Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.


The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

NCD Letter to Rep. Scott Regarding Direct Care Bill

Thursday, September 14, 2017

September 14, 2017

The Honorable Robert C. Scott
Ranking Member
U.S. House Committee on Education & the Workforce
2101 Rayburn House Office Building
Washington, D.C. 20515

Dear Ranking Member Scott:

I write on behalf of the National Council on Disability (NCD) – an independent federal agency with the mission to advise the President, Congress and other federal agencies on disability policy issues – to applaud the introduction of your ‘‘Direct Care Creation, Advancement, and Retention of Employment Opportunity Act’’ and offer our guidance and recommendations to you as your bill will no doubt present many opportunities for discussions regarding the growing concern regarding the direct care workforce shortage. This is a national crisis for many people with disabilities that Congress must address since the Federal Government is the largest payer of direct care workers. Your legislation represents an important first step in pursuit of solutions.

NCD has addressed direct care workforce concerns for well over a decade through reports and roundtable discussions. NCD’s report, “The State of 21st Century Long-Term Services and Supports: Financing and Systems Reform for Americans with Disabilities (2005)” illustrates ongoing stakeholder concerns with the direct care workforce. This report included principles for application to all proposed legislative changes impacting the direct care workforce. In 2010, NCD’s Workforce Infrastructure in Support of People with Disabilities: Matching Human Resources to Service Needs report discussed career advancement and training opportunities to be used as a recruitment and retention tool. And in 2013, NCD convened more than 35 representatives from diverse stakeholder organizations in a roundtable discussion to address the application of the Fair Labor Standards Act to domestic service and its impact on the disabled and aging community. Roundtable participants affirmed the importance of the previously established principles and proffered additional recommendations. The recommendations and principles from our earlier work remain timely and relevant, and we reiterate them here:

  1. People who are elderly and people with disabilities both desire and deserve choices when seeking assistance with daily living that maintains their self-determination and maximum dignity and independence.[[1]](    
  • ​When approving waivers for Home and Community Based Services (HCBS), the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) should make sure direct care workforce wages and compensation packages are sufficiently resourced to ensure a robust workforce.
  1. Without significant reform, the current financing mechanisms (public and private) will soon become unsustainable. The system must be affordable to all Americans regardless of income levels and must leverage public and private support in new ways without impoverishing beneficiaries.[[2]](​    
  • Congress should ensure any current and future legislation pertaining to LTSS provide an adequate funding stream so that direct care workers can earn a fair wage. Low Medicaid reimbursement rates set by the state are not competitive and have created a high turnover rate in this industry. As reported by the Bureau of Labor Statistics (BLS) in 2017, national average turnover rate in all industry is 3.5%.[[3]]( while the average direct care workforce turnover rate is 45%. Low wages and lack of benefits are the primary reason for the high turnover. Personal care assistants (PCAs) make up the majority of direct care workers and earn an average of $11 an hour, this wage is at the bottom quarter of all US wages.[[4]]( In states where the unemployment rate is at historic low levels, the ability of providers to recruit direct care workers is nearly impossible as retail and fast food restaurants are able to pay higher wages for positions less demanding. Recruitment and retention of direct care workers is a federal issue when you consider that 70% of long-term-care services are funded by federal and state programs.[[5]](
  1. The changing demographic picture of the United States demands a universal approach to the design and financing of supports that are responsive to individuals under the age of 65, as well as Americans over 65 who may or may not have disabilities, without sacrificing individual choice and flexibility.           
  • The U.S.  Departments of Education, Health and Human Services, and Labor should create grant programs and financial incentives for states to expand the pool of direct care workers through recognition programs, grassroots campaigns and training efforts.[[6]]( Women between the ages of 25 to 64 comprise the vast majority of direct care workers and workers entering the workforce within this demographic are expected to remain flat through 2024.[[7]]( Programs like Community Connections Career Partnership created by the Ohio Provider Resource Association (OPRA) and the Ohio Alliance of Direct Support Professionals (OADSP) are a twofold solution for the workforce crisis. It assists students who need alternatives from traditional education and introduces a different demographic group to the direct care workforce. Juniors at risk of dropping out of high school develop work experience by traveling on-site to provider-mentor sites and enrolling in the nationally recognized DSPaths curriculum. As juniors, students earn certificates of initial proficiency and progress to certificates of advanced proficiency by their senior year. The provider-mentors are placed first in line for the opportunity to recruit the students upon graduation.[[8]](
  1. Formal and informal caregiving must be sustained, including examination of family needs and workforce recruitment and retention challenges.        
  • Career advancement and training opportunities can impact both recruitment and retention. Both are common strategies across industries in the U.S. to improve the skills of workers and to differentiate and reward employees for completing training and developing additional skills. Such models already exist in the direct care workforce and most are multilevel programs and offer specialized skills based on different client needs.[[9]]( New ways to achieve the necessary competencies and credentials must be developed to turn transferable opportunities into viable solutions to worker shortages.[[10]](
  1. Consumer direction and control of resources afford people with disabilities enhanced opportunities to live fulfilling lives of their own choice and offer an additional means to ensuring quality services.[[11]](        
  • While the available evidence suggests that there is potential for further growth in self-directed services, barriers to expanding access to these options remain significant. Policymakers should look for ways to remove or minimize these barriers and to fairly balance the complex needs of both the service providers and the disability and aging communities. 
  1. An ongoing, coordinated effort is required to systematically monitor how well the disability services infrastructure is responding to people’s needs.
  • A consortium of federal agencies—each with responsibility for some aspect of quality of life for people with disabilities—should design a system to collect and share data. The agencies would include the Census Bureau, the Departments of Labor and Education, and the Centers for Medicare and Medicaid Services.[[12]](

NCD is encouraged by the introduction of your legislation and welcomes the opportunity it presents for discussions on incentives for workforce investment boards to begin addressing this growing national crisis. Your legislation encourages states and home healthcare agencies to develop innovative approaches to improve recruitment, retention, and advancement.

NCD welcomes an opportunity to discuss this issue further with your office and offers our assistance if desired. Please contact Phoebe Ball, Legislative Affairs Specialist, at, or Amy Nicholas, Attorney Advisor, at, to discuss this matter further. Thank you again for your leadership in this important area.


Clyde Terry


[[1]]( National Council on Disability, “The State of 21st Century Long-Term Services and Supports: Financing and Systems Reform for Americans with Disabilities,” December 2005, available at /publications/2005/12152005, September 12, 2017

[[2]]( National Council on Disability, “The State of 21st Century Long-Term Services and Supports: Financing and Systems Reform for Americans with Disabilities,” December 2005, available at /publications/2005/12152005, September 12, 2017

[[3]]( Bureau of Labor Statistics, Job Openings and Labor Turnover-July 2017, September 12, 2017

[[4]]( US Government Accountability Office (GAO), “Long Term Care Workforce: Better Information Needed on Nursing Assistants, Home Health Age, and Other Direct Care Workers, August 16, 2016, available at:

[[5]]( American Society on Aging, “The Direct Care Workforce Raising the Floor of Job Quality,” , July 17, 2017

[[6]]( American Network of Community Options and Resources (ANCOR), “Addressing the Disability Services Workforce Crisis of the 21st Century,” May 2017, available at:

[[7]]( GAO, August 2016

[[8]]( ANCOR

[[9]](  American Society on Aging

[[10]]( National Council on Disability, “Workforce Infrastructure in Support of People with Disabilities: Matching Human Resources to Service Needs,” January 2010, available at:, September 12, 2017

[[11]]( National Council on Disability, “The Case for Medicaid Self-Direction: A White Paper on Research, Practice, and Policy Opportunities” May, 2013 available at,, September 12, 2017 

[[12]]( National Council on Disability, “Workforce Infrastructure in Support of People with Disabilities: Matching Human Resources to Service Needs,” January 2010, available at:, September 12, 2017

An official website of the National Council on Disability