Impact Feature Issue on Direct Support Workforce Development

The Health and Higher Education of Direct Support Workers


William Ebenstein is University Dean for Health and Human Services, and Director of the JFK Jr. Institute for Worker Education, City University of New York.

The developmental disabilities field needs to develop a more comprehensive approach to the frontline workforce, an approach that encompasses wages, health insurance, and educational benefits. Low salaries have barely kept pace with inflation while higher health care costs continue to erode modest incomes. Access to higher education is the only true way to professionalize the workforce and gain a measure of economic security for dedicated, competent staff.

Health Insurance

With funding for community agencies limited by reimbursement rates, it is inevitable that the need for modest wage increases will conflict with efforts to contain health costs. Health expenditures have increased dramatically and a growing share of agency operating budgets is going toward health coverage. Responses, although expedient, may be counterproductive. Wages are stagnant, while increases in health costs are passed along as higher premiums. Inferior plans are offered, with less coverage, more out-of-pocket expenses, and longer waiting periods for new employees. Fewer direct support workers are able to afford health coverage even if eligible.

Increasingly, agencies are replacing full-time workers with part-timers or contract employees who are not eligible for health benefits. In addition, more are shifting the health insurance burden to public insurance by expanding “opt-out” bonuses to Medicaid-eligible workers, resulting in a further erosion of the employer-sponsored system. Some workers are even turning down higher paying promotional opportunities to maintain their income eligibility for public insurance. At the same time, there is evidence that employer-provided health insurance is an important factor in recruiting and retaining frontline staff. Increased job tenure has been reported at agencies that have higher rates of employer-sponsored health coverage, and at agencies that spend more per worker for health coverage. Also, turnover may increase if quitting a job does not result in the loss of health benefits. In surveys, many workers say that employer-sponsored health insurance is an important factor in their decision to take or keep a job. Many employers believe that insurance coverage enhances employee health, morale, and productivity. Thus the value of employer-provided insurance for the health of an organization far exceeds its direct cost.

Higher Education

Educational benefits that provide access to higher education and opportunities for career advancement must be part of the effort to strengthen the workforce. The new service paradigm requires an educated workforce with increased responsibility, more autonomy, knowledge about the disability field, a strong value base, and critical thinking and communication skills. Many agencies now require some college or even a degree for the most challenging direct support positions. For example, of the almost 2,000 direct support staff employed by the YAI/National Institute for People with Disabilities, a large non-profit provider in New York, more than half have at least an associate’s degree, and over 40% hold a bachelor’s degree. To support this trend more employers are providing partial tuition assistance and/or paid educational release time. Creative collaborations with public colleges have leveraged additional resources. Compared to non-credit trainings, educational attainment based on college credits and degrees is recognized nationally, portable to other employers, transferable to other colleges, and linked to promotions and higher earnings.

Disability Studies is an emerging multidisciplinary area of study that has gained acceptance within academia. This dynamic field is rooted in the Disability Rights Movement and starts with the premise that the perspectives and experiences of people with disabilities are central. Increasingly it is playing a role in the graduate education and daily practice of clinicians, teachers and other professionals. Many University Centers for Excellence in Developmental Disabilities are now offering certificate or degree programs in Disability Studies. It is equally important that frontline staff becomes familiar with the core knowledge and shared values inherent in this approach and that it informs their daily practice. Enhancing access to college, and linking Disability Studies coursework to career ladder opportunities, can transform the culture of our field. The incorporation of Disability Studies within higher education, at both the undergraduate and graduate level, is the key to professionalizing the frontline workforce.


The problems facing low-wage workers in our field are similar to those confronting workers in related health and human services occupations. We need to forge an alliance with other stakeholders, including representatives of the long-term care field and organized labor, in the effort to provide a living wage, offer decent health benefits, and expand access to higher education. All these elements must be in play to achieve a stable, well-educated, professional frontline workforce.