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Who Cares? Worker Supply and Demand

Who cares? If your loved one requires care—an elderly relative, a friend who is chronically ill or living with disabilities—then eight out of every ten hours of paid care that your loved one receives comes from a paraprofessional aide. This means a "direct-care" aide or attendant whose formal training is likely to be four weeks or less.

Direct-care workers are the face, voice, hands and heart of our health system for millions of long-term care consumers. Unfortunately, we pay them so poorly, and provide them so little training and support, that they are leaving direct-care for better-paying, easier and safer jobs elsewhere. The U.S. General Accounting Office, in its May, 2001 report to the U.S. Senate, stated:

"Retention of nurse aides is a significant problem for many providers, with some studies reporting annual turnover rates for aides working in nursing homes approaching 100 percent." (GAO-01-750T, Page 2)

In a recent national survey, officials from 42 states reported that nurse aide recruitment and retention were currently major workforce issues in their states.vii

The Direct-Care Workforce

The federal government tracks wage data for three major categories of long-term care health workers: 1) Home Health Aides; 2) Nurse Aides, Orderlies and Attendants; and 3) Personal and Home Care Aides. These individuals work in a variety of settings—private homes, nursing homes, group homes and assisted living facilities, as well as in hospitals. Generally, they provide health, personal care, housekeeping and home management-related tasks for persons needing such assistance.


These positions, as defined by the U.S. Bureau of Labor Statistics (BLS), include:

Home Health Aides

“Provide routine, personal healthcare, such as bathing, dressing or grooming, to elderly, convalescent, or disabled persons in the home of patients or in a residential facility.”

Nursing Aides, Orderlies, and Attendants

“Provide basic patient care under direction of nursing staff. Perform duties, such as feed, bathe, dress, groom, or move patients, or change linens. Excludes Home Health Aides and Psychiatric Aides.”

Personal and Home Care Aides

“Perform a variety of tasks at places of residence. Duties include keeping house and advising families having problems with such things as nutrition, cleanliness, and household utilities. Excludes Nursing Aides and Home Health Aides.”


The typical direct-care worker is female, non-white, unmarried, with children at home. Compared to the rest of the workforce, which is approximately 50 percent female, 80 to 90 percent of direct-care staff are women. They are also disproportionately women of color, with about half being non-white, compared to only one-quarter of the rest of the nation’s workforce.viii

The Rising Demand for Direct-Care Workers...

In 1999, this workforce accounted for approximately 2.2 million workers.ix Of those, approximately 400,000 worked in hospitals, and the remainder worked primarily in long-term care settings.x The GAO reported that the number of these jobs increased at the phenomenal rate of 40 percent during the decade of 1988 through 1998, compared to just 19 percent in the rest of the labor market.xi

Furthermore, the Bureau of Labor Statistics projects that direct-care jobs will continue to increase dramatically, due primarily to the aging of the nation’s population: While total employment in the workforce is projected to grow by just 14 percent from 1998 to 2008, nurse aide employment in general will increase by 36 percent over that period, and home care workers specifically will increase by 58 percent.xii

Pie Chart, Distribution of the U.S. Direct Care Workforce

In fact, Personal and Home Health Aides rank 8th among all occupations in terms of the fastest growing jobs projected between 1998 and 2008.xiii In addition, nurse aides rank 12th in terms of having the largest job growth projected between 1998 and 2008.xiv

...And the Shrinking Supply

While the demand for direct-care staff is expected to increase by nearly 800,000 workers over the ten-year period 1998 through 2008, the truth is that home care and nursing home agencies across the country are already facing high levels of staff vacancies.

This has come as quite a shock to many home care and nursing home providers and consumers: Our long-term care system 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 women would always be available to offer care and companionship for our loved ones—despite low-quality jobs that kept them working, but poor. In short, we took our caregivers for granted.

Bar Chart, U.S. Employment Growth Projections: 1998 - 2008The growing shortage of direct-care workers comes in surprising contrast to a more generalized employment trend. During the past 30 years, women aged 25 through 44—the "traditional" paid caregivers seeking entry-level jobs in the long-term care industry—have joined the U.S. workforce at an unprecedented rate. Yet clearly, most of these women are choosing jobs other than direct-care.

This tripling over the past three decades occurred due to two factors compounding one another. During those years, an increasing number of women from the Baby Boom generation came of adult age, while at the same time a sharply increasing percentage of those women participated in the workforce (45.0 percent participation in 1968, rising to 76.7 percent in 1998).

Yet demographics change, and what we will face over the next decade is the Baby Boom workforce passing through this age range, leaving a much smaller, post-Baby Boom workforce to follow. Moreover, the increased rate of participation of women in the workforce will slow considerably (76.7 percent in 1998 to only 79.5 percent projected for 2008).xv

As shown, the pool of likely entry-level health care workers, women in the civilian workforce aged 25 to 44, is projected to decline by 1.4 percent through the year 2008. Therefore, it would not be correct to assume that the nation’s relatively low unemployment rate is the primary reason for this workforce crisis—in fact, the state with the highest unemployment rate in June 2001 (Washington at 3.9 percent) and the state with the lowest unemployment rate (Connecticut and South Dakota at 2.5 percent) all reported that vacancies of paraprofessional aide workers were a major workforce issue.xvi Clearly, the supply of traditional paid caregivers has changed fundamentally from what the long-term care industry and consumers were once able to presume, and once able to take for granted. Graph, Women Aged 25-44 in the U.S. Civilian Workforce: 1968 - 98; projected 2008

The Widening "Care Gap"

By placing these labor supply demographics against what we already know about the likely increase in demand for long-term care services, the true depth of the coming national "Care Gap" becomes apparent. The U.S. elderly population is projected to double over the next 30 years, while the "traditional" female caregiving population—the cohort of women of care-giving age in the general population between the ages of 25 and 54—is projected to grow during that same period by only 7 percent:

Graph, The Care Gap: The Elderly and Women of Care-Giving Age in U.S.: 2000-2003 (individuals 65 and older; females aged 25-54)This chart already presumes immigration rates at moderate to historic highs. Furthermore, this chart depicts national data; in states with a relatively high elderly population and relatively low rates of immigration (e.g., Pennsylvania), this demographic mismatch is even more acute.

Viewed from a different perspective, the same data produces an "elderly support ratio" that compares the relative availability of caregivers over time. As the chart shows, the U.S. population currently includes 1.74 females aged 25 to 54 per elderly person, at a time when we are already experiencing significant direct-care vacancies. Yet this ratio will decline steadily over the next 30 years and, by 2030, will reach a point where there will be fewer than one woman of caregiving age per elderly individual.

Unfortunately, this shrinking ratio of support will place pressure not only on the formal, paid health care delivery system but also on unpaid caregivers. Since women provide the majority of both paid direct-care services and unpaid family care, the "care gap" in the U.S. will increasingly become a double-bind. When families who cannot care for loved ones at home by themselves turn to the formal system for assistance, they will likely find relatively fewer paid workers available.Bar Chart, Elderly Support Ratio, 2000-2030 (females aged 25-54 per individual aged 65 and older)

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