Fair and Meaningful Reward & Recognition
Local, state, and federal governments play an important role in ensuring fair and meaningful rewards and recognition for health and public safety workers. The government can establish guidelines and requirements for employers and directly implement or fund programs that enhance job quality and promote worker advancement, such as registered apprenticeships and career pathway programs.
Strengthen Worker Compensation and Benefits
Governments can enact policies to ensure health and public safety workers receive competitive, living wages and have access to benefits like health insurance and paid leave. Policy measures can include increasing minimum wage, establishing state wage boards, Medicaid expansion, and wage pass through laws, as well as scholarship and loan repayment programs, which offset the high cost and associated debt burden of health professions education.
Evidence
Studies analyzing the potential impact of raising health worker minimum wage find lower wage health workers like direct care workers would see significant pay increases and improvements in their quality of life.1 Increasing compensation for direct support workers has also been shown to alleviate staffing shortages, decrease turnover rates, increase worker productivity, and improve patient quality of care.2-4 Analyses of hazard pay policies during COVID-19 found they improved health workers’ overall economic well-being and their mental health.5,6 Wage boards, established by state or local legislative bodies and comprised of employees, employers, and the public, have also been used to increase wages in a number of sectors including for home care workers.7
Medicaid policies impact health and public safety workers. Medicaid reimbursement rates can directly impact health worker wages and wage pass through laws are associated with increased wages and increased staffing.8,9 The provision of basic benefits such as health insurance has also been associated with positive health worker outcomes, as described in the Health Organization Rewards & Recognitions section. Medicaid expansion has been associated with increased health insurance coverage among direct care workers.10,11
In addition, health professions loan repayment programs (e.g., National Health Service Corps) can translate to significant reductions in debt for qualifying educational expenses and are effective at retaining providers in underserved areas after their service obligation is met.12
Resources
The Economic Policy Institute Minimum Wage Tracker tracks the rapidly changing local and state minimum wage laws across the country.
State wage boards are comprised of businesses and workers working with the state’s executive branch to determine wages scales for an entire industry. This Vox.com article breaks down the authority, structure, state case examples, and potential applications for state wage boards in increasing worker pay.
The Department of Labor developed the Digital Reference Guide to the Fair Labor Standards Act, which establishes minimum wage, overtime pay, and other provisions affecting workings in the private sector and government.
The Milbank Memorial Fund’s Direct Care Workforce Policy and Action Guide provides an overview of the direct care workforce and state policy lever and innovations, including:
- Michigan, Colorado, and New Jersey increasing minimum wage requirements for direct care workers funded through Medicaid
- Arizona and New Jersey establishing wage pass-through laws requiring increased reimbursements to be directly applied to direct care worker compensation
- Massachusetts and one county in California offering low-cost health insurance through their Medicaid programs to direct care workers
Spotlights
During Women’s History Month 2023, the Mayor of Chicago signed an executive order requiring pay equity audits for city workers, with a focus on identifying racial and gender pay discrepancies. The US Department of Labor’s Office of Federal Contract Compliance Programs issued a directive to promote greater contractor attention concerning the proactive and effective use of pay equity audits to identify barriers to equal pay in their pay-setting and employment practices.
In October 2023, California passed a $25 per hour minimum wage for health care workers at various medical facilities in the state to replace the existing state minimum wage of $15.50 per hour.
New York’s Health Care and Mental Hygiene Worker Bonus Program aims to reward and retain front-line health care and mental hygiene workers by providing those eligible with up to $3,000 in bonus pay. California has similarly enacted legislation which will result in over 800,000 health care workers receiving a total of $1 billion in retention bonuses.
Section 9817 of the American Rescue Plan Act provided states with an increase in federal match funding for Medicaid home and community-based services (HCBS). States could use the additional funds to enhance, expand, or strengthen HCBS, including efforts to stabilize and expand the direct care workforce. Many states used some of the enhanced funding to provide direct care workers with wage increases and bonuses.
References
1 Himmelstein KEW, Venkataramani AS. Economic Vulnerability Among US Female Health Care Workers: Potential Impact of a $15-per-Hour Minimum Wage. Am J Public Health. 2019;109(2):198-205.
2 Weller C, Almeida B, Cohen M, Stone R. Making care work pay. LeadingAge. September 2020.
3 Lopezlira E and Jacobs K. Proposed health care minimum wage increase: What it would mean for workers, patients, and industry. UC Berkeley Labor Center. April 2023.
4 Ziemann M, Pittman P. Under what working conditions? An examination of health worker occupational health and compensation. Fitzhugh Mullan Institute for Health Workforce Equity, George Washington University. May 2022.
5 Scales K, McCall S (2022). Essential support: State hazard pay and sick leave policies for direct care workers during
COVID-19. PHI
6 SEIU 775, Center for American Progress. Higher home care wages reduce economic hardship and improve recruitment and retention in one of the country’s fastest-growing jobs. Seattle, WA, SEIU775; Washington, DC, Center for American Progress
7 Bauer J. Wage Boards Benefit Workers, Businesses, and the Economy. Oregon Center for Public Policy. March 13, 2023.
8 Baughman RA, Smith K. The effect of Medicaid wage pass-through programs on the wages of direct care workers. Med Care. 2010;48(5):426-432.
9 Feng Z, Lee YS, Kuo S, Intrator O, Foster A, Mor V. Do Medicaid wage pass-through payments increase nursing home staffing? Health Serv Res. 2010;45(3):728-747.
10 Campbell S. The Impact of the Affordable Care Act on Health Coverage for Direct Care Workers. PHI. March 2017.
11 Xu L, Sharma H. Effect of Medicaid Expansion on Health Insurance for Low-Income Nursing Home Aides. J Appl Gerontol. 2023;42(2):231-240.
12 Congressional Research Service. The National Health Service Corps. Jan. 4, 2022.
Support Career Development
Governments can invest in career supports and health workforce development programs, such as fellowships, apprenticeships, and career pathways, as well as formally adopt competencies and certifications to elevate and professionalize healthcare and public safety jobs.
Evidence
Community health worker wages are higher in states with certification programs, compared to those without.1 National survey data also indicate that individuals with certifications earn more than those without and that this is especially true for workers with less than a bachelor's degree.2 Apprenticeship programs have resulted in significant increases in earnings for participants, though racial disparities in earnings exist.3,4 These disparities may be partly attributable to participant enrollment in different healthcare occupations. A systematic review of retention of nurses and physicians in hospitals found a main determinant for job retention was career development.5
Resources
The National Governors Association’s 2023 report, Preparing The Next Generation Of The Healthcare Workforce: State Strategies For Recruitment And Retention, includes several strategies and case examples of workforce development incentive strategies that have been implemented at the state level as part of multi-faceted approaches to building and sustaining the health workforce.
The federal government’s Apprenticeship USA and companion Community of Practice websites provide occupational overviews, competency frameworks, and industry resources for apprenticeships in healthcare.
Competency based training standards promote professional recognition and can help attract more people to in-demand health care jobs, like the direct care workforce. In their report Direct Care Work is Real Work: Elevating the Role of the Direct Care Worker, PHI provides a national overview of the direct care training landscape, training program case examples, and opportunities to elevate the role of direct care workers through training, upskilling, and certification.
The Milbank Memorial Fund’s Direct Care Workforce Policy and Action Guide provides an overview of the direct care workforce and state policy lever and innovations, including:
- Michigan, Arizona, and Washington State established competencies and training requirements for direct care workers
- Alabama, Tennessee, Indiana, and others developed career pathway programs linking skills-based workforce training programs that are transferable to degree programs
- Rhode Island and California provide stipends tied to training.
Spotlights
The state of California recently issued standards for Certificate Programs for Community Health Workers, Promotoras(es) and Representatives (CHW/P/R). The certification standards and embedded competencies will allow CHW/P/R to bill under Medicaid, demonstrating that the certificate holder has the experience and skills to deliver billable services. Current and prospective CHW/P/R seeking certification will have multiple options to obtain it via either an Experience (current workers) or Training (new workers) pathway. An overview of the program is provided in a guidance letter issues by the state Department of Health Care Access and Information.
States like New York and Michigan are implementing measures to professionalize the direct care workforce. New York has partnered with the National Alliance for Direct Support Professionals to enhance professional credentialing for direct support professionals in an effort to address worker shortages. In Michigan, advocacy efforts resulted in the development of statewide direct care worker competency guidelines, which were administratively accepted as the state’s recommended set of competencies by the Michigan Department of Health and Human Services. Advocates are now working to develop a competency-based credentialing system for direct care workers that is transferable across all long-term service and support settings.
References
1 Jones TM, Jeung C, Schulte A, Lewis CM, Maddox PJ. Hourly Wages and Turnover of Community Health Workers According to US State Certification Policy and Medicaid Reimbursement, 2010-2021. Am J Public Health. 2022 Oct;112(10):1480-1488.
2 BLS. Professional certifications and occupational licenses: evidence from the Current Population Survey. June 2019.
3 Walton D, Gardiner KN. Expanding Registered Apprenticeship Opportunities to Underrepresented Populations: Findings from the American Apprenticeship Evaluation. August 2022.
4 Zessoules D, Ajilore O. Wage Gaps and Outcomes in Apprenticeship Programs. The Center for American Progress. December 12, 2018.
5 de Vries N, Boone A, Godderis L, et al. The Race to Retain Healthcare Workers: A Systematic Review on Factors that Impact Retention of Nurses and Physicians in Hospitals. Inquiry. 2023;60:469580231159318.
