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In mid-April 2020, as Covid-19 shutdowns and lockdowns were being put in place across the U.S., my grandmother’s health started to decline. With so many unknowns, the assisted living facility where she lived, like most others, had a strict no-visitors policy. When it became clear that my grandmother was in her last hours of life, the facility figured out how to safely allow my aunt into the building for my grandmother’s last breaths.

When my aunt arrived, certified nursing assistants were there, providing comfort and care throughout my grandmother’s passing. At the time, doctors and nurses were being lauded as heroes. CNAs didn’t get that acclaim, though they should have.


Under the supervision of registered nurses, certified nursing assistants provide care in individuals’ homes, nursing homes, subacute/rehab centers, assisted living facilities, and a variety of other settings. Their work is both physically and emotionally taxing. They are responsible for helping their patients with activities of daily living like eating, bathing and grooming, lifting and moving them, making beds, and cleaning living spaces, as well as communicating their patients’ needs to their health care teams and families.

Certified nurse assistants also provide their patients with companionship during difficult and lonely times.

Despite all that they do, CNAs they are not well paid. According to the Bureau of Labor Statistics, the median hourly rate for a certified nursing assistant is $14.83 but, in some states, they make less than $10 an hour. That’s less than many Starbucks or McDonald’s workers are paid.


Most of this undervalued workforce is comprised of women and people of color. The U.S. Census Bureau says women consist of nearly 90% of the nursing assistant workforce. A report by PHI, a nonprofit organization working to improve long-term care services and job quality for direct-care workers, estimates that people of color make up the majority of the nursing assistant workforce, even though they make up one-quarter of the total U.S. workforce. More than one-third of these workers are Black or African American.

Improving job quality for the direct-care workforce is also a matter of racial and gender equity.

Not only are certified nursing assistants underpaid, but they must also spend money before they can earn it. To be certified, they are required to participate in a state-approved training program that can cost anywhere from $400 to $3,000 for a federally mandated minimum of 75 hours (though some states require more) — with limited information about the success rates of these programs — and they must also pay for the cost of final state exams, ranging from $80 to $105.

I recently had the opportunity to work on a team exploring the challenges facing the certified nursing assistant workforce in Massachusetts and across the country as part of the Project on Workforce, a collaborative project between Harvard’s Kennedy School, Business School, and Graduate School of Education. Our team found that only nine states and the District of Columbia offered public information about the average pass rate for the written and clinical test in 2019. In other words, many individuals are assuming the costs of required certification programs with limited knowledge about whether the state-approved training program they enroll in will properly prepare them for the state CNA certification exams and ultimately lead to a return on their investment.

These barriers to entry are at odds with the shortage of health care staff, including certified nursing assistants, in long-term care facilities and for in-home care across the U.S. Many people assume that the shortage is a result of the Covid-19 pandemic. That’s not so: the pandemic only intensified an already-existing shortage of health care staff in long-term care.

Improving working conditions and wages for certified nursing assistants is not only the right thing to do, but smart public policy. Given that Medicaid is the top funding source for nursing homes and other long-term care facilities, increasing Medicaid funding with an appropriated portion for increasing wages of nursing assistants and other lower-paid health care workers can help support these integral health care staff members and address workforce retainment. In addition, states could design CNA tenure and promotion programs, like the recently implemented Illinois CNA Subsidy/Incentive Program, which provides certified nursing assistants with wage increases based on their years of experience, to help keep wages competitive and create career pathways.

Some Americans don’t know what certified nursing assistants do, or why they are needed. Others know it all too well. I often hear people say that, given the low pay, nursing assistants must truly care about helping others and that “it is a calling.” Whether it is a calling or not, these essential workers have bills to pay and families to support. As the minimum wage in many states across the country increases, wages for CNAs need to stay competitive. If an individual can make the same or more money in another industry, with a less strenuous and emotionally taxing position, there is little incentive to join the CNA work force, or stay in it.

I will forever be thankful to the certified nursing assistants who cared for my grandmother during her last few days of life. As an important element of the U.S. health care system, these essential health care workers need to be treated with the same dignity and respect with which they treat our loved ones. We can start by paying them a living wage.

Toni Gingerelli is a public policy advisor and consultant specializing in workforce development, health, and gender equity. She formerly served as chief of staff for New Jersey State Senator Vin Gopal.

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