Dive Brief:

• Black women are more widely represented in healthcare than any other demographic group, but are disproportionately concentrated in some of the industry's most dangerous and lowest wage jobs, according to a new study published in Health Affairs.
• More than one in five of all working Black women are employed in the healthcare sector. Among this group, Black women are most likely to work in the long-term care sector (37%) or in licensed practical nurse or aide occupations (42%), researchers found. By comparison, White women in the healthcare workforce have only a 25% predicted probability of working in long-term care.
• The U.S.'s historical legacies of racism and sexism have shaped the employment trajectories of Black women, dating back to how care work was divided in slavery and domestic service, researchers said. The findings stress the need for policy and institutional changes, such as raising wages for low-paying healthcare jobs, providing pathways for career advancement and addressing racism in the professional pipeline, according to the study.

Dive Insight:

COVID-19 shone a spotlight on racial disparities in healthcare access and outcomes, leading numerous hospitals and healthcare companies to commit to reducing inequalities in the workplace and President Joe Biden to make health equity a key prong of his health policy agenda. However, racism's long-standing impact on the makeup of the healthcare workforce — and subsequent gendered and racialized divisions of care — are more difficult to quantify and address, though it's widely known that low-wage jobs are dominated by women who are Black, Indigenous and persons of color.

The new study, which relies on data from the American Community Survey, aims to explore racism at a macro level and argues structural racism in the labor market is linked to historical legacies of slavery and domestic service, which continue to shape the makeup of the healthcare workforce today.

"Care work is a critical arena in which Black women are located at the intersection of racism and sexism," researchers Janette Dill, an associate professor in the University of Minnesota's health policy division, and Mignon Duffy, a sociology professor at the University of Massachusetts Lowell, said in the study.

Before the Industrial Revolution, the majority of caretaking occurred inside private homes. Most was performed by women, with the most menial housework like scrubbing floors or washing laundry left to slaves and domestic servants, which is still to this day ideologically associated with women who were Black 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," creating patterns that continued even as the economic and social makeup of the U.S. evolved and care work moved into institutional settings, the researchers said.

That resulted in women of color remaining concentrated in the most physically demanding direct care jobs, like nursing aides, licensed practical nurses or home health aides.

The study found Black women make up 6.9% of the U.S. labor force, yet 13.7% of the healthcare workforce — a rate of representation that's roughly double. They're heavily concentrated in long-term care, making up 23% of the long-term care workforce compared with 12% of hospital and 9.6% of ambulatory care workers.

By comparison, White women are more evenly distributed among settings within health are, making up nearly 41% of long-term care workers, 47% of hospital workers and about 49% of ambulatory care workers.

Within healthcare, Black women make up almost one-fourth of all licensed practical nurses and aides. That includes nursing assistants in hospitals and long-term care settings, along with home health aides and personal care workers in private homes. They're also overrepresented at lower levels among community or behavioral health workers (11.8%), registered nurses (10.2%), technicians (9.4%) and therapists (8.1%).

White women are more heavily concentrated among registered nurses (61%) and therapists (56%), and are slightly underrepresented among licensed practical nurses and aides (40%) compared to their overall representation among healthcare jobs.

As a result, Black women have a much higher predicted probability of working in more difficult occupational categories compared to men and women in different racial and ethnic groups, researchers modeled.

"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 researchers said. The overrepresentation continued when researchers controlled for other variables like education, marital status, age or immigration status.

The high probability that Black female healthcare workers will land in these roles exacerbates existing income inequalities — and presents them with difficult and potentially dangerous working conditions, they found.

According to the Department of Labor, the median annual wage for healthcare practitioners and technical occupations, such as registered nurses or physicians, was almost $70,000 in 2020. That's higher than the median annual wage of $42,000 for all other occupations in the economy. However, healthcare support occupations, such as home health aides, had a median annual wage of just $30,000.

And though overall healthcare workers have the highest rates of workplace-related injuries of any other U.S. industry, research has shown nurse aides and nurses are much more likely to experience workplace-related injuries or stress compared to other medical workers.

Dill and Duffy suggested a range of policy changes to help ameliorate the impact of racism, including raising workers' wages, opening up opportunities for upward career mobility such as training programs and instituting programs to directly address racism in the pipeline.

"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," the researchers said.