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Over 300,000 family caregivers provide the lion’s share of care for those with disabilities, including children with special needs, and older Iowans. When family caregivers can no longer provide roundthe-clock support, the direct care workforce becomes an extension of families. They are Certified Nursing Assistants, Home Health and Hospice Aides, Direct Support Professionals, and other Direct Care Workers (DCWs) in nursing homes, group homes, hospices, and the homes of those served.
A state legislator recently asked me, “Is the state doing enough to address direct care workforce issues?” I replied, “If the state was doing enough, we wouldn’t be having the same conversations we were having when I started Iowa CareGivers 33 years ago.”
In 2019, Iowa CareGivers partnered with Iowa Workforce Development (IWD) to conduct a Direct Care Worker Wage and Benefit Survey 2019 DCW Wage and Benefit Survey Summary of Findings which revealed a DCW median hourly wage of under $15 an hour. Numbering 40-65,000, DCWs make up one of the largest segments of Iowa’s workforce. Most are women whose median hourly wage barely budged between 2019 and 2022 with some earning only $9.80 an hour. Over 50% had children enrolled in HAWK-I, the state’s Children’s Health Insurance Program. Others used the Supplemental Nutrition Assistance Program (SNAP) to help them pay for food, childcare subsidies, and other supports that enabled them to work!
The turnover rate of Certified Nursing Assistants working in nursing homes in 2023 was 77% with a price tag of over $120,000,000, using a LeadingAge nursing home industry formula for calculating turnover cost. The high turnover rate is partially caused by poor wages and benefits, and by worker burnout that is at an all-time high.
The state has known about the problems facing DCWs for more than 30 years. It now needs to implement known solutions, one of which is increasing wages. Wages for DCWs can be increased by requiring employers that participate in the Medicaid programs to pay adequate levels of wages, and an increase of the minimum wage for all workers. But other strategies must be explored such as increasing the income eligibility cap on state benefits, something suggested by both Democrat and Republican legislators or tax incentives.
Increasing the minimum wage to $20 or even $15 an hour for DCWs would be an improvement but it comes with a risk. Both a 5-year phased-in approach and an immediate increase to $20 an hour, effective July 2025 have been proposed. A random hourly wage increase could result in the loss of vital state benefits doing more harm to these essential workers. This “between a rock and a hard place” dilemma is what the United Way and others refer to as the “cliff effect” that occurs when a small increase in earnings results in lost benefits. The United Ways’ “Asset-Limited, IncomeConstrained, Employed” (ALICE) report United Way ALICE Report for Iowa provides poverty threshold guidelines that can also help to inform decisions on wage enhancements for DCWs.
With grants from Mid-Iowa Health Foundation and Northwest Area Foundation, Iowa CareGivers is again partnering with IWD to repeat the 2019 Direct Care Worker Wage and Benefit Survey. The findings will be released later this year, and we urge lawmakers to use the new Iowa and DCWspecific data to drive their decisions.
It’s time to invest in this workforce upfront rather than continuing to cover the costs associated with high turnover; workplace injury; state subsidies; mental health needs of burned-out workers; nursing home fines; employers’ reliance on more expensive temporary staffing agencies; the loss in productivity to the business community when employees with caregiving responsibilities reduce hours; and loss of financial security for family caregivers who give up employment to care for loved ones.
More important is the cost in diminished quality of care and life for both those on the receiving and giving ends of care.