This article comes from the winter 2020 edition of the Nonprofit Quarterly as part of an article series on “America’s healthcare crisis.” To learn more about this topic, please join us on Thursday, January 21st, at 2 pm EST for a free webinar on Health, Racial Disparities, and Economic Justice.

As COVID-19 hospitalizations spiraled out of control last spring, thousands of people stood at windows and on front porches or balconies each evening, clapping for doctors and nurses and emergency workers who were risking their lives to care for the sick and dying. That praise was well deserved, but it left out millions of nursing aides, housekeepers, medical assistants, food service workers, and many more healthcare workers largely invisible to the general public. Ten months into the crisis, as COVID-19 surges across the country, millions of low-wage workers who have been crucial to our COVID response are demanding to be prioritized, so that they can stay safe (and sane) and protect their families from a sometimes-fatal disease.

The Healthcare “Underclass”

Over 18.5 million people work in healthcare in the United States.1 Of these, only about 600,000 are doctors. By contrast, nurses account for nearly four million healthcare workers. These nurses are spread along a hierarchy based on education, licensing requirements, and workplace settings. Advanced practice nurses are more akin to primary care doctors, and relatively small in number. Registered nurses (RNs) number about three million, with about two-thirds working in hospital settings. A third category of nurses, licensed practical nurses (LPNs)—sometimes called licensed vocational nurses (LVNs)—number about 607,000, with nearly half working in long-term-care settings.2

Doctors, with their years of education, receive the most respect and privileges of all healthcare providers, earning in excess of $100 per hour.3 RNs, who manage much of the day-to-day care on hospital floors and in long-term-care settings, earn a median wage of $35 per hour.4 LPNs work under the direction of RNs in acute care and long-term-care settings, administering medications, tracking patient status, and keeping patients comfortable; they have considerably less prestige, and earn a median wage of $22.83 per hour.5 Since COVID-19 arrived, nurses up and down the hierarchy have carried much of the burden. Long concerned about understaffing, they find themselves left struggling to care for far too many patients with critical needs as the virus surges.

Nurses, however, are not the only health workers on the front lines. Another seven million workers occupy “low-wage” roles that also involve direct contact with patients. The Brookings Institution parses these workers into three types of occupations:6

  • Healthcare support workers: Those who assist providers such as doctors and nurses—for example, orderlies, medical assistants, phlebotomists, and pharmacy aides.
  • Direct care workers: Home health workers, nursing assistants, and personal care aides who support people with physical, cognitive, and social needs in nursing homes, congregate facilities, and private homes.
  • Healthcare service workers: Housekeepers, janitors, and kitchen and dining workers in hospitals, nursing homes, and other residential care settings.

These workers earn a median wage of $13.48 per hour. Among the lowest paid are home health and personal care workers, who earn a median hourly wage of $11.57.7

Well-paid clinicians tend to be white and male, while nursing and low-wage healthcare jobs are filled by women, with people of color overrepresented among the lowest-paid occupations (see Figure 1). Across low-wage healthcare support, direct care, and healthcare service occupations, 81 percent of workers are female, 25 percent African American, and 21 percent Latinx.8 LPNs, next on the hierarchy, are also mostly female (91 percent), and here, too, women of color are overrepresented: 27 percent of LPNs are African American, and 14 percent are Latinx.9 RNs, too, are 89 percent female, but this higher-wage occupation is dominated by white women. Of RNs, 12 percent are African American, and 7 percent are Latinx. Women of color represent the majority of the lowest-paid healthcare workers: long-term-care nursing assistants and home care workers.10

Low-wage healthcare workers, including LPNs, face an array of challenges, from general lack of respect to inconsistent hours and shifts to less access to paid leave and employer-sponsored health coverage. These are critical protections that workers need to stay home and get well if they become infected. Despite the large numbers of healthcare workers without robust benefits (e.g., 16 percent of home care aides have no health insurance, twice the rate of the general population, and 52 percent work part time11), healthcare employers were exempted from the Families First Coronavirus Response Act, the relief bill passed in April that extended emergency paid leave to workers who became ill with COVID. According to the Kaiser Family Foundation, almost all healthcare workers (17.7 million) were excluded. Though the data were not broken down by occupation, the Kaiser analysis points out that among the excluded workers, 75 percent were women, 39 percent people of color, 24 percent work part time, and 18 percent were low-wage employees. While doctors and RNs are likely to have health insurance and sufficient paid leave to remain out of work for two weeks or more, that is not the case for part-time and low-wage workers.12