Introduction

Home health care workers are part of the “care economy” that makes all other work possible.

These workers include nursing, psychiatric, and home health aides; personal and home care aides; and nursing assistants working in private households. They provide services and support for older adults, people with chronic illnesses, and people with disabilities allowing them to stay in their homes and communities, rather than nursing homes or other institutions. And the COVID-19 public health emergency further highlighted the importance of this workforce, who provide long-term care at a time when congregate settings are limited in their ability to support physical distancing or quarantining.

So why don’t we value these workers?

The underappreciation of care jobs historically and today reflects the prevailing legacy of racism, sexism, and xenophobia. Black women are vastly overrepresented among home health care workers, especially in the Southern United States, where these workers are paid the least. (Louisiana, West Virginia, Texas, Mississippi, and Oklahoma).

There is a disproportionate representation of Black, Latinx, and immigrant women in the Southern home health care workforce and there is an eye-opening history of how Black women in the South became the single largest group of workers in these jobs.

Home health care workers, who make up a substantial share of the larger domestic worker job classification, have long been coming together for fair wages and working conditions. The current policy climate in the South needs an overhaul and there are opportunities for state policymakers to support good jobs for home health care workers. 

Demographic Profile of Home Health Care Workers

Home health care work is both highly racialized and gendered, especially in the South. As shown in Figures A and B, Black and Latinx women are overrepresented in the home health care workforce compared to the overall labor force. While Black women make up 11% of all workers in the South, they account for a remarkable 43% of home health care workers, nearly four times their share in the labor force. Similarly, Latinx women account for an estimated 7% of the Southern labor force, yet they make up more than twice that share among home health care workers at 17%. White women in the South are proportionately represented in the home health care work force relative to their share in the overall Southern labor force.

Similar patterns exist when we look at citizenship status. Here, the term U.S.-born women refers to women who were born in the U.S. or were U.S. citizens at birth, and naturalized citizen women are women who are currently U.S. citizens but were not citizens at birth. We use the term “immigrant women” to refer to both naturalized U.S. citizens and non-citizen women, i.e., women who were not U.S. citizens at time of birth. Due to small sample size concerns, we combine Asian American/Pacific Islander (AAPI) women and women of other races, and do not report statistics for the Midwest.

As shown in Figure C, in the South, immigrant women make up about 6% of the Southern workforce, but they account for approximately 18% of home health care workers – nearly three times their share of the overall workforce. Across the country, immigrant women are overrepresented among home health care workers, although their smaller share of the overall population in the South means they make up a much smaller share of the home healthcare workforce there.

The demographic makeup of this workforce is a crucial factor in the devaluation of the work they do. We can see this across a range of occupations—when workers are primarily women and Black and Brown people, wages tend to be lower. 

Current vs. Better Wages for Southern Home Health Care Workers

In a previous report, we laid out arguments and mechanisms for increasing home health care workers’ wages at the state level. We estimated better wages that we compared with the current wages for home health workers. Figure D and Table 1 (in the appendix) contain the relevant data for states in the South plus the District of Columbia. As detailed in our report, the five states with the lowest estimated current wages for home health care workers are all in the South (namely, Louisiana, West Virginia, Texas, Mississippi, and Oklahoma). In these states, home health care workers typically make less than $12 an hour, compared to the national average of about $13.50. 

Further, even after we adjust for regional differences in cost of living, Southern states still tend to have the largest gaps between current care worker wage rates and rates that would better value care work. At the national level, the average home health care wage is about $8.70 less than our proposed wage benchmark. As shown in Figure D and appendix Table 1, only 3 states in the South have gaps smaller than this national average (Arkansas, Mississippi, and West Virginia).

Why Home Health Care Workers Experience Low Wages: The Ongoing Influence of Racism and Sexism

The current demographic makeup of the home health care workforce in the South is not accidental, and neither is the low pay, lack of benefits, or lack of worker protections. These are noted in the legacy of slavery and Jim Crow. The work that home health care workers do has historically been unpaid work that women provided in the home or, especially in Southern states, enslaved Black women provided. Later, free Black and Latinx women performed this work. Because of who did the work, it was seen as unskilled work and therefore devalued. Black women remained tied to these roles through Jim Crow practices that largely limited all other economic opportunities. For example, in 1940 over three-quarters of Black women were employed as either domestic workers in private homes or as agricultural laborers.

The particularly poor quality of these jobs was maintained by the federal government, which excluded these workers from major federal labor legislation as a concession to Southern White lawmakers. These laws include the National Labor Relations Act (NLRA) of 1935, which was intended to ensure that workers could form unions and use collective bargaining to get fair working conditions, and the Fair Labor Standards Act (FLSA) of 1938, which set the minimum wage workers could be paid and established requirements for overtime compensation. These laws were intended to empower workers, protect them from the exploitative behavior of employers, and ensure they have a reasonable standard of living. Federal lawmakers, however, excluded domestic workers and agricultural workers from these protections. The long history of tying Black, Latinx, and immigrant women to these jobs has reinforced harmful racial narratives, one of many ways the racial hierarchy that is so central to Southern social, cultural, and economic systems is maintained.

Domestic Workers Unite to Organize

Despite the devaluation of their work and their exclusion from important worker protections, domestic workers, including home health care workers, have historically fought and continue to fight to improve the quality of their jobs. In 1881, laundry workers in Atlanta, primarily Black women, formed the Washing Society, a trade organization which successful secured higher wages after 3,000 workers agreed to strike. Also, in Atlanta in the 1960s, Dorothy Bolden founded the National Domestic Workers Union of America, organizing 10,000 domestic workers to win increases in pay and workplace protections. Today, many unions and national and local grassroots organizations continue to organize with home health care workers and other domestic workers around the country and in the South. By organizing, domestic workers are building political power and working with policymakers to enact policies for family-sustaining wages and benefits and long-term careers in the industry.

How State Policymakers in the South Can Support Home Health Care Workers

There are many tools available to policymakers to increase pay and benefits for home health care workers. While much more is needed, there is movement in Southern states and around the country to invest in long-term care services and strengthen the home health care workforce. These tools include federal relief and recovery dollars provided during the COVID-19 public health emergency, state legislation, and partnerships with state agencies.

Federal Relief and Recovery Dollars Allocated to States

Southern states utilized previous federal relief and recovery dollars from the Families First Coronavirus Response Act and the Coronavirus Aid Relief and Economic Security (CARES) Act to increase wages and provide paid leave for home health care workers, primarily through temporary benefits and wage increases or one-time bonuses to support recruitment and retention.

Subsequently, the American Rescue Plan Act (ARPA) allocated $12.7 billion for states to strengthen and expand access to home and community based services (HCBS). Home and community-based services (HCBS) enable people, particularly older adults and people with disabilities eligible for Medicaid, to receive long-term care in their own homes and communities.

States can utilize a temporary 10% increase in their federal medical assistance percentage (FMAP) to expand eligibility and increase access to HCBS while also strengthening the home health care workforce by increasing the pay and benefits of direct care workers.

States using these funds are required to invest in HCBS without supplanting existing state funds for Medicaid HCBS, imposing stricter eligibility standards, reducing the scope and duration of services, or reducing the provider payment rates that could further erode workers’ wages.

Many states in the South—including Alabama, Arkansas, Florida, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia—committed to using federal funds to invest in HCBS. Several of these states are likely to increase wages for home health care workers, as noted in their state spending plans. States may increase direct care worker wages by increasing HCBS provider rates, while also requiring that the majority of these funds are used to increase workers’ wages or by setting a wage floor. Without proper support and implementation for requiring increase in wages, workers may never see the benefits of these efforts, as in North Carolina.

The need for states to leverage these resources, which after a recent extension may now be used through March 31, 2025, is particularly large as efforts to make this funding permanent through the passage of the Build Back Better Act have stalled.

State Legislation

Ultimately, in the absence of federal interventions, permanent state policy solutions are needed to provide stability for workers providing care and people receiving these critical services. State policymakers have many tools available to them to increase pay and benefits and to support a voice on the job for home health care workers. Virginia offers a particularly good example. Previously enacted legislation to gradually increase Virginia’s minimum wage to $15 by 2026 guarantees minimum wage protections for domestic workers for the first time—in many states, domestic workers are exempt from minimum wage protections. Virginia now also guarantees paid leave to home health care workers in the state, who will now accrue one hour of paid leave for every 30 hours of work. In 2021, Virginia also became the first state in the South to pass a Domestic Worker’s Bill of Rights, joining nine other states and two other cities around the country.

Home Care Authorities

Models from elsewhere in the country offer additional strategies for improving job quality for home health care workers. For example, some domestic workers have been able to establish a local or state government entity as their employer for the purposes of collective bargaining, allowing them to negotiate collectively for better wages and working conditions. In California, the Service Employees International Union (SEIU) built a coalition including home health care workers, the disability rights community, and advocates for the elderly and advocated for the creation of home care authorities at the county level, with whom home health care workers can collectively bargain. This model has been replicated in other states (Connecticut, Oregon, Illinois, Massachusetts, Minnesota, and Washington) with state-level authorities. Home care workers in these states have earnings higher than home care workers nationally and they have been able to negotiate other benefits, including healthcare and retirement benefits.

Conclusion

More action by state policymakers is needed to support home health care workers and address systemic inequities experienced by this predominantly Black, Latinx, and immigrant workforce. This is especially the case in the South where Black women workers are overrepresented, making up nearly half of the workforce while receiving the lowest wages relative to home care workers in other parts of the country. This is part of a long history of economic exclusion based on race and gender and why care workers continue to organize for fair wages, benefits, and workplace protections. State policymakers should utilize recent federal relief and recovery dollars, partner with state agencies, and develop legislative vehicles for longer-term policy solutions to improve financing for long-term care services, while also ensuring that care jobs are good jobs.