It might come as little surprise that working in retail or fast food ranks as one of the most common jobs in the U.S. But there’s another industry that also employs nearly 3.7 million workers across the country: According to the Bureau of Labor Statistics BLS), home health and personal care aides dominate across the U.S., particularly in states with aging populations or those that attract retirees, like California.
While this line of work is largely associated with elder care, home care jobs can involve everything from assisting adults with developmental disabilities to dropping in on post-op patients who have been released from the hospital. There are workers in this sector who are trained nurses, while others lack any kind of certification but offer critical support to patients. Despite their prevalence—and the vital services they provide to millions of Americans—home care workers often toil under difficult conditions with low wages and unpredictable schedules. In 2023, the BLS reported that median pay for home health and personal care aides was about $16 an hour, or the equivalent of less than $34,000 in annual income.
Advocacy organizations like the National Domestic Workers Alliance (NDWA) have long sought to shed light on the precarity of home care jobs and the lack of protections for people who work in private homes. (According to a 2023 report, the overwhelming majority of home care workers—85%—are women, and about two-thirds are people of color.) “There’s a lot that goes into having a good job,” says Reena Arora, the director of care policy at the NDWA. “The biggest prominent issue right now is that base hourly wage, so that’s where we’ve been focusing our efforts. But as a labor organization . . . we’re looking at paid time off, health and safety, training, [and] all the other aspects of what makes a job a good job.”
Between the low pay and limited benefits, home care agencies have struggled to retain workers, especially as fast food and retail jobs have grown more appealing due to minimum wage increases. But even as they face challenges on the job, many home care workers feel compelled to build a career in this industry, often motivated by a deep commitment to caregiving. “Being a dedicated, caring worker, I would say that we are priceless,” says Catherine Fortune De Sormeaux, a home care worker in Pennsylvania with 15 years of experience. “Agencies [and] employers—people who give us our paycheck—don’t treat us well. We are somewhat invisible. But our work is not invisible.”
Challenges on the job
Over 15 years in the home care business, De Sormeaux has seen her pay increase to more than $20 an hour, following stints at other agencies and in home care facilities. But many of her peers aren’t so lucky, she says, citing a care worker she recently met whose hourly wage is just $11.50.
Diondre Clarke, a home care worker in North Carolina who now works for the NDWA as a field organizer, had to fight to get even minor pay bumps during her 10 years on the job. “I was making $7.75 for years,” she says. “Every year, they would give us another quarter.” She found there was a pay ceiling of $10 an hour, despite being licensed as a certified nurse aide. (When the pandemic hit, she points out, agencies were desperate to retain workers and willing to pay much more.)
When Clarke started working at home care facilities, she found that she could earn a lot more, up to $20 an hour, but that came with an unmanageable workload and all sorts of other challenges. “You got 10, 11, 12, 13 people to take care of,” she says. “I didn’t have time to go to the bathroom [or] eat because I wanted to do a good job in taking care of them.” She was forced to take on additional work beyond her job description—like doing the laundry when there were no clean bedsheets, or serving food to patients—because the facility was short-staffed. “They would put more duties on us and eliminate other jobs,” she says. “And it’s still that way.”
Insurance coverage also plays a major role in how workers are paid, since they typically earn less when caring for Medicaid patients as compared to those with private insurance. One way to address this issue is by increasing Medicaid reimbursement rates—a major priority for advocates like Arora—but even with more funding, there’s no guarantee that workers actually reap the benefits and see higher wages since the agencies set hourly rates. (There are legislative efforts across several states to ensure that the funding provided through Medicaid reimbursement goes toward raising wages.)
De Sormeaux says that the workload is often the same, regardless of whether a patient is on Medicaid or has private insurance. (The agency she currently works for tends to get fewer Medicaid patients, which helps keep her hourly rate higher.) “I realized the pay has nothing to do with how qualified you are, how certified you are, [or] how long you were working with another agency,” she says. “It was the financial aspect of the agency and Medicaid.”
To comply with HIPAA, agencies can only disclose a limited amount of information about a patient beforehand, which means workers don’t always know quite what to expect when they go to a new home. The physical aspects of caring for patients—which can include moving them if their mobility is limited, or helping them in the shower—can be a major strain, especially for older home care workers. Workers don’t always receive adequate training or high-quality equipment.
One of the reasons Clark took a job with the NDWA was because at the age of 60, she started to find home care work too taxing. Putting aside the physical toll, Clark says she often encountered homes that were too messy, or situations where she had to navigate around other family members. When your job requires you to enter an unfamiliar private setting, there are also legitimate safety concerns: Clark claims she once worked for a patient with dementia who also had a gun in his home. “I had to report that,” she says. “It was a gun in his closet. I needed it to be gone.” De Sormeaux says that patients with dementia could sometimes become aggressive, not only cursing you out but also sometimes getting physically violent.
Building a career in home care
Some home care workers find their way into the industry by chance, after caring for a family member or parent. “I went into it because I really took care of my mom before she passed away,” says Clark, whose daughter is a nurse and caregiver as well. “We were always caregivers, in a sense. So I have a passion to help people. I feel good when I help somebody else feel better, even if it’s just smiling at them or feeding them.” Others almost see it as a calling. “It’s as important as a pilot, these jobs that we do,” De Sormeaux says. “We should be very proud of ourselves.”
While the hours and pay can be inconsistent, home care work has also afforded certain people a degree of flexibility that can be hard to come by in other jobs. After working in a hospital for years, Jenna Berndl—a registered nurse in New York State who works weekends—wanted to try something different. “In the hospital I always felt so stressed that I couldn’t take care of patients the way I wanted to,” she says. “I just felt like I was pulled in a million different directions.” Berndl now says she wouldn’t be able to go back after years of working in a home setting. Though the weekend shift is considered “undesirable,” Berndl is paid as if she works a 40-hour week, and she says the unconventional schedule allows her to avoid paying for childcare during the week.
Toni, a home health aide in New York, works 20 to 40 hours a week for two different families but says she is able to choose shifts based on her availability and family commitment. She worked in manufacturing for decades before moving into home care because she saw a “higher ceiling to advance up to” and clearer career path, where she could move from medical assisting into health information management. But once Toni started working in the field, her plans shifted. “Now I see how much this [work] is needed,” she says of her role.
Of course, there are many workers in the industry for whom the more immediate concerns about wages and working conditions take priority over future career aspirations or credentialing that might help them advance. It’s not uncommon for home care workers to take on extra shifts or work for multiple agencies, in order to earn enough money to support their families. “What we see a lot is that our members are sort of the lowest rung,” Arora says. “So they’re unlicensed personal care aides, but they are often doing the work of a certified nursing assistant—but they are not able to access trainings, [or] the costs are prohibitive.”
As Clark has moved into organizing and advocacy, her hope is to position home care work as a viable path for younger generations—one that should be valued and respected. “We need to put standards [in place] and stick together in solidarity as direct healthcare professionals,” she says. “We’re not just butt wipers.” Clark wants to push her peers to advocate for themselves and demand more—but to never lose sight of their responsibility to the patients in their care. “I treat people like I would want to be treated,” she says. “I try to instill that in other care workers because it’s hard. They’re working two, three jobs just to keep the bills paid because it’s not enough wages.”