Structural Racism And Black Women’s Employment In The US Health Care Sector

The COVID-19 pandemic has brought heightened attention to racial disparities in health outcomes as infections, hospitalizations, and deaths have had a disproportionate impact on Black populations, Indigenous populations, and populations of people of color.¹ In this article we focus on an aspect of racism and health that has gotten somewhat less attention: the role of racism in the stratification of the health care workforce. Specifically, we build on the insights of interdisciplinary scholarship about the gendered and racialized division of care to examine the unique role of Black women in health care. We argue that structural racism in the labor market, linked to historical legacies of slavery and domestic service, has had a strong impact on shaping the health care workforce.

The stratification of the health care workforce and the concentration of women who are Black, Indigenous, and people of color in low-wage health care jobs is well established.^2–5 Scholars have also found that women of color in caregiving jobs often experience discriminatory treatment and racist abuse from both employers and care recipients.^6,7 Our goal here is to broaden the focus beyond individual exposure to racism and discrimination to explore the role of racism at a macro level. Structural racism is defined as structuring opportunity and assigning value based on race, unfairly disadvantaging some individuals and communities and advantaging others.^8,9 Structural racism can only be understood by reference to historical processes, and we look to the history of care to understand contemporary patterns.

Scholars of care define care broadly to include the paid and unpaid labor of caring for people who are young, old, ill, or disabled.^4,10,11 Before the Industrial Revolution, most of this work happened in private homes.⁴ Using an intersectional framework that focuses on gender and race, it becomes clear that not only was most care work performed by women, but also racialized ideologies undergirded a division between what Dorothy Roberts has called “spiritual” and “menial” housework.¹² The spiritual side, dominated by White women of privilege, was work that was considered to require moral character and relational skills: serving as hostess, supervisor of the daily work, or a role model for children. In contrast, the most strenuous and unpleasant tasks (scrubbing floors and washing laundry, caring for the bodily needs of household members, and preparing and cleaning up after meals) were thought to require little or no skill. This menial labor was relegated to slaves and domestic servants and was ideologically associated with women who were Black, Indigenous, and people of color. The legacy of slavery and the high numbers of Black women among domestic servants placed Black women at the center of this culturally constructed division of care. These gendered and racialized ideologies were buttressed by an exclusionary labor market that relegated Black women to a small number of jobs, including domestic work (along with farm work and marginal factory jobs).¹³

Historical studies have shown important continuities in these gendered and racialized patterns as the economy transformed in the twentieth century.^4,14 The expanding service sector, along with the rise of modern medicine, shifted the nature of care work and moved much of it out of private homes and into institutional settings,³ yet paid care work is still overwhelmingly performed by women. White women are disproportionately represented in jobs with supervisory capacity, a public relational element, and some degree of moral authority (registered nurse, teacher, or social worker).^3,4,15 Women of color are concentrated in the most physically demanding direct care jobs (nursing aide, licensed practical nurse, or home health aide), along with the “back-room” jobs of cleaning and food preparation in hospitals, schools, and nursing homes.^16–18

In this article we use this intersectional lens and historical perspective to examine the role of racism in the position of Black women in the contemporary health care sector. We begin by using labor-force data to describe the occupational roles of Black women relative to other groups in health care. We then use multivariate modeling to examine whether these patterns can be explained by differences in education levels or other variables to tease out the role that exclusionary practices and racialized cultural constructions of care have played in shaping Black women’s role in health care.

Study Data And Methods

We used data from the American Community Survey to analyze the probability of Black women working in occupations and sectors within the health care industry. This is an annual nationally representative survey conducted by the Census Bureau. We used data from 2019, which is the latest IPUMS USA data available.¹⁹ The analytical sample ($N$ = 1,127,595) includes respondents ages 18–65 who are part of the labor force.¹⁹ For our second and third sets of analyses, we limited our sample to men and women who work in the health care industry ($n$ = 125,880).¹⁹

Measurement

Our goal in this study was to measure the percentage of Black women working in the health care sector and identify where they are located within the health care workforce in comparison with men and women in other racial and ethnic groups. All employment codes are based on US census industry and occupation codes. Our first dependent variable indicates whether a person is employed in the health care industry. Our second set of dependent variables indicates whether a person works in a hospital, ambulatory care, or long-term care. Our third set of dependent variables indicates the occupational category in which a person works.¹⁶

Our primary independent variable is a ten-category measure that reflects both gender and race and ethnicity. The ten mutually exclusive categories are Black non-Hispanic women, White non-Hispanic women, Hispanic women, Asian non-Hispanic women, other non-Hispanic women, Black non-Hispanic men, White non-Hispanic men, Hispanic men, Asian non-Hispanic men, and other non-Hispanic men. More information about this and all other variables is available on the IPUMS USA website.¹⁹

To explore the potentially distinct labor-market trajectories of different groups of Black women, we examined variation in employment in the health care sector across three groups: women who identify as US-born Black, those who identify as biracial US-born Black and another race or ethnicity, and Black women who are foreign born. We also examined Black Hispanic women separately, but the sample size was too small to draw any conclusions.

In the multivariate models, we include a series of control variables that may be associated with occupational choice, to better isolate the direct impact of race. Additional demographic variables that we included as controls in the analyses are whether a person was born outside of the US (scored as 1), was married (1), or had a child under age eighteen in the household (1), and age and age squared (to account for a nonlinear relationship). Educational level was included as a categorical variable: high school graduate or less (scored as 0), some college (but no degree) (1), associate’s degree (1), or a four-year college degree or more (1). We included education in all analyses except for models predicting employment in health care occupations where educational requirements are such that there is not sufficient variation in education level. We indicated whether a person lived in a metro area (scored as 0), a rural area (1), or an area that is both rural and metro (1), as well as the geographic region—Northeast (0), South (1), Midwest (1), and West (1). The analyses were weighted using the variable PERWT.

Analyses

To measure the percentage of Black women working in health care and where they are located within the sector, we ran a series of logit models. First, we used logit models to estimate the odds of working in the health care sector and then calculated the predicted probability of men and women of different racial and ethnic groups working in health care. Second, we used the same procedure to calculate predicted probabilities for working in hospital, ambulatory, or long-term care settings (among health care workers only). Finally, we used logit models to measure the odds of working in different occupational categories in the health care industry and then calculated the predicted probabilities for working in different occupational categories (among health care workers only). We included the residuals from our first model as predictors in our subsequent sets of analyses to control for whether selection into the health care sector may inform selection into a health care setting or occupation. All statistical analyses were conducted using Stata 17.

Limitations

Our sample in this study included only one year of data, and we were constrained by the coding of race and ethnicity as well as industry and occupation as presented in the American Community Survey. We could not directly measure structural racism, which is an institutional and not an individual characteristic, so we made conceptual links to historical patterns instead of formally modeling a causal relationship.

Study Results

Descriptive Statistics

As shown in exhibit 1, Black women make up 6.9 percent of the labor force in the US and 13.7 percent of the health care workforce—a rate of overrepresentation that is about double. In comparison, White women are overrepresented in the health care sector at a rate of about 1.6 times their representation in the labor force. Black women are heavily concentrated in long-term care, making up 23.0 percent of the long-term care workforce compared with 12.1 percent of hospital and 9.6 percent of ambulatory care workers. White women are more evenly distributed among settings within health care, making up 40.8 percent of long-term care workers, 47.2 percent of hospital workers, and 48.6 percent of workers in ambulatory care.

Within health care, Black women make up 24.9 percent of licensed practical nurses and aides—a very high proportion that is consistent with their overrepresentation in long-term care settings. Note that this category of aides includes nursing assistants in hospitals and long-term care settings as well as home health aides and personal care attendants who work in private homes. They are also overrepresented at lower levels among community or behavioral health workers (11.8 percent), registered nurses (10.2 percent), technicians (9.4 percent), and therapists (8.1 percent). In comparison, White women are most heavily concentrated among registered nurses (61.3 percent) and therapists (56.1 percent) and are slightly underrepresented among licensed practical nurses and aides (39.8 percent) compared with their representation in the health care industry.

This overrepresentation of Black women translates into health care being a key employer for Black women. Overall, more than one in five Black women in the labor force (22.4 percent) are employed in the health care sector. Of these, 64.7 percent are in licensed practical nurse or aide occupations, and 40.0 percent work in long-term care (see online appendix exhibit 1).²⁰ There is some variation: 20.1 percent of US-born Black women, 17.0 percent of biracial Black women, and 34.2 percent of foreign-born Black women work in the health care sector (appendix exhibit 2).²⁰ The variation across groups of Black women indicates that more marginalized Black women, including immigrants and those who do not identify as biracial (and may have darker skin), are more likely to be employed in the health care sector. Past research has shown that colorism affects workers’ experiences in the labor market and may constrain their occupational choices.²¹ In the analyses described below, we categorized all of these groups together as Black women, but the variation in experiences within this group demonstrates the complexity of racialized stratification.

Employment In Health Care

Exhibit 2 shows the predicted probability of working in the health care sector across men and women in different racial and ethnic groups (in these results, racial groups are assumed to be non-Hispanic unless otherwise specified). The logit model used to calculate these predicted probabilities is in appendix exhibit 3.²⁰ The results show that Black women have a higher probability of working in the health care sector (23 percent) compared with all other groups. White, Hispanic, and Asian women, as well as women who identify as another race or ethnicity, all have a predicted probability of working in the health care sector of around 16–17 percent, whereas men in all racial and ethnic groups are far less likely to work in health care (ranging from 4 to 8 percent).

SOURCE American Community Survey, IPUMS USA 2019. NOTES Models used for predicting the probability of working in the health care industry in exhibit 2 are in appendix exhibit 3 (see note 20 in text), where results of significance tests are also displayed. Racial groups are non-Hispanic.

Employment By Setting

Exhibit 3 shows the predicted probability of working in hospital, ambulatory care, and long-term care settings across men and women in different racial and ethnic groups. The logit models used to calculate these predicted probabilities are in appendix exhibit 4.²⁰ These analyses were restricted to health care workers only. We found that Black women have a predicted probability of 37 percent of working in long-term care, 34 percent of working in a hospital setting, and 27 percent of working in an ambulatory care setting. Black women are more likely than any other group to be employed in long-term care and are the only group for which the predicted probability of working in long-term care is higher than in other settings. For example, White women have a predicted probability of 42 percent of working in an ambulatory care setting and 33 percent of working in a hospital setting, and only a 25 percent predicted probability of working in long-term care.

SOURCE American Community Survey, IPUMS USA 2019. NOTES Models used for predicting the probability of working in the health care industry in exhibit 3 are in appendix exhibit 4 (see note 20 in text), where results of significance tests are also displayed. Racial groups are non-Hispanic.

Employment By Occupational Category

Exhibit 4 shows the predicted probability of working in different occupational categories, again across men and women in different racial and ethnic groups. The logit models used to calculate these predicted probabilities are in appendix exhibit 5.²⁰

Within the health care workforce, Black women have a much higher predicted probability of being a licensed practical nurse or aide (42 percent) compared with all other groups. The predicted probability of working as a licensed practical nurse or aide is 33 percent for Hispanic women, 32 percent for Asian women, 31 percent for women who identify as another race or ethnicity, and 29 percent for White women. Black women are less likely to be registered nurses (13 percent) compared with White women (24 percent), Asian women (26 percent), and women who are another race or ethnicity (19 percent). The predicted probability of Black women in the health care workforce working as physicians is 1 percent; advanced practitioners, 2 percent; therapists, 2 percent; technicians, 2 percent; and community or behavioral health workers, 5 percent.

Sensitivity Tests

We conducted a series of sensitivity tests related to unemployment among health care workers, predicting employment in licensed practical nurse and aide occupations separately, rather than combined, as well as selection into the health care industry and health care occupations. These tests are in appendix exhibits 7–12.²⁰

Discussion

The Legacy Of Racism

Although occupational segregation in the labor market by gender and race and ethnicity is a well-studied phenomenon, our findings highlight a number of new dimensions that add to the understanding of racism in the health care sector. First, we have used an explicitly intersectional approach to demonstrate that Black women’s experiences in the health care labor force are unique. Black women are more overrepresented in health care and more concentrated in the lowest-wage direct care jobs (licensed practical nurse and aide occupations) than any other racial or ethnic group of women (and all men). Second, we have shown that this overrepresentation persists when we control for a range of other variables that may explain occupational choice, providing some evidence that occupational channeling at the intersections of race and gender cannot be fully explained by correlations with education, marital status, age, or immigration status.

Finally, we have argued that bringing in the perspective of care scholarship helps illuminate the continuities between the current position of Black women in health care and the historical gendered and racialized division between “spiritual” and “menial” care labor.^3,4,12 Black women work overwhelmingly in the health care jobs that have been constructed as menial, or the “dirty work” of care—direct care for older, disabled, and ill bodies and bodily functions. This is a modern-day incarnation of the division of labor in private homes identified by scholars of slavery and domestic service and is built on the same interplay of structural exclusion and cultural association. Black women faced exclusion from medical schools and nursing training as these occupations became professionalized and White women activists carved out the niche of trained nursing by focusing rhetorically on the moral and spiritual caring aspects of the job.²² Discriminatory exclusion was not outlawed until the 1960s,²² and as with many aspects of racism, the legacy of that discrimination as well as the associated stereotypes are not easily undone.

Low Wages, High Risk

The parts of the sector in which Black women are concentrated are characterized by low wages, lack of benefits, and hazardous working conditions.

Although the health care industry includes a wide range of jobs, the parts of the sector in which Black women are concentrated are characterized by low wages, lack of benefits, and hazardous working conditions. The mean hourly wage in 2019 for home care workers was $12.12, residential care workers earned average wages of $12.69 per hour, and nursing assistants in nursing homes earned $13.90 per hour.²³ Low incomes lead to high poverty among long-term care workers: One in six home care workers live below the federal poverty level, and nearly half live in low-income households.²³ Among Black and Hispanic female direct care workers specifically, about 50 percent earn less than $15 per hour.²

Direct care workers also face difficult and dangerous working conditions. Overall, health care workers have the highest rates of workplace-related injuries of any industry in the United States.²⁴ Within the workforce, nurse aides and nurses are much more likely to experience workplace-related injuries and stress compared with other health care workers.²⁵ In addition to being exposed to biological agents such as viruses, direct care workers are exposed to heavy lifting of equipment and patients, physical and verbal assault, and a range of high-stress conditions including long hours and night shift work.²⁶ Black women are more likely to work in those nursing homes and other long-term care settings that are most understaffed and underresourced, leading to greater risk and exposure to injury or infection.^27,28 During the early stages of the COVID-19 pandemic, workers in long-term care facilities were said to have the “most dangerous jobs in America.”²⁹ In sum, Black women not only are overrepresented in health care but also are working in the hardest, most dangerous, and most underpaid parts of the sector.

Policy Implications

The challenge is to create policy to address the impacts of racism in the health care workforce. We suggest three related strategies: raising the floor for low-wage workers, building career ladders within the sector, and addressing racism in the pipeline.

Raising The Floor

First, policy is needed to raise wages in the direct care jobs of the health care sector where workers are currently most grossly underpaid. This should start with a federal minimum wage increase that is inclusive of all workers (in the United States, as in many other countries, workers who work in private homes have often been excluded from fair labor legislation). A recent study estimated that increasing the minimum wage to $15 would result in a reduction of household poverty rates among female health care workers by up to 27 percent.² Many long-term care facilities and home health care programs in the US are funded by federal and state governments through Medicaid and other programs. To ensure that wage increases do not further exacerbate staffing shortages, the rate at which facilities are reimbursed for patient care in these programs must also be adjusted accordingly and designated specifically to be passed through to workers. Increasing wage levels is a critical component of reimagining health care workforce policies to prioritize social justice and to actively combat racism in health care.⁵

Building Career Ladders

Another strategy for improving racial equity is to build career ladders within health care organizations. Because Black women are so overrepresented in the sector, opening up opportunities for mobility within health care is a key way to combat racist occupational exclusion.³⁰ Career ladders that make meaningful change within an organization identify pathways or tracks for workers’ advancement.³¹ These pathways may involve helping workers locate a training program that will lead to career advancement, such as completing a middle-wage health care credential.³² Nursing career ladders also consistently provide substantial upward mobility for workers in the lower levels of the hierarchy, such as nursing assistants.³³ Health care organizations can and should support access to higher education by partnering with community colleges to create tuition remission arrangements, on-site classes, and flexible scheduling to accommodate coursework.³⁴

Addressing Racism In The Pipeline

We have argued that the ideologies and stereotypes that channel Black women into direct care jobs and the long-term care sector have deep roots in historical patterns of exclusion and cultural constructions of care work. Undoing this will take a focused effort to directly address these biases in conjunction with the strategies outlined above. Just as there are programs in elementary and middle schools to challenge gender norms and promote girls’ interest in science, technology, engineering, and mathematics fields, career exploration opportunities are needed for all students that demonstrate the full range of jobs that are open to them. It is also important to challenge the feminization of care and the racialized association of certain jobs with “menial”—and therefore less valuable—labor. Training programs for health care leaders and managers should directly address racism and sexism in the sector, and health care organizations should create equity and inclusion plans that focus not only on patients but also on the workforce.

Conclusion

Care work is a critical arena in which Black women are located at the intersection of racism and sexism.

Care work is a critical arena in which Black women are located at the intersection of racism and sexism. Black women are overrepresented in health care at higher rates than any other group and are heavily concentrated in low-wage jobs in the long-term care sector and in hospitals. Investing in Black women through targeted investment in care infrastructure can begin to undermine some of the ideological constructions and structural barriers that have devalued both.

ACKNOWLEDGMENTS

Support was provided by the National Institute on Aging (Grant No. P30AG066613 to Phyllis Moen). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The authors thank Odichinma Akosionu J’Mag Karbeah, Chandra Waring, and Caitlin Carrol. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/.

NOTES

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