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care economy
America Runs on Care Work, and I’m Tired of Pretending Otherwise
The labor that sustains human life gets pushed to the margins, while the labor that scales software gets paraded on magazine covers.
Mar 08, 2026
A few days ago, I stared at a federal bar chart on my laptop and felt my stomach drop. I started asking people a party-trick question: What’s the biggest occupation in America? Almost everyone guessed something visible: teachers, retail, fast food, office work. That’s what our culture trains us to notice.
Then I pulled up the Bureau of Labor Statistics’ (BLS) “largest occupations” data, and the answer was sitting there in plain English: Home Health and Personal Care Aides, 3,988,140 people.
I’m not reading that as an abstract statistic but something I see daily through my work in running CareYaya, a social enterprise that helps families find affordable in-home care support. I hear the voices behind those numbers every day: the exhausted daughter trying to keep her job, the older man determined to stay in his own house, the care aide who shows up anyway even when her own life is fraying.
What hit me wasn’t just the size of the workforce, but the silence with which society treats caregivers.
Care work sits at the intersection of everything America avoids looking at directly: aging, disability, dependence, death, and the truth that every “independent” adult is one accident, cancer, or dementia diagnosis away from needing help.
In a country that can’t stop talking about “the economy,” I rarely see the economy described the way it actually functions at street level. I see caregivers keeping older adults safe so that family members can work, so the bills get paid, so other industries keep humming. I see care work acting like the hidden scaffolding under everything else.
And, I see how quickly that scaffolding gets treated as disposable labor.
When I talk to families, they often whisper about their difficulties getting care support almost like they’re confessing a moral failure. “We’re trying,” they tell me, as if the need for help is some private weakness instead of a predictable part of aging or serious illness. When I talk to care aides, they talk about the stress from the care work. They talk about rushing between clients. They talk about loving the work and sometimes still not being able to make rent.
PHI’s snapshot of the direct care workforce puts numbers to what I keep hearing, that median annual earnings for direct care workers were just $25,015. I read that figure and think about what it really means in 2026 America: The largest job category in the nation is, effectively, a low-wage backbone.
I also think about who gets stuck holding the bag. Care work is still treated as “women’s work” in the cultural imagination, and that bias leaks into policy, pay, and prestige. I watch the same pattern repeat: The labor that sustains human life gets pushed to the margins, while the labor that scales software gets paraded on magazine covers.
What makes me angrier is that this isn’t a small sector we can ignore until later. The BLS projects 17% growth from 2024 to 2034 for home health and personal care aides, with about 765,800 openings each year on average. This is not a “future” problem but rather a present problem that is going to grow much worse, faster.
And yet I keep watching public conversations drift toward fantasy. I hear endless speculation about AI replacing workers, while the largest workforce in America can’t even get a stable ladder, a living wage, or basic respect. I hear investors pitch “aging tech” like it’s a consumer gadget category, while the core issue is whether a real human being can afford to do this work and stay in it.
I don’t think this is an accident, but rather, a choice embedded in our system.
Care work sits at the intersection of everything America avoids looking at directly: aging, disability, dependence, death, and the truth that every “independent” adult is one accident, cancer, or dementia diagnosis away from needing help. So we do what societies often do with uncomfortable truths. We outsource them, we underpay them, and we call them “personal responsibility.”
Even the funding structure says it all. Medicaid is the main payer of long-term services and supports in the US, and a recent Centers for Medicaid and Medicare Services brief says so plainly: “Medicaid is the largest payer for long-term services and supports (LTSS) in the United States.” I read that line and think about the whiplash families face when they confront a vast public health need paired with political rhetoric that treats caregivers and recipients like line items to be squeezed.
So when I’m asked what to do, I start with a moral stance and then I get practical.
I want a country that pays the people who keep elders safe, like they truly matter. I want Medicaid rates and payment models that stop forcing providers into churn, and stop forcing workers into poverty. I want training and advancement pathways for care workers, and I want the caregiving workforce to have real power: bargaining power, scheduling power, and dignity at work.
I also want us to stop acting surprised when the care workforce pipeline breaks. If the biggest job in America is care, then the “care crisis” isn’t a niche issue, but a core labor rights issue; a public investment issue; and an economic issue that’s as critical as housing, wages, and healthcare.
When I look back at that BLS bar chart, I don’t see a pop-quiz type question anymore. I see millions of workers holding up millions of families. I see the work that makes the rest of American life possible.
And I can’t unsee the insult of how little we talk about it.
If I want anything from readers, it’s this: I want you to say the name of the job out loud, and then demand that we build an economy that treats it as essential, because it is.
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Medicaid Cuts Put Services for Vulnerable People at Grave Risk
Medicaid doesn’t just provide healthcare. It is the single largest payer for the community-based services people with intellectual and developmental disabilities need to live, work, and thrive in our communities.
May 22, 2025
With the House passing their budget reconciliation bill with a vote of 215-214, hundreds of billions in proposed cuts to Medicaid have moved one step closer toward very real, harmful consequences, including for people with intellectual and developmental disabilities, or I/DD, whose health, safety, and quality of life depend on Medicaid.
Medicaid doesn’t just provide healthcare. It is the single largest payer for the community-based services people with I/DD need to live, work, and thrive in our communities—services that range from assistance with intimate activities of daily living and personal hygiene, to employment supports to find and maintain a job, to providing residential and in-home supports to support independent living.
If lawmakers approve the proposed cuts to Medicaid, state budgets will be unable to absorb the financial shock. Even if targeted to other groups like those made eligible for services through Medicaid expansion, programs that enable people with I/DD to meaningfully participate and thrive in our society will be the first to go. We know because home- and community-based services for people with I/DD are optional services, meaning they are some of the last services to be funded when there’s a state funding shortfall. We saw this following the Great Recession when, following cuts to federal funding, every single state made cuts to services and 36 states specifically made cuts to services for people with I/DD.
If lawmakers truly care about boosting economies, they would invest in, not divest from Medicaid, because these services actually play a critical yet often invisible role in state economies.
Divesting from Medicaid will be devastating to providers of I/DD services who are already struggling immensely due to insufficient Medicaid reimbursement rates that haven’t kept pace with inflation. As a direct result, 90% of community providers report moderate to severe staffing shortages as workers seek out higher-paying jobs in entry-level retail, convenience, and fast food industries. Without sufficient staffing, 69% of community providers report they’re unable to take new referrals for people with I/DD who need and qualify for services.
Medicaid cuts by another name in the form of increased red tape eligibility requirements or work reporting requirements also threaten people with disabilities, who may lose coverage due to barriers completing onerous reporting requirements, even if they are provided an exemption. Such requirements also threaten to further exacerbate the direct support workforce crisis, as 49% of direct care workers rely on public assistance programs themselves, and approximately one-third work part-time or with inconsistent schedules—two job features that are generally incompatible with work reporting requirements. If direct support professionals, the very backbone of disability services, are unable to meet burdensome reporting requirements, it will only force them to find more stable, higher-paying jobs outside of care work.
If lawmakers truly care about boosting economies, they would invest in, not divest from Medicaid, because these services actually play a critical yet often invisible role in state economies.
New York State’s $6.7 billion investment in home- and community-based services generated $14.3 billion in economic activity, while Maine is estimated to have lost out on over $1 billion due to its shortage of direct care workers. That’s because Medicaid-funded services create jobs, while enabling the family members and caregivers of people with I/DD to remain in the workforce too. Without services, families are also more likely to need public assistance.
The House’s budget proposal will force unthinkable decisions on states and providers. It will undoubtedly lead to people with I/DD losing access to services, potentially being forced to languish in their homes without the assistance they need for using the restroom, supportive hygiene, and preparing and eating meals. It will lead to people with I/DD losing their jobs without the employment supports they need to maintain their careers. And it could mean unnecessary institutionalization of people whose right to live and thrive in their communities was codified by the Americans with Disabilities Act and, later, the Supreme Court’s decision in Olmstead v. L.C.
Senators hold the opportunity to continue protecting our most vulnerable populations by rejecting any cuts to Medicaid and not putting further stress on a system already in crisis.
Update: This piece has been edited to reflect the fact that the U.S. House of Representatives passed their budget reconciliation bill on the morning of May 22, 2025.
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We Know How Bad Trump's Tax Policy Is, But Just How Good Will Harris' Be?
Harris wants to invest in the care economy and has signaled support for raising corporate tax rates, while Trump has been largely silent on care investments and signaled support for more tax cuts at the top.
Aug 25, 2024
U.S. Vice President Kamala Harris and former President Donald Trump have starkly different views on taxes and how the tax code can support families.
Harris voices strong support for families through investments in the care economy. She’s vowed to advance paid family leave, affordable childcare, care for disabled or aging family members, and healthcare. This could be funded with a better tax code.
These policies would help all of us care for our families and strengthen our communities. Investing public dollars in care could also narrow racial and gender pay gaps by boosting the pay of care workers—who are mostly women, and many of them women of color.
Strengthening care infrastructure would help us all thrive and make the economy stronger. But we need to collect sufficient revenue to support those transformational policies.
The Trump campaign has been largely silent on care investments. But his campaign has signaled support for more tax cuts at the top. Such cuts would increase inequality and reduce the availability of federal funding to strengthen the care economy.
We saw this in the 2017 tax law that former President Trump signed. It cut taxes for the wealthiest people and corporations, including cutting the effective tax rate for our largest corporations from an average 22% to an average 12.8%. It also preserved loopholes that allow some of the wealthiest corporations to avoid taxes on most—if not all—of their profits.
These tax cuts for the ultra wealthy led to huge losses in federal tax revenue and spiked the national debt, making it harder for the government to fund new investments in priorities that are important to families.
If reelected, Trump has said he wants to slash corporate taxes further—even though some billionaires pay a lower share of their income in taxes than nurses and teachers do.
By contrast, the Biden-Harris administration created a minimum corporate tax so the wealthiest corporations could no longer pay nothing, added a modest tax on stock buybacks, and funded the IRS to better collect taxes from corporations. These policies raised revenue for care investments and other priorities.
Going forward, Harris has signaled support for raising corporate tax rates, which are at historic lows, and closing loopholes.
Harris and Trump also have different priorities on taxes for families. As a senator, Harris championed a tax credit of $6,000 for married couples and $3,000 for single people in her Lift the Middle Class Act. This would have delivered 88% of its benefits to earners under $119,000.
Harris might not promote this specific plan going forward, but it suggests she’d aim to direct benefits to moderate earners instead of the wealthiest. More recently, she’s proposed expanding the Child Tax Credit and adding a $6,000 credit for families with newborns.
By contrast, the tax bill that Trump signed delivered more than half its benefits to the top 5% of households—those with incomes over $263,000. (Like Harris, Trump’s vice presidential nominee, J.D. Vance, has suggested a bigger Child Tax Credit. But Vance has also floated making people without children pay more taxes.)
Taxing the wealthiest and big corporations would support care investments and make our tax code more fair. Strengthening care infrastructure would help us all thrive and make the economy stronger. But we need to collect sufficient revenue to support those transformational policies.
There is strong public support for better care and for fairer taxes. Tax justice advocates should call on both the Harris and Trump campaigns to commit to a fairer tax system—and to use the money it would raise to invest in the childcare, elder care, and healthcare our families need.
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