Transcript for Episode 77

Grant Martsolf: My guest on the podcast today is Jeanette Dill. Jeanette is a sociologist and associate professor in the Division of Health Policy Management at the University of Minnesota School of Public Health. She's an expert in the health care workforce. We'll be talking primarily about issues related to race and gender in the direct care workforce.

So I'm looking forward to our conversation. And Jeanette and I have recently written a grant proposal together and we're starting to write some papers together, so this is a really fun opportunity for me at the beginning of this working relationship to have a wide-ranging conversation about some issues that interest her.

So thanks so much for coming on.

Janette Dill: Thanks for having me. I’m glad to be here.

Grant Martsolf: So I want to chat a little bit about the direct care workforce in the United States. So we know that direct care occupations will likely represent the largest share of growth in jobs in the next 30 years. This is largely explained by the aging of the American population, among other changes in work in the United States.

My first question is, are direct care jobs good jobs?

Janette Dill: That's a good question. Now, I would say many direct care workers find a lot of meaning in the work, and they have always very high levels of job satisfaction because you're working with other people, you're providing that care. It's very meaningful and powerful work.

If we're talking about “good jobs” in terms of extrinsic rewards: wages, benefits, hours, paid leave, all of those kinds of things that we associate with the job, the rewards of a job, then, no. These are not good jobs. Right. And in fact, many of them are quite terrible.

Grant Martsolf: So what about job security? We often hear that the healthcare industry is anti-recession, right? It’s recession-proof.

Janette Dill: I would say that the demand for direct care work is ongoing and fairly consistent, and much of it is publicly funded, right? So it's largely funded by Medicaid. So we see most direct care workers in home health, home care, and in nursing facilities or assisted living. And so those kinds of jobs are largely recession-proof. That said, the compensation that direct care workers receive really can fluctuate based on the economy. So during the pandemic and the recovery from the pandemic, we did see wages go up quite a lot for direct care workers in really positive ways and what I would say is a correction in the labor market. And that was great to see, but if we hit a recession, a lot of those wage gains will likely be clawed back.

Grant Martsolf: What makes upward mobility in direct care jobs so challenging?

Janette Dill: Well, a lot of long-term care, especially, is what I would call really flat, right? If you think of your typical nursing home, you have maybe a few administrators, you have a few nurses, but the bulk of your workforce is going to be nursing assistants, certified nursing assistants, and then your dietary and housekeeping staff. In home health, same way.

So in order for you to move up, you really have to go back to school and you have to get another credential. And that could be to become a licensed practical nurse. You could become an RN or you could go into some of the other sort of mid-level healthcare occupations. Those are big jumps, right? You have to go back to school for quite a while in order to get those credentials and that is really hard for a lot of direct care workers to do who are living often very close to the poverty line, have children, are working non-standard and unreliable hours. It's very hard to go back to school and a lot of times there isn't organizational support for workers to get more education.

If we're talking about workers in bigger health systems - so, for example, you work for a large hospital or you work within a clinic that is associated with a large health system -  we see a lot more upward mobility because those large systems just have many more opportunities for people to move around and to move up, and they have organizational support for people to go back to school. So it really depends where you're located with these.

Grant Martsolf: How do you think about degree expansion within the nursing profession? So we know through the work of folks like Linda Aiken at the University of Pennsylvania that having a bachelor's degree seems to be associated with better outcomes for patients. But at the same time, that makes it even harder for, for example, a nurse’s aid to move up because now not only does she need an associate's degree, but if we get rid of those and needs a bachelor's degree, that seems to push that even farther into the horizon, her ability to move up in the job.

Janette Dill: You know, I see this across lots of women-dominated occupations. There's a lot of credentialing if we think about childcare, right, so formal center-based childcare, if you think about schools… There's just a lot of push for more education, more credentials. Teachers are expected, required to keep working towards their masters, et cetera. And the same is true in nursing, right? That we see this push for ongoing levels of credentialing within the nursing occupation.

I don't want to speak to the quality of care issue because I do think it's likely that that relationship exists. I can't really speak to that because it's a little bit outside of my research area. But one thing that I really struggle with in women-dominated occupations is that these increases in credentials just aren't really getting us anywhere. Right? Women are getting more and more education and the gender-wage gap is exactly the same as it was twenty years ago. So, women have really bought into meritocracy and to education. We've thrown everything into that ring, right? But it's not actually benefiting us in the labor market to the degree that you might expect.

Grant Martsolf: And I think, and I'm not an expert in the staffing literature either, but one question I keep asking is: is the effect size sufficiently large in terms of improved outcomes to justify the damage that it could do to working-class Americans? And I'm a little skeptical about that, to be honest with you.

Janette Dill: Well, and I also just wonder, is it, do you need to provide a little extra training for your associate-level RNs? Are there some organizational supports that maybe you want to put into place? And can organizations support that rather than basically…

I think there's a really nice literature in sociology on how since the 1970s there's been a real push towards individual responsibility towards education and training. That organizations take less and less responsibility and they push it on workers so that when they hire you, you are expected to have all the training and credentialing that you need for the job. And that benefits organizations, but it's very hard for workers who have trouble accessing higher education.

Grant Martsolf: And it benefits universities as well.

Janette Dill: It also benefits universities. That’s true. I guess I should note that conflict of interest of higher education.

Grant Martsolf: That's right. And I'm in a nursing school, which is an even deeper conflict of interest.

Yeah. So you talk a lot about the ways in which racism and sexism play out in low status, low pay of direct care work. So I want to explore this a little bit with you. What is the connection between America's history of slavery and direct care jobs, especially in long-term care?

Janette Dill: Yeah, I guess I would say in the U.S. – and this is not unique to the U.S. right? I mean, we can see this across many countries and we could talk about how care is organized in other countries as well. – but, in the U.S. we have relied on slavery and other forms of very low-paid domestic workers to provide a lot of the hands-on care that we require. And this pattern of having black women provide domestic care, as well as immigrant women, persists today.

So one of the studies that I've published recently shows that really 25% of black women are employed in the health care sector and they're overrepresented in these lowest level direct-care types of occupations. And it's consistent with this pattern of, like I said, black women, immigrant women, other women of color providing the hands-on dirty work care in the U.S.

The nursing profession also, as it emerged, has been very heavily dominated by white women. It has really worked to – and I don't want to give too much agency to like a particular occupation, right –  but as the nursing occupation has worked to professionalize, they have created a lot of credentialing and barriers for upward mobility. So people who could access higher education, like white women, were more likely to become nurses. And they really pushed off a lot of the dirty work that we find nursing assistants and home health aids doing onto those who couldn't access higher education.

Grant Martsolf: So one thing when we talk about structural racism that is hard is that sometimes it feels little abstract. We're not quite sure what to do about it because it feels like this sort of nebulous thing that exists in the ether, but sometimes it's hard to concretize. So what are the actual mechanisms through which structural racism and sexism works among direct care workers? How can we look at it? Because if we can't figure out the mechanism, it's very hard to change, right?

Janette Dill: Yeah. I would say one of the biggest drivers – and this is again, very hard to grasp, right? So like, I'm going to say something and, and I'm going to acknowledge that it's very hard for us to put our fingers on – but, I do think that there is a gendered and racialized assumption that women, and specifically many women of color and immigrant women, will do this work and do it for not very much money, right?

And we can think of, in our minds, other people doing this type of work. Like, what if you had a white male walk into your room as a nursing assistant? You would be surprised, right? You wouldn't be expecting someone like that to do that role. And because we have this expectation of who's going to do this particular role, we also carry within us this expectation that they're going to do it for not very much money.

If we think about other working-class jobs, there's more of an expectation of higher wages, right, even though they might require the same level of education, the same kind of physical types of labor, the same kind of skill if we think about construction work or manufacturing. But the expectation for wages is different, right? So there's a gendered and racialized expectation. In the sociology literature, they call it the wage penalty for providing care, and it's present in many very heavily feminized occupations.

Grant Martsolf: Yeah. So, one way that we can think about improving working conditions, particularly wages, is through stronger unionization. So what are the biggest challenges to organizing direct care workers?

Janette Dill: Oh yeah, that's a good one. I think that it can be a very big challenge, especially in home health because workers are very loosely employed, and that is a challenge for organizing lots of what I would call low-wage workers. So, you know, maybe they're employed by an agency, maybe not. Maybe they're hired by an individual, right? But they're not working within large organizations. So that unionization process can be challenging.

I would say you see more unionization among direct care workers that are employed in large organizations. But if you think of your small adult care home or assisted living or nursing home, a lot of long-term care, especially, they're not working within large systems. They're working for independent facilities, and so trying to unionize is a big challenge.

Grant Martsolf: So I read your most recent paper looking at unionization of direct care workers. One thing that was very interesting to me is that it seemed like minorities and men were more likely to unionize than other representatives from other demographic groups. Do you have any insight into that? Why are men and minorities more likely to unionize than white women?

Janette Dill: I'll speak to them separately because I think it's two different things going on.

I think men are more likely to be located in places where you just have more unionization. So men tend to locate themselves in larger health systems in places where they have more advantages and higher wages in general. So I think that they're just more likely to be, they're usually in the less marginalized type of jobs.

For, specifically we found that black workers and especially black women – our sample is almost entirely women, so we don't do an interaction between gender and race mainly because our group of men direct care workers is very small, so it's very hard to do an interaction – but black women especially are the most likely to unionize, followed by other workers of color. And that is consistent with national statistics, actually, that black workers are the most likely to unionize.

I've done some other work on credentialing and direct care workers opting into getting more education and more credentials. And really what we find is that white workers go the credentialing pathway. They're like, “We're going to get certifications, we're going to go to school. We're going to try and get higher wages through credentialing.” It's much more common for white workers, whereas for black workers and Latino workers, other workers of color, they're much more likely to be unionized. So they're using that collective bargaining strategy to try and get higher wages.

Grant Martsolf: Do you think Covid will change any of this? I thought I saw some papers, at least some articles suggesting that there was a swell of unionization efforts within direct care workers during Covid. Or is that still happening? Is that waning?

Janette Dill: Yeah. You know, I have seen a little evidence around that and I worked some with U Healthcare Minnesota and I think that they have had growth in unionization during Covid.

I think time will tell in terms of those trends, but I do think that there is strong union support right now among the general public, and so I'm hopeful that we'll see growth in unionization among direct care workers.

I mean, it's lower than what we see among, for example, nurses. I think – you could correct if I'm wrong here – but I think about 20% of nurses are unionized and for direct care workers it's like 11 or 12%. So I think that there's a long way to go.

I think it's harder, like we talked about, to get direct care workers unionized because of the types of places that they're employed, but I think that they… There's a lot of research in sociology that suggest that workers on the lower end of the wage spectrum actually benefit the most from unionization in terms of wage increases. So I think that there is enormous value and benefit in terms of greater unionization among direct care workers.

Grant Martsolf: So how do you think about healthcare costs now that you are a health services researcher in a school of public health and a health policy management school? I'm sure many of your colleagues think about healthcare costs. Actually, I know that to be the case.

Janette Dill: But they should, I don’t know that many of them too, but they should.

Grant Martsolf: Oh, really? 

Well, so we talk a lot about reducing healthcare costs, but it seems to me very obvious that if we increase wages for direct care workers, will it necessarily be increasing healthcare costs. How do you think about that? How do we solve that tension between healthcare costs and higher wages for healthcare employees?

Janette Dill: Yeah, I mean, I think that this is just an enormous challenge as our population ages, and it is just going to be an ongoing tension, right? Because the direct care workforce is huge and enormous, and the capacity for the direct care workforce is, I would say, limitless, right? Because people always want and need more care.

So how much are we going to invest in this workforce? And obviously increasing wages of direct care workers, if we choose to do that, it will increase healthcare costs and most, as I said earlier, most direct care workers work in long-term care, which is largely paid for by Medicaid.

And Medicaid is usually a partnership between states and the federal government. But if states are going to invest more money into Medicaid, that puts direct care wages and job quality in direct conflict with many other very valuable things like higher education and schools and caring for roads and all of those things that state governments pay for.

So I like to be really mindful of that, right? Like, this is not an easy problem to solve. We can't just say, “Raise wages!” and all of this will go away. Right. But I do think that there – and I feel like this is quite controversial to people; I feel a lot of tension when I say this in the policy world – but I feel like there's a lot of room for thinking about redistribution of how we spend our healthcare dollars and really prioritizing the types of services that are care for chronic diseases and preventive care. And if we did that, then we would be funneling a lot of money back to direct care workers.

I think you and I talked about before how physicians really have been successful in capturing most of the wealth within the healthcare system. That was true a while ago and it's increasingly true. And I think that we should be thinking about the types of inequality and deep stratification that we have in the healthcare system and if we want there to be such a vast difference between the top and the bottom in terms of how we compensate in the healthcare system.

Grant Martsolf: Yeah. We've sort of shown over and over again that the difference between the US and other countries in terms of healthcare expenditures is almost entirely prices and almost entirely wages. But not of direct care workers, but of physicians and nurses. And so I think we will have to have a certain reckoning with wage redistribution in a way that is going to make everyone quite uncomfortable.

Janette Dill: If we want to continue to have direct care work widely available, right?

Grant Martsolf: Right.

So I'm going to switch our focus a bit to talk about male employment, especially working-class male employment. And it's the project that we're kicking off thinking about job conditions among working-class male healthcare workers and how that contributes to overall wellbeing. So I want to spend a little bit of our time talking specifically about that.

So we know that men are dropping out of the workforce completely, especially men without college degrees, and “without college degrees” is another way of saying “working class.” So how do you explain the rise in working-class men simply dropping out of the workforce? Is this entirely a story of deindustrialization?

Janette Dill: Well, I will say, I'm certainly not an expert on working-class men, so I don't want to overstep there, but I think if we look at the change in the economy since the 1970s, we've had a decline in male-dominated, industrial types of jobs and an enormous increase in care work occupations, including those in the healthcare sector.

If you think about almost any large city, one of the largest employers in a city is going to be your large health system. In rural areas, often one of the biggest employers is going to be a healthcare organization, if you're lucky enough to have one in rural areas.

And so these types of jobs have really come to dominate the employment landscape over the last 50 years. And most of healthcare jobs are done by women, over 75%.

Grant Martsolf: So why do we care more about getting women into male-dominate occupations than getting men into female-dominated occupations?

Janette Dill: I feel like there's a pretty easy answer to that, and that is, in general, we feel much more comfortable with women taking on sort of male attributes and male roles. If we think about young children, right? This is an example that's often given. It's very acceptable for a girl to be a tomboy. But if we think about the opposite, of a young boy wanting to dress like a girl or take on more women or more feminine attributes, that makes people feel often very uncomfortable.

And I think the same is true when we think about jobs, right? We are very comfortable encouraging of women to take on male-type jobs or jobs that we associate with men and we're very uncomfortable with men doing work that is associated with women.

I would also say that a lot of the jobs that are associated with women are not great jobs, as we've talked about as well. So there's not a lot of reason or not a lot of financial reason why men would want to go into these jobs. That's not the case for all women-dominated jobs. I don't want to say that across the board, but for direct care jobs in particular, it's hard to think about why men would be motivated to go into those jobs for a financial reason.

Grant Martsolf: I also saw that in one of your papers that often men who transitioned into female-dominated jobs, it seems like a stop gap in order to put the breaks on unemployment. And then it seems like they eventually transition back into male-dominated fields like manufacturing. So what explains that sort of dynamic? Why do men often transition back to male-dominated jobs? Is it the money? They realize they don't like the care jobs? What's your instinct? What’s driving that phenomena?

Janette Dill: Yeah. And again, I would say that this is primarily instinct, right? I don't have a lot of research, numbers to back this up.

But my sense is, and I think you and I have talked about this, is that men are not necessarily turned off by working with other women. That's not usually the problem. That's not the concern. Usually what makes them uncomfortable is doing tasks that are associated with “femaleness” or with women performing that work. And so they tend to move away from it or are promoted, right? And sort of move out of the direct hands-on type of work.

So if we think about like schools, right? It's very common for teachers to be often very women-dominated and then for the principal to be a man, right? That's a very common pattern that we see. And the same is true in healthcare, where men tend to be promoted up and so they move out of that direct hands-on care.

Grant Martsolf: Is that the “glass escalator” that people talk about – primarily, that men will get promoted out of the direct care jobs – is that what we mean by the “glass escalator”?

Janette Dill: Yeah. The “glass escalator,” it's just playing off the “glass ceiling.” Right? And it's this phenomenon that we would look at men in women-dominated jobs like nursing, they tend to be promoted faster and they also earn higher wages. 

It's basically that men just have advantages in the labor market. And that's true in mixed-gender occupations. It's true in male-dominated occupations. And it's also true in women-dominated occupations. We shouldn't be surprised, right? So those advantages emerge very quickly for men, even if they're working largely with women.

Grant Martsolf: So do you see any differences between men and women in terms of their motivations for engaging in care work? It's on an older paper that you wrote, looking at different motivations for entering particular occupations, thinking about prosocial motivations, intrinsic motivations, extrinsic motivations.

Do you have a sense of what's driving men into care work? Is it the extrinsic “I need a job and I need money”? Do you see any differences across men and women in those motivations to participate in the jobs?

Janette Dill: Yeah. You know, I think it depends on what job you're talking about, right? But if we're talking about nursing – and I would be glad to hear your opinion on this too – I think that we often say that women are motivated to go into a job because they want to provide care for other people, right? Like it should be this altruistic or highly prosocial motivation. I don't really love that gendered expectation that women should want to do these things, and that it should be separate from the compensation and the need to be paid and have a good job just like everyone else. So, but I think it's very socially acceptable for women to say that, right? And to feel that, right? That they want to go into this job because they want to care for other people.

I think for men, there's less of that expectation. So they might want to go in and be a nurse because it's a really good job to have in today's economy and you can make pretty good wages right out of college. And you could work whatever hours you want. You can move wherever you want. And there are all those advantages and that's totally fine for men to say.

But yeah, that would, that would be sort of my instinct. What are your thoughts on that?

Grant Martsolf: I don't have a great theory, to be honest with you. When I talked to some of the male students in the nursing school at Pitt, the answers seemed to be about the same. “I wanted a job where I could care for people, and I wanted a field where I know I have a job.” So the answers themselves don't seem particularly different from me.

I do know that I entered nursing school. My mother's a nurse, my grandmother's a nurse, many, many of my aunts are nurses and I think that there's probably something there… My dad, who was a primary care physician, said, “Do not go to medical school.” So, I think there's something there in seeing, having someone close to you. A lot of male nursing students that I've talked to have that sort of relationship.

But I don't have a great theory for what's driving that. It sounds like, I think there's a lot of work to be done in this space to figure out why men enter these fields, what gives them satisfaction?

One thing I was thinking about is, your papers showed that, actually, people that enter nursing in direct care work for prosocial reasons seem to actually get more burned out. If they're literally there by this motivation to care for other people, they seem to get a little more discouraged, more burned out easily. But if you're just there because you like the job or you need a paycheck, they seem to get less burned out. What do you think is driving that relationship?

Janette Dill: Yeah, I don't know. I think maybe if you recognize that your job is a job, right, you maybe put up some more boundaries in your life. And I think when we view our job as a calling or something that is very much part of who we are. I think we could probably say this is professors. So drawing that boundary line between, “This is what I do for work” and “This is who I am” can be hard. But it can also be demoralizing if your job is asking too much of you and you can't say no, or if you don't feel supported by your organization or you feel betrayed by your organization, or you feel shame in the types of things you're having to do at work. All of those things, I think, can, if you don't have a strong sense of “This is the job that I do for pay,” that it can be more impactful and lead to more feelings of burnout.

Grant Martsolf: So one thing that I was thinking about as I was reading your papers: at the end of most papers like this, there's this idea that we need to change culture, change cultural understanding of what constitutes female work. Practically, how is that done? Do we need more TV shows about male caregivers? What does that take? That always, again, that feels like a discussion point that I'm not quite sure how we do that.

Janette Dill: How we do it. Yes. And I can't say that I have a great answer. Right. I mean I do think, since, I don’t know – I'm happy to hear your thoughts on this as well – since I started teaching, which was, I don’t know, like 15 years ago, there has been a shift in the media portrayal of care. By that I say, it’s very common to see men in laundry detergent commercials now, right? It's much more common to see men in domestic roles on the screen. And I feel like when I first started, that was very rare.

Does that make a difference? Well, I don't know. I really don’t know. I mean, I think when I think about how a job is valued, I always feel like it's a conversation between the way we compensate it, which communicates value, and the way we perceive it. So the way we have the societal perception, right. And they feed back and forth with each other because the compensation, if it increases, that increases societal value, right? This increasing societal value can also lead to increasing wages, right? And so it's sort of this symbiotic relationship.

Because I think about manufacturing in the 1970s or sixties, right? Whatever. And if we think about those jobs, probably weren't great jobs, I'm thinking. Like a lot of them, right, like very hard work, dirty conditions. But a lot of people, I think, have an enormous nostalgia for that kind of work, they really value that work because it provided a pathway into the middle class. Right? So because it paid well, it allowed us to respect that kind of work and to really value it.

Direct care work, there's just no pathway. It's just poverty. It's just poverty wages. And maybe we would say, “Oh, yeah, these workers provide really valuable services.” But because we're not compensating it in a way that reflects that value, no one actually believes that. Right? And so I think that in order for these jobs to really be valued, to really be respected, it can't just be about the way that they're shown at the media. I mean, maybe that helps a little bit, but there also has to be a change of compensation so that we are increasing the way that the jobs are being paid.

Grant Martsolf: Yeah. Although I always remember that there's only about 25 years of heyday in American manufacturing. Right. It was only from about 1950 to about 1972 when there were actually good union jobs that could really elevate people to the middle class.

And you're exactly right, I was at the Carrie Furnace, which is an old mill in Pittsburgh that's been shut down for many, many years, but they've turned it into sort of a museum, and I forget the numbers, but it was something like they lost one person every single month to death. So like, these are horrible jobs, you know, people falling into the blast furnaces. I can't think of a worse way to die than falling into a blast furnace.

But you're exactly right. There is some glamorization about it. But they still weren't great jobs, even in terms of pay, conditions or any of that, and again, until about 1950.

Janette Dill: Yeah, sometimes I also think about like public sector jobs, right? So public sector jobs, may be not great jobs, but they come with a whole host of robust protections that you get when you work for state government and that includes really good health insurance and a pension plan and things like that.

And so people can feel… like post-office jobs, right? And the public sector has been degraded, right? I will say that. But on the other hand, when I look at wages among low-wage workers, public sectors always look way better, right? And so when we provide protections around these types of jobs, they can become really good jobs and become respected jobs.

Grant Martsolf: So when I was a young nurse, so I actually did work as a nurse for a very short amount of time. I always had a sense that the older female nurses didn't like me very much. So in many ways I still remember how mean those women were to me. And now that I have a little critical distance, I realized that their treatment of me was multifactorial, much of it being my own fault. I was a 22-year-old kid who, I wasn't probably very good at the job. But there's always a part of me that felt like that had something to do with me being a male in a female-dominated space. Do you think my instincts are correct? Obviously, you don't know exactly the nature or that job, but in general, do you think that my instincts are correct? Do women want men in these jobs?

Janette Dill: Well, you know, I have a couple of – so I teach in our Master's of Health Administration program in our division in our department, and I have a couple of male nurses in my class right now, and I should ask them if they had similar experiences because both of them have left floor nursing now. I think both of them would say they never intended to be a floor nurse forever. But it's interesting that they're in their mid-twenties and they're like, “See ya, done with that.”

You know, there is quite a bit of evidence, not from my own research, but from other people's work that there is some, I don't want to say bias against men in these jobs, but there is some societal hesitation around men in these jobs, especially like childcare. There's been some audit studies that men are really not welcome to enter childcare jobs and that they'll be, I don't want to say discriminated against, but they'll be passed over in the hiring process. Same with education. And so I think it's very likely that they did not appreciate having a man in the role.

I will say too, also, we're talking about gendered assumptions, like deep, deep, deep gendered values around who should be providing care and it's not just the men who hold these assumptions, right? It's the women too! When I would teach undergrad sociology, a lot of times my students, you know, I would bring up this issue of, you know, changing economy, what are the men going to do? And a lot of times the women would say like, “I don't want my boyfriend to do that work. Oh, gross.” Like, “That would make me feel uncomfortable. I don't want them to do that.” So, I don't think that these gendered assumptions are just things that men hold. 

Grant Martsolf: Well, those are all my questions. This has been a lot of fun. And I'm so grateful that we're beginning to work together. Now we can continue having these conversations in private and I really hope that a lot of these issues that we didn't quite have an answer for, hopefully in the next few years, you and I working together, we'll be able to come up with some answers to these questions.

Janette Dill: Yeah, I'm really looking forward to it.