Effect of Self-Directed Programs on Direct Care Worker Wages

Project start: 9/01/2022

Some states offer self-directed models in their LTSS programs, in which consumers control how available funds are used to purchase the support they need to maximize health and function in the community, including direct hiring of direct care workers (DCWs) who assist them in the home and community. The purpose of this project, which would be conducted in collaboration with RTI International, is to examine the effect of these models on direct care worker wages, specifically the wages of personal care assistants (PCAs).

Direct care workers (DCWs) play an essential role in the health and well-being of over 20 million Americans who receive long-term services and supports (LTSS). In 2020, 2.4 million DCWs provided care in people’s homes. These workers assist older adults and people with disabilities complete self-care and other daily tasks. Their efforts require considerable technical and interpersonal skills, but these essential workers receive low pay and rarely receive benefits. Almost one-half (45%) of DCWs live below 200% of the federal poverty level, and about one-half (47%) rely on public assistance. In 2020, national median pay was $13.02 per hour, or $27,080 per year, for home health aides and personal care assistants (PCAs). Previous research by RTI International shows that wages for DCWs lag behind those for workers with similar entry-level requirements, such as janitors, retail salespeople, and customer service representatives. This research also shows that state policies aimed at improving DCW wages, such as Medicaid wage pass-throughs, wages floors, and tying wages to training and certification, may have improved wages for DCWs but not eliminated the wage gap with other entry-level workers in most states with these policies.

Self-directed LTSS programs allow consumers autonomy in determining the use of the funds available for support. Among other things, consumers may use funds to hire and pay direct care workers. Self-directed LTSS programs vary by state (and sometimes by program within a state). In some cases, consumers have flexibility to set the hourly wage, known as “budget authority,” and may choose to pay wages that differ from those paid to workers hired by care management organizations. In other programs, direct care workers are unionized, allowing for collective bargaining of wages. Some states also made temporary changes to their programs in 2020 in response to the COVID-19 pandemic, such as loosening restrictions on hiring family members. This study will examine changes in the wage gap between PCAs and other entry-level workers in the states that have implemented self-directed models since 2011.


Key Questions

This project aims to answer two questions:

  • Which states have implemented self-directed programs since 2011?
  • What is the change in the wage gap between PCAs and other entry-level workers in states that have implemented self-directed programs since 2011?


This study is a collaboration with RTI International.

For more information, contact Susan Chapman.



Tyler, DA, Fujita, M, Chapman, SA. Effect of Self-Direction on Personal Care Aide Wages. University of California, San Francisco, 2023.