Report: Poor wages and benefits for Iowa direct care workers fuel staffing crisis

Fran Mancl was thinking ahead. A certified nursing assistant at a nursing home, he wasn’t making enough to plan for his retirement. So, for 12 years, he worked part-time as a customer service representative so he could stay in the full-time direct care job he loved.

Not everyone was able to take the same approach. Mancl saw his co-workers struggle under a high workload with low wages, and saw his employers fail to bring in replacements when those co-workers burned out. Mancl was left with more responsibilities than he could handle.

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“What I experienced that gave me the most emotional stress was how the lack of quality care was compromised or was lost, not provided when direct care workers left the profession because it didn't offer a living wage,” Mancl said. “I admit it bothered me, because it made me look bad that I couldn't fulfill my role.”

According to the results of a recent survey conducted by Iowa CareGivers and Iowa Workforce Development, roughly one quarter of full-time direct care workers have more than one job. Direct care workers include certified nurse aides, home care aides, direct support professionals and others who provide hands-on care in any setting.

The 2025 Direct Care Worker Wage and Benefit Survey found low pay was the most frequently cited reason workers left the profession, more than burnout or a lack of respect.

Direct care workers, nursing homes and aging services providers agree that it’s past time to increase wages, and they say better pay wouldn’t only help staff, it would help employers and residents by reducing turnover and shortages. But the industry’s reliance on government funding means solutions aren’t so simple.

Direct care workers’ wages and benefits are lacking

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Although employers are required to report wage information, Di Findley, founder and executive director of Iowa CareGivers, said surveying direct care workers themselves offers a different perspective.

“For example, employers are asked if they offer health care coverage, and most employers do,” Findley said. “But if you ask the direct care worker if they have health care coverage, then it's a different picture, because they may not have it, because they can't afford it.”

While nearly 37 percent of direct care workers who responded to the survey reported having health insurance through their employer, a similar percentage reported using Medicaid for coverage or going without any coverage at all.

The report also found that while the median hourly wage for direct care jobs had risen from $13.80 in 2019, to $19.72 in 2025, when accounting for inflation, direct care workers’ wages only increased by $2.62 an hour in those six years.

Brent Willett, president and CEO of the Iowa Health Care Association, said he was surprised by the report’s wage findings. The Iowa Health Care Association is the trade association for for-profit nursing homes in the state. Willett said the survey’s wage information is different from what the Iowa Department of Health and Human Services shows in its reports.

“But I don’t want that to overshadow the fact that we still have as Iowans, we still have a long ways to go to ensure that certified nurse aides are being paid for the job that they’re having,” Willett said.

Medicaid reimbursements don’t match the cost of care

Willett pointed to low Medicaid reimbursements as a key influence of worker wages. According to KFF, Medicaid covers half of Iowa nursing home residents. However, Medicaid reimbursements only average around 82 cents for every dollar a nursing home spends on caring for these residents.

Samantha Heibel, executive director of LeadingAge Iowa, a trade association for not-for-profit and mission-driven housing and care providers for older adults, said her association’s members are keenly aware of how closely revenue is tied to wages.

“I, just yesterday, met with providers and asked if they had to prioritize funding, workforce or regulatory relief, what's the top thing on their mind this legislative session? And they all said, of course, workforce, but the workforce can't come without the funding,” Heibel said.

Low wages bring higher staff turnover. Mancl said he started tracking how much time he spent training new staff before the pandemic. Almost a third of his time was devoted to training, but the turnover rate was nearly two-thirds, creating a consistent need for more staff.

Some workers need support from state assistance to make ends meet. The 2025 Direct Care Worker Wage and Benefit Survey found 14 percent of respondents used the Supplemental Nutrition Assistance Program (SNAP) to help them purchase food for their families.

Mancl recalled a coworker who came to work in tears one day, having lost her SNAP eligibility because she worked extra hours.

“She lost eligibility because she was trying to help out and fill care gaps that were real and needed to be covered,” Mancl said. “Plus, Christmas was approaching, and she wanted to buy nice gifts for her kids.”

Multiple parties agree direct care workers need better pay

Findley said debate among stakeholders has distracted from attempts to address the interrelated problems of low pay and poor staff retention.

“We know what the problem is. Wages are low,” Findley said. “So we know what the solution is, and that is to increase wages.”

Willett said governmental changes are needed to adequately address the problem.

“The lever that we have is to work with our state and federal partners to help them understand the need for investments in Medicaid,” Willett said.

Iowa CareGivers held an event in November to convene stakeholders, which included industry representatives, workers and family members. Findley said the next step is to bring the group together again and brainstorm solutions.

“We're not going to agree on everything, but if we can come up with one or two strategies that we can agree on, reach consensus on, and move forward and advocate for those changes … then that would be a good thing,” Findley said.

Comments: fern.alling@thegazette.com