Is Iowa doing enough to help direct care workers?

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 round the-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 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. A summary of findings revealed a DCW median hourly wage of under $15 an hour. 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.

Over 50% had children enrolled in the state’s Children’s Health Insurance Program. Others used the Supplemental Nutrition Assistance Program (SNAP) to help them pay for food, child care 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 million, using a LeadingAge nursing home industry formula for calculating turnover cost.

The high turnover rate is partially caused by poor wages and benefits. Worker burnout is at an all-time high. Iowa now needs to increase wages by requiring employers that participate in the Medicaid programs to pay adequate wages. But other strategies must be explored. Something suggested by both Democrat and Republican legislators, raising the minimum wage 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. An hourly wage increase could result in the loss of vital state benefits, doing more harm to these essential workers. The “cliff effect” occurs when a small increase in earnings results in lost benefits.

The United Way’s “Asset-Limited, Income Constrained, Employed” (ALICE) report 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. It’s time to invest in this workforce up front 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 when employees’ caregiving responsibilities reduce hours. More important is the cost in diminished quality of care and life for both those receiving and giving care.

Di Findley is executive director of Iowa CareGivers