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Building a High-Quality Long-term Care Paraprofessional Workforce

Wages & Benefits


Susan Harmuth, Health Systems Analyst, North Carolina Department of Health and Human Services, Division of Facility Services, Raleigh, NC.

Susan C. Eaton, Ph.D., Assistant Professor of Public Policy, Wiener Center for Social Policy, John F. Kennedy School of Government, Harvard University, Cambridge, MA.

Even with record-low unemployment in many parts of the country, wages and benefits for aide-level health care workers remain very low:

  • Of the 2 million paraprofessional health care workers in the United States, about 600,000 have incomes below the Federal poverty level.
  • Only 1 in 10 workers has individual employer-sponsored health insurance, despite an employer-offer rate of 90 percent.
  • Only 1 in 25 has family coverage, despite an employer-offer rate of 22 percent.

In part because of low wages and benefits, long-term care (LTC) facilities and providers across the country are encountering difficulty recruiting and retaining direct care workers, even in those States with high unemployment. Facilities and providers are feeling pressure to increase wages and benefits, however, many financially strained LTC providers cannot afford to raise worker wages.

Sixteen States have begun to address this problem through legislation to improve worker wages and benefits by:

  • Increasing payments to LTC providers.
  • Mandating that increased payments be "passed through" to health care workers.

Wage pass-throughs at the State level have been conducted primarily through increasing Medicaid payment rates and mandating either a fixed or percentage wage increase for workers.

State wage pass-through laws for health care workers have mandated wage increases for a variety of health care providers (e.g., nurse aides, home care workers, nurses) and for providers working in a number of care settings (e.g., nursing homes or home health agencies). States are enforcing wage pass-through laws through:

  • Audits.
  • Cost reports.
  • Surveys.
  • Other mechanisms.

However, there is no strong accountability mechanism in place in many States.

The North Carolina Division of Facility Services conducted a survey of States and found that:

  • Thirty-three percent of States reported that they had found or expected their wage pass-throughs to have a positive impact on the recruitment and retention of direct care workers.
  • However, 50 percent said the pass-throughs had no impact or an unknown impact.
  • About one-half of States were considering changes to their wage pass-through laws.
  • Most States do not collect baseline data so they can measure the effect of their efforts.

Although there are limited data on wages and benefits for health care paraprofessionals, many factors about compensation remain unknown.

Example: Average wages and employer benefits are known, but there is much less information on:

  • Entry-level wages.
  • Potential for advancement.
  • Employee uptake of benefits.
  • Effectiveness of government interventions, such as the wage pass-through.

More research and information are needed to better determine how States can address this LTC workforce issue.


Cramer B, Harmuth S. Results of a follow-up survey to States on wage supplements for Medicaid and other public funding to address aide recruitment and retention in long-term care settings. Raleigh (NC): North Carolina Division of Facility Services; 2000 Nov.

Cramer B, Harmuth S, Gamble E. Comparing State efforts to address the recruitment and retention of nurse aide and other paraprofessional aide workers. Raleigh (NC): North Carolina Division of Facility Services; 1999 Sep.

Straker JK, Atchley RC. Recruiting and retaining frontline workers in long-term care: usual organizational practices in Ohio. Oxford (OH): Scripps Gerentology Center, Miami University; 1999 Jun.

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