The need for long -term services and supports (LTSS) is dire. By 2050, 27 million Americans will depend on LTSS, more than doubling the need for these services since 2000. Nationwide, hundreds of thousands of older adults and people with disabilities are on wait lists to access home-based services, which are otherwise often unaffordable.

Compounding this problem, the sector faces a workforce shortage which has only been exacerbated by the COVID-19 pandemic. It’s expected that there will be 7.4 million job openings for direct care workers — home health aides, hospice workers, nursing home workers and others — due to growth and turnover by 2029. In no small part, this shift is due to the job’s precarity: unpredictable hours and low compensation, made all the more stressful by pandemic conditions.

This precarity is not accidental: Paid care was provided by slave labor, and later, the labor of an exploited class of domestic servants. Today, 86% of care workers are women and 59% are people of color nationwide. Our existing LTSS system has been built on the backs of these women, and care workers have been fighting to be included in basic worker protections and rights ever since. The national average wage is $13.56 per hour for this workforce, putting safe and affordable housing out of reach for over a third of workers. There can be no healthy LTSS system, or true freedom for these workers, without a fundamental shift in their compensation and agency in their work.

Worker cooperatives lead the way

Worker cooperatives can lead the way towards a healthy, sustainable LTSS system. For example, the largest worker cooperative in the nation, the Bronx-based Cooperative Home Care Associates (CHCA), provides workers training and ownership of their work. While the national turnover rate before the pandemic was above 60% annually, CHCA’s cooperative model kept their turnover rate far lower — at around 20%. By investing in its workforce, CHCA is a model for improving care quality. Converting existing businesses to cooperatives, and launching new cooperatives, can help proliferate this successful model.

We must also address the issue at the heart of the LTSS crisis: how we pay for it. Medicaid is the sector’s largest funder, and there is clearly a lack of resources for care services. As the demand for LTSS grows, states and the federal government simply cannot provide enough funding through general revenue for clients to access essential services and workers to earn decent wages.

For the majority of families who do not qualify for Medicaid, the out-of-pocket costs are unaffordable. For clients, households bear the cost of care themselves until they meet income and asset thresholds to qualify for services through Medicaid. Middle-class and working-class families find themselves drained of wealth they had hoped to pass down to future generations. For unpaid family caregivers who take care of friends or family members, care comes with significant economic stress. The majority of unpaid caregivers are women, whose careers are often stymied by care obligations. According to AARP, families provided $470 billion in unpaid care in 2017, which has generational implications.

Mel King Fellows Program

Addressing these issues will require an overhaul of the LTSS system, which demands the expertise of practitioners, longtime advocates, labor representatives and novel thinkers in the financial sector. At MIT’s Community Innovators Lab, or CoLab, we are honored to announce our 2022-2024 Mel King Fellows Program. We are convening a group of 18 leaders in the field who represent 1 million workers, billions of dollars in capital, and work in deep partnership with hundreds of organizations. As we bypass the two years mark since the beginning of the pandemic, we are urgently looking to create a society that is safe and just — for workers, clients and their families.

Through the fellowship, we will endeavor to transform the current system, by investing in workers and cooperatives, and devising strategies to create dedicated public revenue to finance LTSS. We will also support Fellows in achieving the policy priorities that can make an immediate impact in the sector. In New York, our Fellows are working to pass the Fair Pay for Home Care bill, while in California, our Fellows are leading the Time for $20 campaign. These short-term campaigns will improve living standards and reduce workforce shortages, but solving the problems in the LTSS sector will require systemic change. In the long-term, we will be working to invest in worker-owned cooperatives in the care sector, and building models for a sustainable financing system of care that works for everyone.

MIT CoLab’s Centering Equity in Long-Term Care Class of the Mel King Community Fellows Program will support these leaders to fight for a future where care is accessible, affordable and justly compensated. Follow along with our efforts and reach out to learn more.

Yorman Nunez is the director of the Just Urban Economies (JUE) program at MIT CoLab, a center for planning and development within the Department of Urban Studies and Planning. CoLab connects local stakeholders throughout the Americas with resources at MIT to legitimize local knowledge and advance economic development approaches that are socially just, environmentally sustainable, and deeply democratic. As the director for JUE, Yorman manages CoLab’s domestic projects and is responsible for co-developing the strategies and principles that guide them.  He is a co-founder of the Bronx Cooperative Development Initiative.

Grant Williams is a workforce and economic development specialist, with a Master’s in City Planning from MIT. In addition to co-leading two Mel King Community Fellowship cohorts with MIT CoLab, he has served as a Policy Analyst at City Hall in NYC and worked as a community economic development practitioner in Brooklyn, NY.