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Black women are overrepresented and underpaid in health care’s toughest jobs, study shows

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Black women are more overrepresented in health-care jobs than any other demographic groups, and are concentrated in its lowest-paid and most dangerous roles — disparities that are products of structural racism and sexism, according to a new study published this month in the journal Health Affairs.

Black women make up nearly 7 percent of the U.S. labor force, but nearly 14 percent of the health-care workforce, according to the study. Within health care, the study notes, Black women are most likely to work in the long-term care sector, currently making up 23 percent of that labor force, and as licensed practical nurses or aides, constituting 25 percent of those workers. These roles “are characterized by low wages, lack of benefits, and hazardous working conditions,” according to the study.

As co-author Janette Dill, an associate professor in the division of health policy and management at the University of Minnesota, put it: “They are taking care of peoples’ bodies, and feeding them, and bathing them, and taking people to the bathroom — it’s very hard physical labor.”

Shantonia Jackson, a 52-year-old certified nursing assistant at City View Multicare Center in Cicero, Ill., is in charge of caring for anywhere from 30 to 60 residents at a time, she said. As a result, “there’s not enough time in the day” to give all of them the care they deserve, said Jackson, who is Black.

“It’s like nobody is caring for the people. … It’s like I’m a number,” said Jackson, who also serves as a member of the SEIU Healthcare union and an advisory board member to the Center for Equity, a national advocacy organization for long-term care workers.

City View administrators did not respond to requests for comment.

According to Dill, large caseloads like Jackson’s are partly due to a mass exodus of health-care workers from their jobs due to low pay and burnout amid the demands of the coronavirus pandemic.

Dill undertook the study with Mignon Duffy, an associate professor of sociology at the University of Massachusetts Lowell. To conduct the study, Dill and Duffy used data from the 2019 American Community Survey — an annual national survey conducted by the U.S. Census Bureau — to analyze the probability of Black women’s employment in different occupations and sectors of the health-care industry. They controlled for various factors that could otherwise explain occupational choice, including education, marital status, age or immigration status, the study notes.

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Their analysis found that Black women have a higher probability of working in the health-care sector — 23 percent — than all other groups: White, Hispanic and Asian women, as well as women who identify with another race or ethnicity, have a predicted 16 to 17 percent probability of working in the sector, and men across racial and ethnic groups have a much lower probability of working in health care, ranging from 4 to 8 percent.

While White women make up a higher overall proportion of the health-care labor force — at 46 percent of the workforce — than Black women, they have a lower rate of overrepresentation than Black women in the sector compared with their overall workforce participation, the study notes. White women are also more evenly distributed among different settings within health care, and are slightly underrepresented among lower-paid licensed practical nurses and aides compared with their overall representation in the industry, according to the study.

Working in the health-care sector is rife with risk, according to the study: Health-care workers have the highest overall rates of workplace-related injuries of any private industry in the nation, and nurses and nurse aides are more likely to experience stress and injuries in the workplace than other health-care workers, other studies have shown.

For Black women, the risks are even higher: “Black women are more likely to work in those nursing homes and other long-term care settings that are most understaffed and under-resourced, leading to greater risk and exposure to injury or infection,” the study notes.

But while Black women do some of the hardest work in health care, their paychecks don’t reflect it, according to the study, which cites research from the Paraprofessional Healthcare Institute — an advocacy and policy research organization focused on direct-care workers — showing that home-care workers made a mean hourly wage of $12.12 in 2019, while residential-care aides earned average hourly wages of $12.69, and nursing assistants in nursing homes earned $13.90 hourly.

That research also notes that 1 in 6 home health-care workers live below the federal poverty level, and nearly half live in low-income households. And about half of Black and Hispanic female direct-care workers earn less than $15 an hour, according to a 2019 paper published in the American Journal of Public Health. (While the American Community Survey tracks income, Dill and Duffy didn’t include it in their paper to focus on “representation and where Black women are located within the health-care sector,” Dill said.)

Jackson makes $16.90 an hour. Before the pandemic, she was earning less than $15 an hour, leading her and hundreds of other nursing home workers around Chicago to go on strike in November 2020.

But her higher pay still doesn’t reflect the rising cost of living, Jackson said: “The rent is going up, the [cost of] food is going up, but the pay is not going up.”

Tracy Mills Jones agrees. Mills Jones, a 57-year-old long-term care worker in Palmdale, Calif., earns $16 an hour through the state’s in-home support services program to care for two clients, one of whom is her brother, she said.

“I’m changing all the sheets, I’m changing diapers, I’m doing all the work as an in-home care provider, and they’re only paying us dirt cheap,” said Mills Jones, who is Black.

Sometimes her low pay means “I have to pick whether I’m going to eat or pay a bill,” she added.

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Mills Jones’s union, SEIU Local 2015, is leading a campaign to bump California caregivers’ salaries up to $20 an hour. For Mills Jones, that increase would be transformative, she said: “$20 [an hour] would make me a member of society. … I literally live from check to check.”

A spokesperson for the Los Angeles County Department of Public Social Services said the agency “cannot release any personal information as to whether or not she is a provider.” (The Washington Post reviewed Mills Jones’s pay stubs from the state.)

According to the study, higher-paying roles in health care are hard to come by for Black women: They’re less likely to be registered nurses compared to White and Asian women and women of other racial and ethnic groups, and they have only a 1 to 2 percent rate of predicted probability to work as physicians, advanced practitioners, therapists or technicians.

In their paper, Dill and Duffy argue that these realities are products of the legacy of slavery, when White people forced Black women to work as unpaid domestic servants in their homes.

From that history flowed a distinction between “spiritual” and “menial” housework, law professor Dorothy Roberts argued in a paper that Dill and Duffy cite: Privileged White women did housework — including serving as hostesses and as role models for children — that was seen as superior to other tasks, while Black women were tasked with more labor-intensive tasks, including scrubbing floors, doing laundry and preparing meals.

Some of these assumptions about who does what kind of housework still haven’t changed, which contributes to keeping Black women locked in low-wage and dangerous health-care-related work, according to Dill: “We have a cultural assumption that women of color will provide care for us and they will do it pretty cheaply and that is their role.”

Jackson sees the historical connection in her work, too: “People act like, since we did it in slavery, we can do it again, and we still don’t have to get paid … but it should be about being happy about your job, being proud that you can help take care of somebody’s loved one,” she said.

The solutions to rectifying the disparities facing Black women in health care, Dill and Duffy argue in their paper, lie in increasing pay, creating more opportunities for career advancement and addressing racism in the workforce pipeline. They recommend raising the federal minimum wage to $15, citing a recent study that showed that doing so would reduce household poverty rates among female health-care workers by up to 27 percent.

Building better career pathways could include higher-ups at health-care organizations facilitating workers’ participation in training programs that will help them advance in their careers, they write. And addressing racism in the pipeline would require challenging “the feminization of care and the racialized association of certain jobs with ‘menial’ — and therefore less valuable — labor,” they write, adding that this should start in schools and that health-care leaders and managers should spearhead equity and inclusion plans.

For Jackson, reforming health care is essential to the future of the workforce: “I want this industry to change so our young people can be here to take care of us, because the way the industry is going now, nobody’s going to be around.”

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