t happen by accident. “It requires that we
help people make that jump. And unfortunately, that doesn’t happen too
Johan Uvin said if there isn’t this “supported progression” for home
health aides, they may move out of health care altogether and look for
different occupations. In some cities, “you can get a job cleaning rooms
at a hotel for $22 an hour.”
Uvin said there are encouraging signs of innovation. Some training
institutions offer clear pathways from, say, home health aide to
certified nursing assistant to licensed practical nurse to registered
nurse. “It’s a very worker-centered way of thinking about it,” he said.
Uvin said this moment presents an opportunity to change things not just at the grass roots, but also at the policy level.
For example, students could be given access to federal financial aid
such as Pell grants for short-term career training programs. Other
inducements for training programs could create more comprehensive
pathways for their home health aide students. “There’s a lot we can do
with incentives through policy,” Uvin said.
He said the current system, requiring home health aides to go through
a training program and get certified in order to get a job that doesn’t
even pay “survival” wages, will just “magnify the inequities that
“And that’s just unjust.”
This story about home health aides was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for our higher education newsletter.
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