Among the greatest challenges in human services during the past decade has been attracting and retaining the workforce needed to support our growing population of seniors and people with disabilities.
For home care positions, particularly in the less skilled jobs, there are simply not enough people.
Personal care attendants, often referred to as home care workers, do the difficult work of supporting seniors and people with disabilities so they can remain in their own homes. This can include bathing and toileting and mobility, helping their clients run errands, light housekeeping and meal preparation. They are not medical professionals but may monitor health and behavior.
The workforce shortage is not just an industry problem; these direct care jobs are mostly funded by the Medical Assistance program, which is what we call Medicaid here. There are significant policy and state budget implications.
Strategies to address the workforce shortage have varied, from building better training and feeder systems, to MA payment policies that directly account for labor costs.
There is another approach for personal care attendants, which dates to a 2013 law when the Legislature provided PCAs with a unique opportunity to form a union.
The bargaining unit identified by the law is a growing subset of PCAs — those who provide services as part of a program option called “self-directed care.”
Self-directed care has quickly become the preferred model for many people with disabilities who use services to live at home. With self-directed care, the person needing services hires their own worker and directs care. Traditionally, home care workers were provided through PCA agencies that employed the workers.
Under self-directed care, the person needing care is the employer — they hire, fire and direct the home care worker. Agencies provide support such as payroll services.
As a result of this shift, there is now a large cohort of direct care workers who have no employment connection with a PCA agency — around 35,000 in Minnesota.
In 2014, these workers chose to unionize, joining SEIU Healthcare Minnesota, and in 2015 signed their first contract with the state.
Last year the bargaining unit celebrated its 10th anniversary. What have we learned in the past decade?
We know for certain that the pay of home care workers has increased.
The first SEIU contract set a new “wage floor” of $10.75 per hour for all direct care workers in the bargaining unit. At the time, based on the best information available, home care workers were paid an average of about $10/hour.
So, wages for most workers increased immediately under the first contract. Prior to this, state law provided no wage floor for home care workers (other than the state minimum wage).
Since that first contract, SEIU has won significant increases in wages and added some benefits.
The wage floor in the 2025 contract is $20.00 per hour, almost twice the first contract a decade earlier, and well above the $14.75 needed to keep up with inflation. The 2025 contract also builds in higher wages for more experienced workers, creating the sort of career path for home care workers that exists in most other professions.
Over the years the contracts have also added paid time off, time-and-a-half for some holidays and made additional training available to workers.
According to SEIU, health care and retirement remain goals for future contracts. As of now, workers in the bargaining unit receive a $1,200 health care stipend, and a state-union trust will be launched to explore creation of a defined-contribution retirement plan.
All of this has clearly helped the home care workers.
But there’s another question to consider: Has unionization helped the people who need home care workers to live independently in the community?
That’s not easy to answer directly, but several indicators point in a positive direction.
First, there must be an adequate supply of people willing to provide home care. Otherwise, those needing services risk institutionalization or burdening family and friends. The wage gains under the PCA union contracts have helped those jobs remain competitive in the labor market. Not surprisingly, raising wages has increased the pool of people willing to do home care and stay in the field.
Second, stability in care is critical; turnover leads to gaps in care that leave people with disabilities in precarious and even life-threatening circumstances. And, turnover is high; being a home care worker can be difficult and emotionally draining work.
SEIU shared an internal analysis with me that showed an increase in worker retention in 2025, after the latest contract went into effect. While this analysis could not prove causation, it is well established that pay is a prime factor in worker retention.
I also spoke with Jeremy Heyer, who has received services from home care workers for over 20 years. He told me he believes the union has helped to elevate the profession and improve perceptions of PCAs by policymakers. Prior to unionization, he felt the state viewed these jobs as low-wage work that anyone could do.
He said he believes this has created more interest in becoming a home care worker and elevated the quality of the workers.
He also described how SEIU includes clients as part of their feedback processes, to ensure the concerns and priorities of both workers and those receiving care are considered.
When the law was debated in 2013, one of the concerns regarding unionizing PCAs was the cost; that it would drive up the cost of the program and the state budget.
Not surprisingly, given the wage increases noted above, costs have gone up.
The monthly MA payment per PCA enrollee has almost doubled since unionization, increasing from $1,948/month in 2013 to $3,740/month in 2025. This is the best proxy measure of the union contract’s impact on the state’s PCA spending.
But this increase is not an outlier; it is in line with growth in other home and community-based services in Minnesota over the past 12 years.
And that brings us full circle: The reason all these services cost more is because they are labor-intensive, and in a tightening labor market you need to pay more to get the same level of service.
And now we have to factor in how the Trump administration’s targeting of immigrants — mainstays in these jobs for decades — will exacerbate the shortage.
The rising cost of disability services was on the legislative agenda in 2025, but no action was taken. And, federal cuts to Medicaid make the budget issue urgent.
But there is no clear solution. If we want to support seniors and people with disabilities and help them live in the community instead of in institutions, we need workers to do it. The days of relying on a plentiful supply of caring people that would work for low wages are gone. Which is a good thing.
In the past, PCAs might have been overlooked in this debate. Now, I expect they will be at the table, providing a voice for those who do the hard work that makes home and community services possible — as well as for the people they care for.
