Nursing Aides, Home Health Aides, and Related Health Care Occupations -- National and Local Workforce Shortages and Associated Data Needs

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Chapter 1. Project Overview | Chapter 2. Paraprofessional Workforce Supply and Demand | Chapter 3. Important Data Issues | Chapter 4. Existing National Data Sources | Chapter 5. State-Level Data Issues | Chapter 6. Occupation and Industry Classification Systems | Chapter 7. Current Data Collection Practice: CNA Registries | Chapter 8. Conclusions | Appendix A. Project Advisory Committee | Appendix B. Proposed State Data Collection Instrument | Appendix C. Occupational and Industry Definitions | Appendix D. Sample Data | Appendix E. Issues from Four States | Appendix F. CNA Registry Details | Appendix G. Annotated Bibliography | Appendix H. References

Chapter 2. Paraprofessional Workforce Supply and Demand

This chapter describes issues with the paraprofessional workforce supply and demand. It includes the following subsections:

• Introduction
• Long-Term Care Overview
• The Labor Shortage
• Dynamics of the Paraprofessional Labor Market

Introduction
Direct care paraprofessionals are often described as the “eyes and ears” of the long-term care system. They have intimate daily contact with the clients in their care. It is here that, as Genevieve Gipson of the National Network of Career Nurse Assistants has said, “the system touches the client” [Paraprofessional Healthcare Institute (PHI), 1998]. It is the quality of this relationship between the consumer and the caregiver that consumers most often cite as having the greatest impact on their quality of life.

Until recently, policymakers and long-term care providers have largely ignored the direct care paraprofessional workforce. Now, however, the situation has changed. Long-term care providers across the country report they are unable to attract and retain sufficient numbers of workers. In response, at least 40 states have begun to address the problem, either by passing legislation or creating taskforces to study the problem [PHI, 2000 and North Carolina Division of Facility Services, 2000].

Long-Term Care Overview
Stakeholders
The stakeholders in the U.S. long-term care system are those the system touches each day through contact with nursing homes, assisted living and residential-care facilities, and home care. They are:

• Paraprofessional Workers
• Long-Term Care Consumers and Families
• Provider Agencies
• Payers

Paraprofessional Workers
Although there is very little data available on paraprofessional workers, existing data sources provide basic information on their personal characteristics and work conditions. For more detailed data, see Appendix D.

Job Market
The number of health care paraprofessionals in the workforce grew 40% between 1988 and 1998, a rate of growth double that of the overall workforce [General Accounting Office (GAO), May 2001]. Currently, paraprofessionals in all formal health care sectors total approximately 2.2 million [GAO, May 2001]. According to BLS projections, the paraprofessional workforce is expected to grow by another 36% between 2000 and 2010, with the largest increase, 62%, in personal and home care aides.

As Table 2-1 shows, the majority are employed in long-term care settings, such as home health care agencies, nursing facilities, and residential care facilities. Other workers staff hospitals, adult day care centers, non-medical home care, and other settings. Currently BLS classifies paraprofessional workers in the three categories shown in Table 2-1. Appendix C provides definitions of each category.

Table 2-1. Employment of Paraprofessional Workers in the US, by Industry Group, 2000

Source: BLS, OES

There is also a sizable gray market of direct care workforce who consumers hire directly. This workforce is significant, but not well documented. For example, Table 2-1 does not include workers in the employ of individual clients. One national study has found that of home care workers providing assistance to the Medicare population, 29% were self-employed [Leon and Franco, 1998a].

Personal Characteristics
Direct care paraprofessionals are predominantly female, and about 60 to 70% are Caucasian. A significant minority is foreign-born, particularly in home care settings. More than 30% have at least some college education, which seems contrary to the public perception of these workers. A little less than a half are married.
Age groups of paraprofessionals differ slightly by employment settings. The majority of paraprofessionals in institutional settings, e.g., nursing facilities, are younger than age 55. Many are also younger than 25. Their mean age is in mid- to late-thirties. On the other hand, most home care aides are between 25 and 64, with mean ages in the early forties. Additional details are provided in Table D-8 in Appendix D.

Work Conditions
As Table 2-2 shows, median wages for direct care paraprofessionals range from $7.50 to $8.89. It lists national median hourly and annualized wage estimates for three job categories for 2000. Annualized full-time employment is assumed to be 2080 hours per year.

Table 2-2. Median Wages of Direct Care Workers in U.S. 2000 Full-Time Earnings

Source: National median hourly and corresponding annualized wages from data from National Occupational Employment and Wage Estimates for 2000, as published by the U.S. Bureau of Labor Statistics.

However, 20 to 30%, regardless of job category, work only part-time. While about half of the part-time workers report a preference for part-time employment, more than 10% also report that they could only find part-time jobs. Paraprofessionals work about 30 hours a week on average. Table 2-3 shows the annualized wage for each job category, assuming the worker has 30 hours of work per week, which equates to 1,560 hours annually. Additional details are provided in Table D-9 in Appendix D.

Table 2-3. Median Wages of Direct Care Workers in U.S. 2000 Part-Time Earnings

Note: Annualized wages calculated by multiplying the median hourly wage times 30 hours per week times 52 weeks per year.

There are wage differences not only by job category but also by employment setting. As Table 2-4 shows, institutional settings tend to have higher wages than home care providers. Wage levels also vary by work level. For example, nursing aides can earn, depending on their work level, between $7.40 and $16.64 per hour. Note, however, that even the highest level of direct care worker can earn only a little more than $15 per hour. Additional details are provided in Table D-9 in Appendix D.

Table 2-4.  Median Wages of Direct Care Workers by Employment Setting: 2000

Source: BLS Occupational Employment Statistics

Considering their low wages, it is not surprising that many direct care paraprofessionals are among the working poor. Almost 20% live below the poverty level, which is much higher than the national average of 12 to 13% [U.S. Census Bureau, 2000]. They are more likely than other workers to rely on public benefits to supplement their wages. Among single-parent nursing home and home health aides, 30% to 35% receive food stamps [GAO, May 2001].

As for benefits, less than half of paraprofessionals in long-term care settings receive health insurance through their employers. Many workers rely on publicly funded healthcare, either because their employers do not offer health insurance coverage or because they cannot afford the employee contribution. For example, more than 10% of paraprofessionals are Medicaid recipients. Some workers also receive health insurance through other government programs such as Medicare and CHAMPUS. [See Table D-9 in Appendix D for more details.] Pension plans are also available to less than half of paraprofessionals in long-term care settings. Availability of benefits is relatively poor for paraprofessionals relative to similar workers in hospitals.

Paraprofessionals are also more vulnerable to occupational injuries and illnesses than other occupations. In 1999, workers in nursing and personal care facilities had more than twice as many injuries and illnesses involving days away from work (448.7 per 10,000 full-time workers) as all private industries (188.3 per 10,000 full-time workers). Home health providers and hospitals also had significantly more injuries and illnesses involving days away from work (280.5 and 251.4 per 10,000 full-time workers). Nationally, nursing home aides experience 18.2 injuries per 100 workers–more than 200,000 injuries per year-more than some high-risk occupations like coal mining (6.2 per 100), construction (10.6 per 100), and warehousing/trucking (13.8 per 100) [Service Employees International Union, 1997]. A large portion of nursing home and home care injuries result from overexertion and falling. These data suggest problems related to lifting and/or transferring residents/patients without proper equipment, skills, or assistance. Tables D-19 and D-20 in Appendix D provide additional details.

For additional information, see the U.S. Census Bureau (2000) Poverty 1999 at http://www.census.gov/hhes/poverty/poverty99/pv99est1.html.

Long-Term Care Consumers and Families
The long-term care consumers in the U.S. currently number about 12 million [Kaiser Commission on Medicaid and the Uninsured, November 1999]. A diverse population with a wide age range and a variety of service needs, these individuals have in common the fact that they require assistance with the personal activities of daily living, hygiene, and household maintenance. Most consumers receive care in home- or community-based settings such as adult day care facilities. About 12% of the long-term care population receives care in nursing homes or other institutional residential facilities [Kaiser Commission on Medicaid and the Uninsured, November 1999].

The elderly make up approximately half of the long-term care population and use a disproportionately greater share of long-term care services. They have varying levels of impairment, ranging from loss of physical mobility to Alzheimer’s and related diseases.¹ Approximately 5.1 million elderly receive long-term care in their communities, while another 1.3 million live in nursing homes. Of those who receive care in their community, approximately 60% rely exclusively on unpaid caregivers, i.e., family and friends [Stone, January 2001].

Approximately 5.3 million non-elderly adults and an estimated 400,000 children also require long-term care [Kaiser Commission on Medicaid and the Uninsured, November 1999]. These individuals include persons with mental retardation and serious mental illness, as well as adults living with AIDS and children with developmental disabilities due to congenital HIV infection or maternal substance abuse. Of those 18 to 64, three-quarters rely exclusively on family and friends to provide care.

Other individuals require long-term care due to conditions like heart disease, multiple sclerosis, cerebral palsy, spinal cord injury, and stroke. In general, improved trauma care and medical technologies are extending the lives of those with life-threatening or debilitating illnesses or conditions, thus expanding and changing the composition of the long-term care population.

The need for direct care services is expected to grow substantially during the next 30 years. Some contributing factors are:

• The baby boom generation is aging, and the population of those requiring paraprofessional care is increasing, as are the acuity levels of those in need. ²
• Technological advances are extending the lives of those who have high care needs.
• The preference for and ability to live in home- and community-based settings is increasing. Home- and community-based care settings require proportionately more paraprofessional-level staff than do facilities. The trend toward consumers choosing community-based care is likely to accelerate due to the Supreme Court’s decision in Olmstead versus L.C., which confirmed the right of nursing-home-eligible people with disabilities to live in the least restrictive setting. To comply, public agencies have to provide more and better community-based services.

Provider Agencies
Agencies that provide long-term care services range from small, community-based nonprofit agencies to massive, for-profit chains. As Table 2-5 shows, they provide care in a range of institutional and home- and community-based settings.

Table 2-5. Providers of Long-Term Care in the U.S., 1998

Source: Charlene Harrington, et al. (November 1999) 1998 State Data Book on Long-term Care Program and Market Characteristics (San Francisco, CA: Department of Social and Behavioral Sciences, University of California) http://www.hcfa.gov/medicaid/ltchomep.htm

One dominant trend throughout the long-term care industry in recent years has been a significant increase in the percentage of for-profit providers. For example, in home care, for-profit ownership increased from 6% in 1980 to 43% in 1995 [National Association of Home Care (NAHC), 1997]. Growth in for-profits has been greatest in the southern and western states.

Within the past three years, the long-term care industry has experienced the most chaotic public reimbursement environment of the past 30 years, threatening the financial viability of the entire industry.³ In 1997, the U.S. Congress passed the Balanced Budget Act, which both restructured and significantly reduced reimbursements to home care agencies and nursing home facilities in the U.S. This disrupted the long-term care sector, closing more than 25% of all Medicare-funded home care agencies in the following three years [NAHC, 2000] and placing four of the ten largest for-profit nursing home chains into Chapter 11 bankruptcy proceedings by the year 2000 [Stoil, 1999 and Grassley, 2000].

Overall, the trade press and political and economic observers of the long-term care industry expect continued consolidation of provider agencies and growth in total services to meet increased long-term care demand. For example, Medicaid programs for home care services are now expanding in many states in response to the disruption in Federal Medicare funding. Also, the U.S. Department of Health and Human Services has recently granted waivers to allow communities to use Medicaid funds for home- and community-based services.

Payers
As Figure 2-1 shows, three sources finance most of the Nation’s long-term care system: public payers (primarily Medicaid and Medicare), private insurance, and individual “out-of pocket” payers. In 1999, expenditures for long-term care services totaled some $123 billion.

Figure 2-1. Long-Term Care Payers

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These expenditures were divided among payers as follows:

• Medicaid: 40.4% ($49.7 billion)
• Medicare: 15.0% ($18.5 billion)
• Private insurance: 12.0% ($14.7 billion)
• Out-of-pocket: 25.1% ($30.9 billion)
• Other private payers: 4.4% ($5.4 billion)
• Other public payers: 3.0% ($3.7 billion)

[Source: Health Care Financing Administration (HCFA), 1999, http://www.hcfa.gov/stats/nhe%2Doact/tables/T9.htm]

For 2000, long-term care expenditures for the elderly alone were expected to reach $123 billion, according to the U.S. Congressional Budget Office (CBO). Sales of long-term care private insurance have increased somewhat in recent years and are projected to expand to about 18% of the total of all long-term care spending for the elderly by 2020 [CBO, March 1999]. This will likely reduce the percentage of out-of-pocket expenditures, while government sources, Medicare and Medicaid, are expected to continue funding approximately 60% of elderly long-term care in 2020 [CBO, March 1999].

With public funds paying 60%, government health reimbursement policies are critical in shaping both consumer demand for services and the labor supply. Restricting the services that programs such as Medicaid or Medicare cover to a large extent constrains demand. For example, when Congress passed the Balanced Budget Act of 1997 and limited Medicare spending for home care, fewer consumers received home care because they couldn’t afford to pay for the services privately. These programs also affect the labor supply in that, when reimbursement rates are low, providers can’t raise wages to attract and retain workers.

The Labor Shortage
The Current Problem
Throughout the long-term care industry, providers report unprecedented turnover and vacancy rates. However, hard numbers are difficult to establish, because there is no standard formula for calculating turnover. One report identified national studies that cite anywhere from a 45 to 105% turnover rate in nursing homes. For home care, numbers range from 12% to 60% [Stone, January 2001].

Stone also compiled data reported from a number of State studies. California, for example, estimated an overall employee turnover rate in nursing homes of 67.8%, with the nursing assistant rate even higher. Between 1996 and 1998, New York’s turnover rates for nursing assistants averaged 42%. In 1999, Ohio’s nursing assistant turnover rate ranged from 88% to 137%. By contrast, home health aide turnover ranged from 40 to 76%. The North Carolina Division of Facility Services reports that nursing assistant turnover exceeded 100%. Notably, in North Carolina, the nurse aide registry showed more inactive than active nurse aides. Florida, similarly reported that only 53% of the state’s trained CNAs are working in a health-related field one year after certification. New Hampshire reported that 11,000 CNAs have let their licenses lapse since 1993 [New Hampshire Community Loan Fund, February 2001]. As Diana Findley of the Iowa Caregivers Association has noted, the problem isn’t necessarily “a shortage of certified workers; the problem is job satisfaction. People are leaving the profession at the same (or possibly faster) rate than new CNAs are being certified” [Direct Care Alliance, October 2000].

Nursing homes are not required to report vacancy rates, so few statistics are available. In Massachusetts, according to the Direct Care Workers Initiative, nursing homes are experiencing anywhere from 10 to 20% vacancy rates. Home health agencies are even less likely to report vacancies, not wanting to admit that they are being forced to turn away deserving clients. Nonetheless, the NAHC states, “In all geographic regions of this country, there is an ongoing inability to hire staff to provide the most fundamental care needed. The crisis for home care used to be lack of adequate business opportunities. Now agencies have to turn away requests for service for lack of competent, appropriately trained staff” [NAHC, February 2000].

Impact on Stakeholders
High rates of staff vacancies and turnover negatively affect all stakeholders.
Impact on Workers
In the short term, the labor shortage is causing job quality to deteriorate. The impacts include:

• Higher rates of injuries: Many nursing home injuries consist of back problems resulting from lifting or transferring residents without proper equipment or assistance. The high risk of injury by healthcare workers is corroborated by data from the BLS Survey of Occupational Injuries and Illnesses [BLS, 1999].
• Higher levels of stress and frustration: Pressured by administrators to “speed up,” direct care workers can’t provide the level of care their clients require, making the job increasingly stressful and less personally satisfying [Wilner, 1994; Foner, 1994; Diamond, 1992].
• Less training and support: High turnover and vacancies leave new workers with fewer mentors for on-the-job learning, less time for training, and less support from supervisors who are themselves over-stretched.

Impact on Long-Term Care Consumers
In July 2000, CMS reported that understaffing severely affected the quality of care in 54% of the nation’s nursing homes. Possible affects are:

• Inadequate, unsafe care: High turnover results in inexperienced staff, with fewer senior staff available as mentors. Remaining staff often serves more clients in a rushed or unsafe manner. For example, workers may be forced to feed residents too quickly leading to problems with choking or malnutrition, or they may try to transfer or lift residents without assistance from a colleague. This can lead to injuries to the resident and the worker.
• Care without continuity: Constant replacement of staff disrupts the care setting, precludes individualized care, and inhibits the development of strong relationships, which are centrally important to both the client and the caregiver.
• Denial of care: Clients are simply turned away or, for those clients who are admitted, underserved.

The National Citizens’ Coalition for Nursing Home Reform (NCCNHR) selected staffing issues as the key focus of their September 1998 annual meeting, while thirteen State chapters of the national Alzheimer’s Association made staffing issues their top priority in the year 2000. In addition, a recent report published by The Commonwealth Fund found that inadequate staffing, a lack of individualized care, and high nurse aide turnover are key causes of malnutrition and dehydration, affecting an estimated one-third of our nation’s nursing home residents [Sarah Greene Burger et al., June 2000].

Impact on Providers
Staff vacancies and high turnover have become primary concerns for providers, while the industry copes with challenges ranging from mounting regulatory paper work to shrinking reimbursement rates. The impact of direct care staffing problems on providers includes:

• High recruitment and training costs: High turnover and competition for workers force providers to divert financial and managerial resources to additional advertising, hiring incentives, and orientation activities.
• High retention costs: Since providers are offering relatively unattractive jobs in a competitive environment, they are more likely to be selecting from a pool of candidates with greater barriers to employment within the health care field-low education, poor work histories, poor health, drug or alcohol abuse, inadequate child care or transportation-than was true just two or three years ago. This means, in turn, that providers have to devote more resources to oversight.
• High separation costs: As employee turnover reaches high levels, providers devote more resources to administrative functions related to terminations.
• High temporary replacement costs: Many facility-based providers fill slots with “temp” agency replacement staff at hourly costs of up to 100% more than that of regular employees [Forschner et al., 2001].
• Foregone income: Providers have more demand for their services than the workforce can meet. Subsequently, they turn away some of the demand, as well as the income that demand would have produced.

Causes of Vacancies and High Turnover
There are four primary causes of paraprofessional vacancies and high turnover:

• Nature of the job
• Lack of respect from management
• Better job alternatives
• Baby boom demographics

Nature of the Job
The nature of direct care jobs tends to be difficult. As noted above, wages are low, and benefits are few. Ironically, most direct care paraprofessionals do not receive employer-paid health insurance [Case et al., March 2002 and Himmelstein et al., April 1996]. Home care work typically offers only part-time hours and thus part-time pay, and aides in many nursing homes serve too many beds, creating unsafe conditions for both client and worker.

Lack of Respect from Management
Focus groups with paraprofessionals, conducted across the State of New Hampshire, document that supportive supervision at nursing homes is rare and that, in home care, supervision is nearly nonexistent [Kopiec, October 2000]. Though the aide has significant knowledge and insight concerning the client’s condition, he or she is often ignored, treated as invisible by the rest of the health care system.

Better Job Alternatives
Though the economy has slowed since the late 1990s, unemployment is still low and vacancies continue throughout the service industry. Many entry-level positions in fast-food restaurants and retail venues offer jobs that are safer and less demanding than direct care positions, and they pay as well or better. Offered the alternative of stable and safe service-sector employment, many paraprofessionals are choosing to leave the health field.

Baby Boom Demographics
Baby boom demographics have created a care gap that will worsen over the next 30 years. The number of people who require paraprofessional care is growing, while the number of those who traditionally provide that care–primarily women between the ages of 25 and 54–is not.

The expanding demand for health and personal care services derives from several factors, including: medical advances that allow those with chronic illnesses and disabilities to live longer; technology that permits high-need individuals to live in home- and other community-based settings; and most of all, a growing elderly population. At the same time, a smaller population cohort following the baby boom is now passing through the U.S. workforce, yielding relatively fewer workers available for care giving tasks.

Figure 2-2 shows that the U.S. elderly population is projected to double over the next 30 years, while the traditional female care giving population is projected to grow by only 7%.

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Source: U.S. Census Bureau, National Population Projections, Summary Files, “Total Population by Age, Sex, Race, and Hispanic Origin”

http://www.census.gov/population/www/projections/natsum-T3.html

In short, the demographic mismatch between the demand for and supply of direct care workers is a long-term structural problem that will persist, even if higher unemployment rates return.⁴

Viewed from a slightly different perspective, these data can help calculate an “elderly support ratio,” comparing the relative availability of caregivers over time. As Figure 2-3 shows, the U.S. population currently includes 1.74 females between the ages of 25 and 54 per elderly person–at a time when the field is already experiencing a significant labor shortage. Yet this ratio will decline steadily over the next 30 years and, by 2030, reach a point where there will be fewer than one woman of care-giving age per elderly individual.

Figure 2-3. Elderly Support Ratio, 2000-2030
(Females aged 25-54 per individual aged 65 and older)

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Source: Calculated from U.S. Census Bureau, National Population Projections, Summary Files, “Total Population by Age, Sex, Race, and Hispanic Origin,”

http://www.census.gov/population/www/projections/natsum-T3.html

Unfortunately, this shrinking ratio of support will place pressure not only on the formal, paid direct care paraprofessionals, but also on family caregivers. Since women provide the majority of both paid direct care services and family care, this “care gap” in the U.S. will increasingly become a double bind: families who cannot care for their loved ones by themselves will find, when they turn to the formal system for assistance, relatively fewer paid staff available.

Dynamics of the Paraprofessional Labor Market ⁵
As is true for every sector of the economy, health care employers compete for workers within a dynamic labor market. However, if the health care labor market were functioning perfectly, direct care vacancies would not continue for long. That is, the supply of workers would expand to meet demand, as employers adjusted compensation upward to attract and retain more workers.

Unfortunately, several factors prevent our health care system from achieving rapid labor-market equilibrium to fill all available positions. These factors include:

• Expanding pressures on the demand for health care services
• Limitations on the supply of additional workers
• Restrictions on the ability and/or willingness of employers to increase compensation sufficiently to attract an adequate supply of workers
• Limitations on public resources for improving services and wages

To understand the dynamics of the long-term care industry, it is helpful to sketch the key attributes of this imperfectly functioning labor market.

Demand for Paraprofessionals
Demand for health care workers is pushed by such factors as the aggregate number of consumers living with more complex health problems and the strong preference for consumers to receive services within their homes. As noted earlier, these demand factors are now creating pressure for increased direct care services.

However, while these factors increase the need for more labor, other market attributes suppress, or at least distort, the effective demand for labor, as determined by the level of services that payers are able or willing to fund. In particular, since much of the funding for health care comes from public and private third-party payers who have strong financial incentives to limit costs, effective demand as determined by third-party payers will typically be less than the need as perceived by either consumers or health service providers.

Federal and State third-party payers must fund an array of public services in addition to health care. Subsequently, they have an interest in containing costs. Similarly, private insurers–accountable to shareholders and corporate purchasers–control costs through capitation arrangements, utilization reviews, and rigorous definitions of what constitute medically necessary services. Completely independent of increased requests for health services, third-party payers may therefore choose to constrict, or perhaps even reduce, effective demand for long-term care services, which in turn suppresses effective demand for labor.

Therefore, the health care labor market can best be understood as driven by massive demographic and technological forces accelerating aggregate demand for services–while simultaneously, powerful third-party payers, both public and private, attempt to brake that demand through regulatory constraints and cost-containment measures. This reality makes forecasting difficult. For example, despite an absolute decline in home health aides nationwide during 1999 due to major cuts in Medicare funding, the BLS still predicts that home health aides and personal aides will increase by 47% and 62%, respectively, nationwide between 2000 and 2010, supposedly still one of the fastest-growing occupations in the Nation [Tables D-15 and D-16 in Appendix D]. In all, it is reasonable to expect a continued expansion of effective demand for health care-related labor, but an expansion that is likely to remain irregular and balky, depending largely on political and financial and not simply care-related factors.

Supply of Paraprofessionals
As noted earlier, the pool of traditional caregivers–women between the ages of 25 and 54–is predicted to increase by only 7% during the next 30 years. Even more stark: the pool of likely entry-level workers–women in the civilian workforce aged 25 to 44–is projected to decline by 1.4% during the next eight years.

This somewhat narrower age range is particularly crucial, since this is the cohort that provides the recruits for whom health care employers must compete. The current decline of these younger women in the civilian workforce follows three decades of significant expansion, nearly tripling from 1968 through 1998. Note that these were the decades during which our current long-term care system was designed.

The expansion of this female cohort during the past three decades was caused by two interacting factors: 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 (45.0% in 1968, rising to 76.7% in 1998).
Now, however, the baby boom workforce has passed through this age range, leaving a smaller workforce to follow. Moreover, the rate of increased participation of women in the workforce is slowing considerably (from 76.7% in 1998 to only 79.5% projected for 2008). Figure 2-4 shows this progression from 1968 to 2008.

In addition to these demographic realities, changes in the educational level of women of color also impact the long-term care workforce. From 1990 to 1998, the proportion of black women over age 25 with a high school education increased from 51.3% to 76.7%, and those completing four or more years of college increased from 8.1% to 15.4% [Stone, January 2001]. These women will no longer be willing to accept the same low wage jobs that were the only option available to the generation before them.

These demographic projections of a smaller pool of potential direct care workers take into account welfare reform, which has already moved millions from the welfare rolls and into the workforce.⁶ Many direct care workers live on incomes below the poverty level and rely on public support for their families. Thirty-six percent of nursing home and home health aides live in families with incomes below $20,000. These workers are more than twice as likely as other workers to receive food stamps and Medicaid and much more likely to lack health insurance [GAO, May 17, 2001].

Figure 2-4. Women Aged 25-44 in the Civilian Workforce (in Thousands) 1980 through 2000; projected 2010)

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These demographic projections also assume relatively high net international annual migration levels ranging between 780,000 and 950,000 now through the year 2030.⁷ Congress sets U.S. immigration policy, and only a small portion of immigration visas (less than 13% over the past five years) are employment-related. Of employment-related immigrants, more than half are professionals or other high-skilled workers.

Therefore, only a substantial change in immigration policy would significantly expand the pool of potential direct care staff. Yet given the low wages and benefits associated with these positions, any major targeting of immigrants for paraprofessional jobs would have to address the political and economic realities of importing low-wage workers, individuals whose essential needs for food, housing, child care, and transportation would have to be subsidized, at least in part, by taxpayer dollars. If more immigrant workers enter a community, their needs for housing, schools, medical care, childcare, and transportation will affect existing resources.