Health Professionals

By Janette Dill and Mignon Duffy

doi: 10.1377/hlthaff.2021.01400

Structural Racism And Black

HEALTH AFFAIRS 41,
NO. 2 (2022): 265–272
This open access article is
distributed in accordance with the

Women’s Employment In The US terms of the Creative Commons

Attribution (CC BY 4.0) license.

Health Care Sector

Janette Dill (dill0221@umn

ABSTRACT The objective of this study was to describe how structural .edu), University of Minnesota,
Minneapolis, Minnesota.
racism and sexism shape the employment trajectories of Black women in
the US health care system. Using data from the American Community Mignon Duffy, University of
Survey, we found that Black women are more overrepresented than any Massachusetts Lowell, Lowell,
Massachusetts.
other demographic group in health care and are heavily concentrated in
some of its lowest-wage and most hazardous jobs. More than one in five
Black women in the labor force (23 percent) are employed in the health
care sector, and among this group, Black women have the highest
probability of working in the long-term-care sector (37 percent) and in
licensed practical nurse or aide occupations (42 percent). Our findings
link Black women’s position in the labor force to the historical legacies
of sexism and racism, dating back to the division of care work in slavery
and domestic service. Our policy recommendations include raising wages
across the low-wage end of the sector, providing accessible career ladders
to allow workers in low-wage health care to advance, and addressing
racism in the pipeline of health care professions.

T
he COVID-19 pandemic has
brought heightened attention to ra-
cial disparities in health outcomes
as infections, hospitalizations, and
deaths have had a disproportionate
impact on Black populations, Indigenous popu-
lations, 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 caregiv-
ing jobs often experience discriminatory treat-
ment 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 struc-
turing 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 ref-
erence 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 hap-
pened in private homes.4 Using an intersectional
framework that focuses on gender and race, it

F e b r u a ry 2 0 2 2 41:2 H e a lt h A f fai r s 265

Health Professionals
becomes clear that not only was most care work
performed by women, but also racialized ideolo-
gies undergirded a division between what
Dorothy Roberts has called “spiritual” and “me-
nial” housework.12 The spiritual side, dominated
by White women of privilege, was work that was
considered to require moral character and rela-
tional skills: serving as hostess, supervisor of the
daily work, or a role model for children. In con-
trast, 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 serv-
ants and was ideologically associated with wom-
en 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 con-
structed division of care. These gendered and
racialized ideologies were buttressed by an ex-
clusionary labor market that relegated Black
women to a small number of jobs, including do-
mestic work (along with farm work and marginal
factory jobs).13
Historical studies have shown important con-
tinuities in these gendered and racialized pat-
terns as the economy transformed in the twenti-
eth 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 set-
tings,3 yet paid care work is still overwhelmingly
performed by women. White women are dispro-
portionately represented in jobs with superviso-
ry 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, li-
censed 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 occupa-
tional 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 exclu-
sionary practices and racialized cultural con-
structions of care have played in shaping Black
women’s role in health care.
266 Health A ffairs F eb r u a ry 2 0 2 2 41:2
The parts of the
sector in which Black
women are
concentrated are
characterized by low
wages, lack of
benefits, and
hazardous working
conditions.
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 work-
ing 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 occupation-
al 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 wom-
en, Black non-Hispanic men, White non-Hispan-
ic men, Hispanic men, Asian non-Hispanic men,
and other non-Hispanic men. More information
about this and all other variables is available on

Care work is a critical
arena in which Black
women are located at
the intersection of
racism and sexism.
the IPUMS USA website.19
To explore the potentially distinct labor-mar-
ket trajectories of different groups of Black wom-
en, we examined variation in employment in the
health care sector across three groups: women
who identify as US-born Black, those who iden-
tify 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 varia-
bles 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 em-
ployment in health care occupations where edu-
cational requirements are such that there is not
sufficient variation in education level. We indi-
cated 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 geo-
graphic region—Northeast (0), South (1), Mid-
west (1), and West (1). The analyses were weight-
ed 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 esti-
mate the odds of working in the health care sec-
tor 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 prob-
abilities 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 occu-
pational 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 con-
ducted 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 indus-
try and occupation as presented in the American
Community Survey. We could not directly mea-
sure 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 concentrat-
ed 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 am-
bulatory 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 representa-
February 2022 41:2 Health Affa irs 267
Health Professionals

Exhibit 1

Health care industry and occupational distribution in the US, by gender, race, and ethnicity, 2019
Women (%) Men (%)
Categories Black White Hispanic Asian Other Black White Hispanic Asian Other
Full labor force 6.9 28.3 8.1 3.1 1.1 6.1 31.8 10.1 3.3 1.2
Health care 13.7a 46.2 10.6 5.1 1.7 3.4 13.1 3.1 2.5 0.5
Settings
Hospital 12.1 47.2 8.6 6.1 1.5 3.8 13.8 3.4 3.0 0.6
Ambulatory care 9.6 48.6 11.8 4.7 1.7 2.4 15.1 3.1 2.7 0.6
Long-term care 23.0b 40.8 12.1 4.3 1.9 4.5 9.1 2.5 1.5 0.4
Occupations
Physicians 3.2 22.9 2.6 9.8b 1.0 2.8 39.4 4.4 12.5b 1.3
APs 4.2 46.0 3.9 7.7a 1.3 1.5 26.9 2.3 5.5 0.7
RNs 10.2 61.3a 6.6 7.7a 1.7 1.5 7.6 1.4 1.9 0.3
Therapists 8.1 56.1 8.5 3.1 1.6 2.6 14.1 2.9 2.6 0.5
Techs 9.4 54.6 9.4 6.3a 1.3 2.6 9.6 2.8 3.4 0.6
LPNs/aides 24.9b 39.8 16.5a 4.7 1.9 3.4 4.8 2.4 1.3 0.4
Community/
behavioralc 11.8 48.3 8.9 3.0 1.9 4.4 16.4 3.2 1.6 0.5

SOURCE American Community Survey, IPUMS USA 2019. NOTES Racial groups are non-Hispanic. AP is advanced practitioner. RN is
registered nurse. LPN is licensed practical nurse. aRepresentation levels between two and three times that in the labor force.
b
Representation levels more than three times that in the labor force. cCommunity or behavioral health.

tion 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 la-
bor 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 ra-
cialized 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 re-
sults, racial groups are assumed to be non-
Hispanic unless otherwise specified). The logit
model used to calculate these predicted proba-
bilities 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 ra-
cial and ethnic groups are far less likely to work
in health care (ranging from 4 to 8 percent).
Employment By Setting Exhibit 3 shows the
predicted probability of working in hospital, am-
bulatory 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 exhib-
it 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 work-
ing in a hospital setting, and 27 percent of work-
ing in an ambulatory care setting. Black women
are more likely than any other group to be em-
ployed 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 am-
bulatory care setting and 33 percent of working
in a hospital setting, and only a 25 percent pre-
dicted probability of working in long-term care.
Employment By Occupational Category
Exhibit 4 shows the predicted probability of
working in different occupational categories,
again across men and women in different racial

268 H e a lt h A f fai r s February 2022 41:2

 Exhibit 2
Predicted probability of working in the US health care sector, by gender, race, and ethnicity, 2019
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.
and ethnic groups. The logit models used to cal-
culate these predicted probabilities are in appen-
dix exhibit 5.20
Within the health care workforce, Black wom-
en have a much higher predicted probability of
being a licensed practical nurse or aide (42 per-
cent) compared with all other groups. The pre-
dicted probability of working as a licensed prac-
tical nurse or aide is 33 percent for Hispanic
women, 32 percent for Asian women, 31 percent
for women who identify as another race or eth-
nicity, 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 per-
cent). The predicted probability of Black women
in the health care workforce working as physi-
cians is 1 percent; advanced practitioners, 2 per-
cent; therapists, 2 percent; technicians, 2 per-
cent; 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 se-
lection 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 dimen-
sions that add to the understanding of racism in
the health care sector. First, we have used an
explicitly intersectional approach to demon-
strate 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 occupa-
tions) 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 ev-
idence that occupational channeling at the inter-
sections of race and gender cannot be fully ex-
plained 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 “spiri-
tual” 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
F e b r u a ry 2 0 2 2 41:2 Health Affairs 269
 Health Professionals

Exhibit 3 work” of care—direct care for older, disabled,

and ill bodies and bodily functions. This is a
Predicted probability of working in specific US health care industry settings, among health
care workers only, by gender, race, and ethnicity, 2019
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 as-
sociation. 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 Discrim-
inatory exclusion was not outlawed until the
1960s,22 and as with many aspects of racism, the
legacy of that discrimination as well as the asso-
ciated stereotypes are not easily undone.
Low Wages, High Risk 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 condi-
tions. The mean hourly wage in 2019 for home
care workers was $12.12, residential care work-
ers 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 pov-
erty among long-term care workers: One in six
home care workers live below the federal poverty
level, and nearly half live in low-income house-
holds.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 dan-
SOURCE American Community Survey, IPUMS USA 2019. NOTES Models used for predicting the prob-
gerous working conditions. Overall, health care
ability 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. workers have the highest rates of workplace-
related injuries of any industry in the United
States.24 Within the workforce, nurse aides and
Exhibit 4 nurses are much more likely to experience work-
place-related injuries and stress compared with
Predicted probability of specific US health care occupations among health care workers other health care workers.25 In addition to being
only, by gender, race, and ethnicity, 2019 exposed to biological agents such as viruses, di-
LPNs/ Community/ rect care workers are exposed to heavy lifting of
Physicians APs RNs Therapists Techs aides behaviorala equipment and patients, physical and verbal as-
Women sault, and a range of high-stress conditions in-
Black 1.0% 1.7% 13.1% 2.1% 2.1% 41.5% 5.1% cluding long hours and night shift work.26 Black
White 2.3 5.3 23.6 3.5 3.2 28.5 5.0 women are more likely to work in those nursing
Hispanic 1.1 2.0 11.1 2.8 2.5 32.8 5.4 homes and other long-term care settings that are
Asian 6.4 7.7 25.6 1.9 3.2 32.1 2.8 most understaffed and underresourced, leading
Other 3.0 4.5 19.0 2.9 1.8 30.9 5.9
to greater risk and exposure to injury or infec-
Men
tion.27,28 During the early stages of the COVID-19
Black 3.3 2.4 7.7 2.7 2.2 22.7 6.4
pandemic, workers in long-term care facilities
White 12.6 10.4 10.1 2.5 2.0 14.5 4.2
Hispanic 6.1 3.9 8.2 2.6 2.9 18.0 5.7
were said to have the “most dangerous jobs in
Asian 16.6 10.8 12.4 2.1 4.5 20.8 2.2 America.”29 In sum, Black women not only are
Other 10.6 6.6 9.9 2.3 3.5 18.8 4.1 overrepresented in health care but also are work-
ing in the hardest, most dangerous, and most
underpaid parts of the sector.
SOURCE American Community Survey, IPUMS USA 2019. NOTES Models used for predicting the
probability of working in the health care industry are in appendix exhibit 5 (see note 20 in text), where
results of significance tests are also displayed. Racial groups are non-Hispanic. AP is advanced
practitioner. RN is registered nurse. LPN is licensed practical nurse. aCommunity or behavioral health.

270 Health A ffairs F e b r u a ry 2 0 2 2 41:2

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 lad-
ders 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 in-
creasing 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 lev-
els 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. Be-
cause Black women are so overrepresented in
the sector, opening up opportunities for mobili-
ty 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’ advance-
ment.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 substan-
tial upward mobility for workers in the lower
levels of the hierarchy, such as nursing assis-
tants.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 cour-
sework.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 his-
torical patterns of exclusion and cultural con-
structions 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 ex-
ploration opportunities are needed for all stu-
dents that demonstrate the full range of jobs that
are open to them. It is also important to chal-
lenge the feminization of care and the racialized
association of certain jobs with “menial”—and
therefore less valuable—labor. Training pro-
grams 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 wom-
en 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. Inves-
ting in Black women through targeted invest-
ment in care infrastructure can begin to under-
mine some of the ideological constructions and
structural barriers that have devalued both. ▪

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/.

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Health Professionals
NOTES
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from: https://www.cdc.gov/corona
virus/2019-ncov/cases-updates/
cases-in-us.html
2 Himmelstein KEW, Venkataramani
AS. Economic vulnerability among
US female health care workers: po-
tential impact of a $15-per-hour
minimum wage. Am J Public Health.
2019;109(2):198–205.
3 Glenn EN. Forced to care: coercion
and caregiving in America.
Cambridge (MA): Harvard Universi-
ty Press; 2010.
4 Duffy M. Making care count: a cen-
tury of gender, race, and paid care
work. New Brunswick (NJ): Rutgers
University Press; 2011.
5 Hess C, Hegewisch A. The future of
care work: improving the quality of
America’s fastest-growing jobs [In-
ternet]. Washington (DC): Institute
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APPENDIX

Appendix Exhibit 1. Black women’s representation in health care

% of Black women
Health care industry 22.4%
Non-health care industry 77.6%
Total 100%
Hospital 33.9%
Health care workforce only

Ambulatory care 26.1%

Long-term care 40.0%
Total 100.0%
Physicians 1.5%
Advanced practitioners (not RNs) 2.3%
RNs (including APs) 19.1%
Therapists 2.6%
Techs 3.1%
LPNs/aides 64.7%
Community and behavioral health 6.7%
Total 100.0%
Data source: IPUMS-USA (2019)

Appendix Exhibit 1 shows how Black women are distributed across the health care sector and health care
occupations. Around 22% of Black women work in the health care industry, while 78% of Black women work in
non-health care jobs. Forty percent of Black women who are health care workers work in long-term care.
Almost 65% of Black women who are health care workers are employed as LPNs or Aides. In contrast, Exhibit 1
in the main manuscript shows what percent of an occupation is composed by each racial-ethnic group. Exhibit
1 shows that 25% of LPNs/Aides are Black.

Appendix Exhibit 2. Black women’s representation in health care, by group

Health care
Non-health care industry
Black US-born 79.3% 20.1%
Biracial Black 83.0% 17.0%
Black foreign-born 65.8% 34.2%
Data source: IPUMS-USA (2019)
Appendix Exhibit 3. Logit models predicting employment in the health care industry
Odds Ratio (SE)
Gender and race-ethnicity
Black women Ref Ref
White women 0.711*** (0.008)
Hispanic women 0.712*** (0.011)
Asian women 0.710*** (0.014)
Other women 0.697*** (0.018)
Black men 0.248*** (0.005)
White men 0.162*** (0.002)
Hispanic men 0.159*** (0.003)
Asian men 0.322*** (0.008)
Other men 0.204*** (0.008)
Demographic variables
Not US born 0.911*** (0.010)
Married 1.058*** (0.008)
Child(ren) under 18 in household 1.124*** (0.008)
Age 1.032*** (0.002)
Age squared 1.000*** (2.18e-05)
Education
High school or less Ref Ref
Some college 1.408*** (0.012)
Associate degree 2.885*** (0.028)
College degree or more 2.330*** (0.022)
Geographic location
Metro area Ref Ref
Rural 1.121*** (0.012)
Mixed rural and metro 1.104*** (0.010)
Northeast Ref Ref
Midwest 0.959*** (0.009)
South 0.850*** (0.008)
West 0.782*** (0.008)
Constant 0.0928*** (0.004)
R 2

Observations 1,127,595
* p<0.05, ** p<0.01, *** p<0.001
Data source: IPUMS-USA (2019)
Appendix Exhibit 4. Logit models predicting employment in hospitals, ambulatory care, or long-
term care
Ambulatory Long-term
Hospitals care care
Odds Ratio Odds Ratio Odds Ratio
(SE) (SE) (SE)
Gender and race-ethnicity
Black women Ref Ref Ref
White women 0.968 2.011*** 0.499***
(0.028) (0.061) (0.0151)
Hispanic women 0.927** 2.088*** 0.507***
(0.034) (0.076) (0.0196)
Asian women 1.338*** 1.521*** 0.493***
(0.062) (0.073) (0.0273)
Other women 0.964 1.639*** 0.667***
(0.071) (0.113) (0.0541)
Black men 1.694*** 0.913 0.639***
(0.093) (0.055) (0.0377)
White men 1.136*** 1.825*** 0.444***
(0.039) (0.064) (0.0173)
Hispanic men 1.582*** 1.515*** 0.397***
(0.084) (0.082) (0.0258)
Asian men 1.471*** 1.606*** 0.373***
(0.087) (0.094) (0.0307)
Other men 1.251** 1.744*** 0.446***
(0.132) (0.184) (0.0590)
Demographic variables
Not US born 0.902*** 0.775*** 1.590***
(0.024) (0.020) (0.0475)
Married 1.097*** 1.174*** 0.721***
(0.020) (0.021) (0.0152)
Child(ren) under 18 in household 0.895*** 0.996 1.138***
(0.016) (0.018) (0.0247)
Age 1.023*** 1.012** 0.962***
(0.005) (0.005) (0.00560)
Age squared 1.000*** 1.000*** 1.000***
(0.000) (0.000) (0.000)
Education
High school or less Ref Ref Ref
Some college 1.326*** 1.331*** 0.599***
(0.032) (0.031) (0.0140)
Associate degree 2.236*** 1.169*** 0.365***
(0.056) (0.030) (0.0101)
College degree or more 1.857*** 2.173*** 0.132***
(0.046) (0.052) (0.00441)
Geographic location
Metro Ref Ref Ref
Rural 0.972 0.649*** 1.780***
 (0.028) (0.019) (0.0552)
Mixed rural and metro 0.959* 0.727*** 1.595***
(0.024) (0.018) (0.0445)
Northeast Ref Ref Ref
Midwest 1.020 1.016 0.963
(0.026) (0.025) (0.0276)
South 0.952** 1.373*** 0.709***
(0.021) (0.031) (0.0188)
West 0.917*** 1.458*** 0.670***
(0.023) (0.036) (0.0207)
Residuals for Model 1 0.977*** 1.023*** 0.975***
(0.005) (0.005) (0.00633)
Constant 0.209*** 0.404*** 1.465***
(0.021) (0.040) (0.165)
Observations 125,880 125,880 125,880
* p<0.05, ** p<0.01, *** p<0.001
Data source: IPUMS-USA (2019)
Appendix Exhibit 5. Logit models predicting employment in health care occupational categories
Advanced
Physicians practitioners RNs Therapists Technicians LPNs/Aides Community
Odds Ratio Odds Ratio Odds Ratio Odds Ratio Odds Ratio Odds Ratio Odds Ratio
(SE) (SE) (SE) (SE) (SE) (SE) (SE)
Gender and race-ethnicity
Black women Ref Ref Ref Ref Ref Ref Ref
White women 2.873*** 3.417*** 1.939*** 1.751*** 1.569*** 0.488*** 0.958
(0.304) (0.327) (0.092) (0.179) (0.154) (0.015) (0.066)
Hispanic women 1.078 1.009 0.775*** 1.445*** 1.215* 0.618*** 1.085
(0.147) (0.124) (0.052) (0.177) (0.142) (0.024) (0.093)
Asian women 9.641*** 5.838*** 1.575*** 0.936 1.570*** 0.594*** 0.538***
(1.125) (0.647) (0.118) (0.147) (0.219) (0.035) (0.071)
Other women 3.137*** 2.762*** 1.496*** 1.547** 0.872 0.548*** 1.222
(0.530) (0.473) (0.167) (0.322) (0.185) (0.044) (0.169)
Black men 3.409*** 1.462** 0.544*** 1.428** 1.061 0.332*** 1.333**
(0.511) (0.252) (0.062) (0.249) (0.188) (0.021) (0.155)
White men 15.32*** 7.549*** 0.762*** 1.430*** 0.952 0.182*** 0.895
(1.560) (0.726) (0.045) (0.168) (0.119) (0.008) (0.075)
Hispanic men 5.986*** 2.251*** 0.658*** 1.439** 1.410** 0.238*** 1.211
(0.742) (0.321) (0.073) (0.237) (0.233) (0.016) (0.152)
Asian men 26.06*** 7.485*** 0.679*** 1.094 2.270*** 0.293*** 0.421***
(3.011) (0.901) (0.078) (0.211) (0.396) (0.026) (0.074)
Other men 11.48*** 4.412*** 0.911 1.302 1.688 0.246*** 0.869
(1.895) (0.796) (0.205) (0.528) (0.605) (0.034) (0.184)
Demographic variables
Not US born 1.376*** 0.794*** 1.008 0.750*** 0.857* 1.719*** 0.664***
(0.070) (0.044) (0.044) (0.057) (0.069) (0.054) (0.041)
Married 2.176*** 1.935*** 1.331*** 1.140*** 1.259*** 0.761*** 1.011
(0.083) (0.070) (0.036) (0.056) (0.065) (0.016) (0.042)
Child(ren) under 18 in household 0.838*** 0.823*** 1.098*** 0.886*** 0.904* 1.081*** 0.923**
(0.028) (0.027) (0.028) (0.041) (0.047) (0.024) (0.036)
Age 1.176*** 1.133*** 1.098*** 0.989 0.989 0.957*** 1.134***
(0.012) (0.011) (0.008) (0.014) (0.014) (0.006) (0.014)
Age squared 0.998*** 0.998*** 0.999*** 1.000 1.000 1.000*** 0.999***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Education 1.376*** 0.794*** 1.008 0.750*** 0.857* 1.719*** 0.664***
High school or less -- -- -- Ref Ref Ref Ref
Some college -- -- -- 1.267** 1.770*** 1.035 1.466***
(0.136) (0.138) (0.024) (0.096)
Associate degree -- -- -- 6.330*** 3.290*** 0.360*** 1.341***
(0.598) (0.238) (0.010) (0.097)
College degree or more -- -- -- 5.567*** 0.586*** 0.040*** 4.124***
(0.550) (0.054) (0.002) (0.265)
 Geographic location 1.267** 1.770***
Metro Ref Ref Ref Ref Ref Ref Ref
Rural 0.383*** 0.545*** 1.103** 1.023 0.886 1.367*** 0.938
(0.030) (0.034) (0.042) (0.078) (0.080) (0.044) (0.061)
Mixed rural and metro 0.353*** 0.583*** 0.988 0.935 0.769*** 1.312*** 0.987
(0.023) (0.031) (0.034) (0.062) (0.057) (0.038) (0.056)
Northeast Ref Ref Ref Ref Ref Ref Ref
Midwest 0.870*** 0.837*** 1.156*** 1.098 1.080 0.917*** 0.832***
(0.042) (0.040) (0.042) (0.073) (0.081) (0.028) (0.045)
South 1.016 0.941 1.348*** 1.304*** 1.290*** 0.795*** 0.816***
(0.043) (0.040) (0.044) (0.077) (0.087) (0.022) (0.041)
West 0.750*** 0.975 1.067* 1.258*** 1.096 0.881*** 1.016
(0.035) (0.044) (0.040) (0.083) (0.085) (0.028) (0.053)
Residuals from Model 1 1.147*** 1.045*** 0.972*** 0.924*** 1.011 1.024*** 0.950***
(0.010) (0.010) (0.007) (0.012) (0.015) (0.007) (0.010)
Constant 0.000** 0.002*** 0.008*** 0.011*** 0.015*** 5.418*** 0.002***
(0.000) (0.000) (0.001) (0.003) (0.005) (0.630) (0.001)
Observations 125,880 125,880 125,880 125,880 125,880 125,880 125,880

* p<0.05, ** p<0.01, *** p<0.001

Data source: IPUMS-USA (2019)
Notes: We include 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.
Appendix Exhibit 6. Logit models predicting employment in the health
care industry, without control variables
Odds Ratio (SE)
Gender and race-ethnicity
Black women Ref
White women 0.777***
(0.010)
Hispanic women 0.598***
(0.010)
Asian women 0.801***
(0.015)
Other women 0.699***
(0.022)
Black men 0.230***
(0.006)
White men 0.169***
(0.003)
Hispanic men 0.122***
(0.003)
Asian men 0.332***
(0.008)
Other men 0.189***
(0.009)
Constant 0.289***
(0.003)
Observations 1,472,672
* p<0.05, ** p<0.01, *** p<0.001
Data source: IPUMS-USA (2019)
Appendix Exhibit 7. Percentage of workers in the health care industry that are currently
unemployed, by gender and race-ethnicity
Percent of full
Frequency
sample
Black women 470 2.8%
White women 1,476 1.5%
Hispanic women 330 2.1%
Asian women 119 1.2%
Other women 83 2.7%
Black men 132 3.1%
White men 388 1.5%
Hispanic men 89 2.0%
Asian men 42 0.9%
Other men 24 2.4%
Total 3,153 1.7%
Appendix Exhibit 8. Logit model predicting employment in the health care industry, excluding
workers who are currently unemployed
Odds Ratio (SE)
Gender and race-ethnicity
Black women Ref Ref
White women 0.663*** (0.010)
Hispanic women 0.632*** (0.012)
Asian women 0.629*** (0.016)
Other women 0.654*** (0.023)
Black men 0.223*** (0.007)
White men 0.111*** (0.002)
Hispanic men 0.126*** (0.003)
Asian men 0.273*** (0.008)
Other men 0.171*** (0.009)
Demographic variables
Not US born 0.978 (0.013)
Married 1.013 (0.010)
Child(ren) under 18 in household 1.117*** (0.011)
Age 1.026*** (0.003)
Age squared 1.000*** (0.000)
Education
High school or less Ref Ref
Some college 1.504*** (0.018)
Associate degree 2.856*** (0.038)
College degree or more 2.335*** (0.030)
Geographic location
Metro area Ref Ref
Rural 1.166*** (0.018)
Mixed rural and metro 1.129*** (0.015)
Northeast 0.861*** (0.012)
Midwest
South 0.762*** (0.009)
West 0.742*** (0.010)
Constant 0.123*** (0.007)
Observations 1,076,441
* p<0.05, ** p<0.01, *** p<0.001
Data source: IPUMS-USA (2019)
Appendix Exhibit 9. Gender and race-ethnicity representation in LPN and Aide
occupations
% of Black women
Health care industry 22.4%
Physicians 1.5%
Advanced practitioners (not RNs) 2.3%
RNs (including Aps) 19.0%
Therapists 2.5%
Techs 3.1%
Licensed practical nurses (LPNs) 8.8%
Aides 56.3%
Community and behavioral health 6.6%
Total 100%
Data source: IPUMS-USA (2019)
Appendix Exhibit 10. Logit model predicting employment in the LPN and Aide occupational
categories
LPN Aide
Odds Ratio Odds Ratio
Gender and race-ethnicity
Black women Ref Ref
White women 0.793*** 0.504***
(0.047) (0.016)
Hispanic women 0.615*** 0.688***
(0.047) (0.027)
Asian women 0.890 0.613***
(0.108) (0.037)
Other women 0.627*** 0.609***
(0.100) (0.050)
Black men 0.557*** 0.364***
(0.077) (0.024)
White men 0.359*** 0.203***
(0.035) (0.010)
Hispanic men 0.404*** 0.271***
(0.061) (0.019)
Asian men 0.770 0.298***
(0.145) (0.028)
Other men 0.455*** 0.275***
(0.134) (0.040)
Demographic variables
Not US born 1.057 1.731***
(0.069) (0.055)
Married 1.025 0.740***
(0.045) (0.016)
Child(ren) under 18 in household 1.119** 1.054**
(0.049) (0.024)
Age 1.027** 0.951***
(0.012) (0.010)
Age squared 1.000* 1.000***
(0.000) (0.000)
Education
High school or less Ref Ref
Some college 2.606*** 0.815***
(0.137) (0.019)
Associate degree 1.008 0.333***
(0.065) (0.010)
College degree or more 0.043*** 0.044***
(0.009) (0.002)
Geographic location
Metro Ref Ref
Rural 1.385*** 1.278***
(0.087) (0.0436)
 Mixed rural and metro 1.360*** 1.224***
(0.073) (0.0374)
Northeast Ref Ref
Midwest 0.859** 0.950
(0.054) (0.0302)
South 1.004 0.781***
(0.055) (0.0225)
West 0.782*** 0.929**
(0.052) (0.0300)
Pearson residual 1.045*** 1.014**
(0.0152) (0.00732)
Constant 0.024*** 5.377***
(0.006) (0.646)
Observations 125,880 125,880
* p<0.05, ** p<0.01, *** p<0.001
Data source: IPUMS-USA (2019)
Appendix Exhibit 11. Predicted probability of working in a health care occupation
Community
and
Thera- LPNs/ behavioral
Physicians APs RNs pists Techs Aides health
Full sample of adults in the labor market
Black women 0.3% 0.6% 3.6% 0.6% 0.5% 13.8% 2.1%
White women 0.5% 1.3% 4.7% 1.0% 0.6% 6.5% 1.4%
Hispanic women 0.2% 0.4% 2.0% 0.7% 0.5% 7.1% 1.9%
Asian women 1.4% 2.2% 5.5% 0.7% 0.7% 7.4% 0.8%
Other women 0.6% 1.0% 3.7% 0.8% 0.4% 7.2% 2.0%
Black men 0.3% 0.2% 0.6% 0.3% 0.2% 2.1% 1.1%
White men 0.7% 0.6% 0.5% 0.2% 0.1% 0.7% 0.5%
Hispanic men 0.2% 0.2% 0.3% 0.2% 0.2% 0.8% 0.6%
Asian men 1.6% 1.4% 1.2% 0.3% 0.5% 1.9% 0.4%
Other men 0.8% 0.5% 0.7% 0.2% 0.3% 1.2% 0.6%
Sample restricted to workers in the health care industry only
Black women 1.0% 1.7% 13.1% 2.1% 2.1% 41.5% 5.1%
White women 2.3% 5.3% 23.6% 3.5% 3.2% 28.5% 5.0%
Hispanic women 1.1% 2.0% 11.1% 2.8% 2.5% 32.8% 5.4%
Asian women 6.4% 7.7% 25.6% 1.9% 3.2% 32.1% 2.8%
Other women 3.0% 4.5% 19.0% 2.9% 1.8% 30.9% 5.9%
Black men 3.3% 2.4% 7.7% 2.7% 2.2% 22.7% 6.4%
White men 12.6% 10.4% 10.1% 2.5% 2.0% 14.5% 4.2%
Hispanic men 6.1% 3.9% 8.2% 2.6% 2.9% 18.0% 5.7%
Asian men 16.6% 10.8% 12.4% 2.1% 4.5% 20.8% 2.2%
Other men 10.6% 6.6% 9.9% 2.3% 3.5% 18.8% 4.1%
Data source: IPUMS-USA (2019)
 To explore how selection into the health care industry may influence the distribution of workers in
health care occupations, we include the predicted probability of working in a health care occupation among a
full sample of adults in the labor market as well as a restricted sample of adults that work in the health care
industry (shown in Exhibit 11). Among women, the patterns of predicted probability of working in a health
care occupation in the full sample of workers are similar to the patterns found among the sample that is
restricted to workers in the health care industry only. When we look at the aide/LPN occupational category,
which is the primary occupational category of focus in this paper, we find similar patterns in both samples.
Among the full unrestricted sample, Black women have a 13.8% probability of working as an aide or LPN, while
white women have a 6.5% probability, indicating that Black women are about 2.1 times as likely as a white
woman to work as an aide or LPN. Among health care workers only, Black women have a 42% probability of
working as an aide or LPN, while white women have a 29% probability, indicating that Black women are about
1.4 times as likely as white women to work as an aide or LPN. In both samples, we see racialized patterns of
employment in the aide and LPN occupational category.
Notably the probability of being an RN is more evenly distributed among racial-ethnic groups in the full
unrestricted sample (for example, 3.6% of Black women and 4.7% of white women are RNs), whereas in the
health care worker sample, white women have a much higher probability of being an RN as compared to Black
women (24% as compared to 13%, respectively). For men, we see far greater variability in the predicted
probability of working in a health care occupation among the full unrestricted sample and the sample of
health care workers only, largely because men are far less likely than women to work in the health care sector
and in a health care occupation.
To further explore how education may interact with race-ethnicity in terms of who selects into the
LPN/aide occupational category, we calculated the predicted probability of working as an aide/LPN among
workers with high school degree or some college (shown in Exhibit 12). We find that Black women with a high
school degree or some college have a predicted probability of working as an aide or LPN/aide of 16.4%, while
women in all other racial-ethnic groups have a predicted probability of 8-8.7%. Our findings show that Black
women with a high school degree or some college are more than twice as likely to work as an aide or LPN as
their counterparts in other racial-ethnic groups. This indicates that the selection of Black women into the
LPN/aide occupational category is operating independently of education.

Appendix Exhibit 12. Predicted probability of working as an LPN/aide among workers with high
school degree or some college
Black women 16.4%
White women 8.0%
Hispanic women 8.2%
Asian women 8.7%
Other women 8.6%
Black men 2.3%
White men 0.8%
Hispanic men 0.9%
Asian men 2.3%
Other men 1.3%
Data source: IPUMS-USA (2019)
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