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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Soc Sci Med. 2022 May 5;303:115000. doi: 10.1016/j.socscimed.2022.115000

Professional certification and earnings of health care workers in low social closure occupations

Janette Dill a,*, Jennifer Craft Morgan b, Jane Van Heuvelen c, Meredith Gingold d
PMCID: PMC10156129  NIHMSID: NIHMS1894395  PMID: 35544997

Abstract

There has been rapid growth in professional certifications in the health care sector, but little is known about the rewards to workers for attaining professional certifications, especially in low social closure occupations where the barriers to entry (e.g., higher education, degrees, licensure) are relatively limited. In this study, we focus on the attainment and rewards for professional certifications in four health care occupations – personal care aides, medical transcriptionists, medical assistants, and community health workers – where certification is generally not required by state or federal regulation but may be attractive to employers. Using the Current Population Survey (IPUMS CPS) from 2015 to 2020, we find that workers of color have significantly lower odds of attaining a certification, while women are 1.2 times more likely than men to an earn a certification. On average, workers who have earned a professional certification have weekly earnings that are 4.8% higher than workers who do not have a certification. Men experience the largest increase in weekly earnings (11.3%) when they have a professional certification as compared to those without, while women experience lower gains from professional certification (3.8%). Black and Hispanic workers experience modest rewards for certification (weekly earnings that are 1.2% and 5% higher, respectively) that are lower than the rewards gained by white workers (6% higher weekly earnings). Our findings suggest that professional certifications may have modest benefits for workers, but professional certifications often come with significant costs for individuals. Strategies for reducing inequality in the return to credentials and for improving job quality in the care sector are discussed.

Keywords: Direct care work, Health care workforce, Certification, Training, Unions

There has been rapid growth in credentialism in all sectors over the last several decades, with the health care sector leading the way in the percentage of workers who hold occupational credentials (Cunningham, 2019; Kleiner and Krueger, 2013). While historically credentialing has been required of workers with a college degree or associate degree (e.g., registered nurses, physicians, pharmacists, etc.) (Friedman et al., 2014), increasingly credentials are required of workers without a college degree. Professional trade organizations, seeking greater power and higher wages for members, have been quick to develop and require credentials, as well as organizations who seek workers with standardized skills (Carter, 2005). However, little is known about the rewards of professional certification for workers, especially for workers who have lower levels of education and work in unlicensed occupations (Albert, 2017).

The current study investigates the rewards of professional certification for health care workers in occupations where a certification is generally not required by state scope of practice regulations but may be valued by employers. We have chosen to focus on four health care occupations: personal care aides, medical transcriptionists, medical assistants, and community health workers. In each of these occupations, workers can choose to complete a variety of professional certificates. This certification system is embedded not in the formal education system, but rather trade, industry, and professional associations that offer occupational certifications that vouch for an individual’s work-related skills and abilities. While these certifications have some similarities to credentials available in traditional schools and colleges, they often do not require formal coursework and instead rely on competency-based evaluations to determine who earns a credential (Albert, 2017; Carter, 2005).

The occupations of focus in this study - personal care aides, medical transcriptionists, medical assistants, and community health workers – are what we refer to as low social closure occupations. Social closure primarily operates through mechanisms that constrain the labor supply to occupations (Budig et al., 2019; Weeden, 2002), and we identify these occupations as low social closure occupations because the barriers to entry (e.g., higher education, degrees, licensure) are relatively limited. In general, workers in these occupations need a high school degree with potentially some post-secondary training, but typically less than an associate or college degree. While certification may be required by employers for these occupations, certification or licensure are largely not required by states for workers to be employed in these occupations (Association of State and Territorial Health Officials, 2017; Center for Disease Control, 2013; Skillman et al., 2018); personal care aides and medical transcriptionists are not required to have a professional certification in any state, medical assistants are required to have professional certification in four states, and while at least ten states have voluntary state certification processes for community health workers, certification is not required for employment for community health workers in any state.

The movement towards state and professional credential requirements may benefit some workers in low social closure occupations in terms of wages, but credentialing may have racialized and gendered consequences for the most vulnerable groups due to structural barriers to training and education (Department of the Treasury Office of Economics et al., 2015; Dill and Morgan, 2018). Credentialing requires that individuals invest resources in training and education, but little is known about the attainment and rewards for professional certification in low social closure health care occupations and how rewards are gendered and racialized. In this study, we use the Current Population Survey (IPUMS CPS) to first examine which workers are more likely to earn professional certification and if any gender and racial-ethnic differences exist. We then measure the relationship between professional certification and wages among workers in low social closure health care occupations. As a comparison to certification, we also examine the relationship between wages and unionization, which is another form of social closure in the workplace (Rosenfeld, 2014; Rosenfeld and Denice, 2019; Weeden, 2002).

1. Literature review

Occupational credentialing has long been used in the health care sector to establish professional boundaries and knowledge jurisdiction (Abbott, 2014; Freidson, 1988), but these requirements have traditionally been in place for more highly skilled workers (e.g., physicians, registered nurses, pharmacists). However, there is an increasing expectation within the health care sector that workers will earn and maintain occupational credentials, even at the lowest levels (Carter, 2005; Ducey, 2009; Nancarrow and Borthwick, 2005).

This study focuses on sub-baccalaureate certificates that workers can earn but are not required for employment in the health care sector. Certifications are credentials that demonstrate a level of skill or knowledge needed to perform a specific type of job. The fundamental difference between a license and a certification is that licenses convey a legal authority to work in an occupation, while a certification on its own does not (Cunningham, 2019). Individual employers may require certification for hire in the occupations that are included in this study (personal care aides, medical transcriptionists, medical assistants, and community health workers), but state and federal regulations largely do not require workers to have a certification to be employed. The certifications earned by personal care aides, medical transcriptionists, medical assistants, and community health workers are available through professional trade organizations and the state, and while workers may be required to complete some training to be eligible to take a certification exam, workers typically do not earn a degree (or even college credit, in many cases) when completing a certificate. We have included descriptions of types of professional certifications for the occupations in our sample in Table 1.

Table 1.

Examples of professional certifications across low social closure occupations.

Occupation Examples of typical credentials Criteria for completion Type of award
Personal Care Aides Certified Nursing Assistant (CNA) 75–120 h of training; state-based competency exam Most are state-based
Medical Transcriptionists Registered Medical Transcriptionist (RMT)
Certified Medical Transcriptionist (CMT)
Registered Healthcare Documentation Specialists (RHDS)
Certified Healthcare Documentation Specialist (CHDS)		 Up to four semesters and an associate degree; for some credentials experience can be substituted for coursework
All require an exam and exam fee		 Occupation-based associations & testing bodies
Medical Assistants Certified Medical Assistant (CMA)
Registered Medical Assistant (RMA)
National Certified Medical Assistant (NCMA)
Certified Clinical Medical Assistants (CCMA)		 Up to two semesters of college-level content All require an exam and exam fee Occupation-based associations & testing bodies
Community Health Workers Certified Community Health Worker (CCHW)
Certified Health Education Specialist (CHES)		 24 h-160 h of training and experience; competency exam in at least ten states Most are state-based with completion of training required to achieve credential; grandfathering of those with work experience
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Another form of social closure in the workplace is unionization, which we draw on as a comparison to credentialing. With unionization, state-sanctioned collective bargaining and the threat of the withdrawal of labor, the defining features of union organization, fundamentally alter the conditions of employment (Weeden, 2002). Occupations performed by workers without a college degree have historically relied on unionization to raise wages and improve job quality (Brady et al., 2013; Mishel, 2012). However, as rates of unionization have fallen in the US, occupational credential requirements have risen dramatically; more workers today are impacted by occupational regulatory requirements than unionization (Kleiner and Krueger, 2010). Credentialing is the “new unionization” to the extent that occupational trade associations and workforce development organizations adopt credentials as a social closure strategy to limit entry into an occupation and raise wages. However, unlike unionization, the responsibility for obtaining credentials largely falls on individuals (Halpin and Smith, 2017). Unions are associated with improved job quality and higher wages, particularly in low-skill occupations (Brady et al., 2013; Card, 2001; VanHeuvelen and Brady, 2021; Western and Rosenfeld, 2011); in this study, we will directly compare wage differentials associated with unionization as compared to professional certification.

The rewards for professional certification among health care workers in occupations with low social closure.

Low social closure health care occupations are disproportionately filled by women and women of color, and the expectations of credentialing have significant implications for these workers and job quality in female-dominated occupations (Duffy, 2011; Glenn, 2010). Gender and racial inequalities disproportionately affect large segments of workers in low social closure health care occupations, and racist and sexist assumptions have long been evoked to devalue the work performed by health care workers in low social closure occupations, denying them basic protections and transformative job improvements that would help counteract generations of discrimination (Dill et al., 2020; Duffy, 2007; Tronto, 2011). For example, in 2020, median annual earnings personal care workers were $27,080 (U.S. Bureau of Labor Statistics, 2022). While medical assistants and community health workers typically earn higher wages than personal care workers, these are occupations that are also plagued by chronic devaluation and low compensation (Gutiérrez et al., 2021; Skillman et al., 2018). Given the low wages of many low social closure health care occupations, the question of whether credentialing improves compensation within these occupations is essential.

The limited research on the effect of certification on worker wages suggests it is much smaller as compared to licensure (Kleiner and Krueger, 2013). On the other hand, a study by Albert (2017) offers evidence that there is a substantial positive effect of certification for young adult workers. He finds returns for certification are higher than the earnings premia some researchers have associated with credentials earned in the higher education system (Altonji and Mansfield, 2011; Becker, 2009), though such premia are undoubtedly uneven across occupations and employment settings. Within the health care workforce, a recent study of community college students suggests that long-term certificates are associated with wage increases in health care but short-term certificates are not, although certificates offered through community colleges operate somewhat differently than professional certification (Bettinger and Soliz, 2016).

The most relevant study to the current study was recently published by Kim (2020), who examined the relationship between wages and certification or licensure among workers in the occupational category of nurse aides, psychiatric aides, and home health aides. The federal government mandates that nurse aides or home health aides employed by home health agencies or nursing homes whose services are reimbursed by Medicare or Medicaid should receive a minimum of 75 h of training and be certified by demonstrating their competency through evaluation. However, there is variation in certification in the occupation across workers who are employed in settings that are not reimbursed by Medicare or Medicaid, e.g., patients with private insurance. Kim finds that credential-holding was related to higher annual earnings and increased probability of working full-time, year-round, and having access to employer-provided health insurance and retirement savings plans. The positive effects, however, were modest in size.

Case studies of health care organizations have had mixed findings about the value of certification for health care workers in low social closure occupations. In an evaluation of seventeen workforce development programs for health care workers in low social closure occupations, Dill et al. (2019) found that certification – when valued by employers and incorporated in career ladders – can create a pathway for meaningful wage increases and upward mobility. However, occupational credentialing had only a modest impact on worker wages and worker career mobility in most settings (Dill and Morgan, 2018). In an ethnography of low social closure health care workers in New York City, Ducey (2009) is highly critical of workforce development efforts in health care organizations that require health care workers in low social closure occupations to participate in ongoing training and credentialing. This leads them to accumulate many low-level certifications that do little to improve their wages or provide significant upward mobility. Thus, Ducey argues that many workforce development or career programs provide “false promises” of upward social mobility. Ducey’s research suggests credentialing may be exploitive of marginal low-wage workers and may act as a barrier to advancement for low-level health care workers (Glazer, 1991).

Gender and racial differences in attainment of professional certification and rewards for certification.

There is little research on who attains professional certification. In terms of gender, women are more likely to earn associate degrees than men, indicating that they may also be more likely to complete a professional certification (Hanson, 2021). It is unknown if that advantage exists in access to professional certification, and there is some evidence that Black men and women and other groups of color are targeted by for-profit educational organizations, which provide shorter training programs that often result in professional certification (Cottom, 2017).

The evidence regarding gender differences in returns to education is inconclusive. Several studies have shown that gender differences in returns to education vary by field of study; female-typed certifications may be devalued by employers in terms of the job-related skills they signal if those skills are thought to be more naturally endowed to women rather than acquired through education (Ridgeway, 2011; Ridgeway and Correll, 2004). In terms of variation in returns to education by race-ethnicity, a recent study by Budig et al. (2021) found that Black women’s earnings are multiply disadvantaged, both by their lower educational attainment relative to white women, and their lower returns to education relative to all groups studied. Workers who are born outside of the US may also lack resources and opportunities to professional certification and may not be rewarded as highly for professional certification (Batalova and Fix, 2019).

There is a significant need for research on the impact of credentialing on the lives of health care workers in low social closure occupations, which will have important implications for how worker associations, professional societies and policymakers advocate for “good jobs” in today’s economy. The first goal of this paper is to measure which workers are more likely to gain occupational certification, looking closely at gender and race-ethnicity. The second goal of this study is to measure the relationship between weekly earnings and occupational certification, as well as the relationship between weekly earnings and unionization, among health care workers in low social closure occupations. We test for differences in the rewards of certification and unionization across gender and race-ethnicity.

2. Methods

We use the IPUMS Current Population Survey (IPUMS CPS) to analyze the relationship between wages and professional certification (Flood et al., 2020). The CPS is a monthly US household survey conducted jointly by the US Census Bureau and the Bureau of Labor Statistics (BLS). A battery of labor force and demographic questions, known as the “basic monthly survey,” is asked every month. The CPS sample is representative of the civilian, household-based population of the United States. In recent years, each monthly CPS has included about 140,000 individuals living in about 70,000 households. We use data from January 2015, which is when the question about professional certification was added to the CPS, through February 2020.

The analytical sample includes individuals that: 1) were employed as a wage or salaried worker and had wage observations as part of the Outgoing Rotation Earner Study component of the CPS, 2) work full-time, and 3) work in one of the four health care occupations of focus in this study, including personal care aides, medical transcriptionists, medical assistants, or community health workers. The sample includes 5185 workers. Descriptive statistics for the sample are included in Table 2. We separate workers by whether they had 1) no certification and are not a union member, 2) had professional certification, or 3) were a union member or covered by a union contract.

Table 2.

Descriptive statistics.

No certification or union Certification Union
Weekly earnings $634.89 $719.18 $704.17
Health care occupations
 Personal care aides 64.5% 36.3% 69.8%
 Medical transcriptionist 2.7% 0.8% 1.2%
 Medical assistants 28.4% 60.3% 20.6%
 Community health workers 4.4% 2.7% 8.4%
Certification and unionization
 Certification – 100% 32.7%
 Union member – 9.5% 100%
Demographic variables
 Male 12.9% 10.9% 20.2%
 Female 87.1% 89.1% 79.8%
 White 52.2% 59.6% 38.9%
 Black 20.0% 17.1% 21.5%
 Hispanic 19.5% 16.5% 24.6%
 Other race-ethnicity 8.2% 6.8% 15.0%
 Born outside the US 20.1% 15.7% 26.8%
 Age 43.0 41.8 45.4
Degree
 High school or less 46.2% 23.8% 47.0%
 Some college 25.0% 26.5% 24.6%
 Associate degree or less 16.0% 32.6% 12.8%
 College degree 12.8% 17.1% 15.6%
Region
 Northeast 15.8% 17.7% 24.6%
 Midwest 18.4% 18.2% 16.5%
 South 33.0% 31.7% 8.7%
 West 32.9% 32.4% 50.2%
 N 3131 1733 486
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Notes: There are some individuals (n = 159) who are both unionized and have a professional certification. For the descriptive statistics, we have included them in both the certification and union columns.

Data source: IPUMS-CPS (2015–2020)

There were a small number of workers who both belonged to a union and had a professional certification (n = 158), and these workers are included in both columns in Table 2. Workers without a professional certification or union coverage are the largest group, making up about 60% of workers in our sample. Among non-union and non-certificate workers in our sample, 65% are personal care aides, 2.7% are medical transcriptionists, 28% are medical assistants, and 4.4% are community health workers. The average weekly earnings are $634, 87% are women, around 52% are white, 20% are Black, 20% are Hispanic, and 8% identify as another rate. Most workers without professional certification have a high school degree or less (46%).

Workers who have a professional certification earn $719 per week on average. The largest occupation is medical assistants (60%). Around 90% are women, and a higher percentage of workers with professional certification are white (60%) compared to the other groups of workers. A substantial percentage of workers with professional certification have completed some college (27%) or an associate degree (33%).

Workers who are unionized have weekly earnings of $704 on average. The largest occupation is personal care aides (70%). Around 80% of unionized workers are women, and higher percentage of unionized workers belong to a racial-ethnic minority group: 22% are Black, 25% are Hispanic, and 15% are an another race-ethnicity. Most workers who are unionized have a high school degree of less (47%). Descriptive characteristics of workers by occupation, including rates of certification and unionization, are included in Appendix Table 1.

Measurement.

We have two dependent variables. In our first analysis, the dependent variable is the attainment of a professional certification. The CPS indicates whether the respondent has a professional certification or state or industry license; we assume that workers in our sample have earned a professional certification – and not a professional license - because occupations included in the sample do not have licensure requirements. The dependent variable in our second analyses is the natural log of weekly earnings. Weekly earnings are inflation-adjusted to 2020 dollars. To standardize weekly earnings across workers, we only include fulltime workers in our sample and control for hours worked per week in our analyses.

Our key independent variables are mechanisms of social closure. First, we measure whether an individual has a professional certification (1) versus no certification (0). To compare forms of social closure, we also include a variable that indicates whether an individual is a union member (1) or covered by a union contract (0). We also control for the occupation that workers are in, including indicating if a worker is a personal care aides (1), medical transcriptionists (1), medical assistants (0), or community health care workers (1), as there is some variation in wages across occupation. Occupations are based on US Census Occupational Codes.

We include a number of demographic variables in our models, including whether an individual is a women (1) or man (0). The race-ethnicity categories we include are: white (0), Black (1), Hispanic (1), and other racial-ethnic identity (1). We also include whether someone was born outside of the US (1) and age and age squared to account for the non-linearity of age. Educational attainment level is included as a time-varying categorical variable: high school graduate or less (0), some college (but no degree) (1), associate degree (1), or a four-year college degree or more (1). We include education in our model because, while professional certification may be part higher education, it can be completed through a professional trade organization and may not involve formal higher education. We include four geographic regions in our models: the northeast (0), south (1), midwest (1), and west (1). We include dummy variables that indicate the calendar year of data collection (not shown in tables). Finally, all analyses are weighted to ensure that the sample is representative of the US population. Using the IPUMS-CPS data, variables that are part of the Outgoing Rotation Group (Earner Study) are weighted using the variable EARNWT.

Analyses.

This paper includes two sets of analyses. First, we use a logit regression model to predict which workers are more likely to have earned a professional certification, focusing on demographic variables as key independent variables. Second, to address our research question of the rewards for professional certification, we run a model using logged inflation-adjusted weekly earnings as the dependent variable and include professional certification and unionization as predictors. We then calculate the predicted earnings of workers with and without professional certification across key demographic groups, including men and women, and racial-ethnic groups, as well as predicted earnings for unionized and non-unionized workers. To calculate predicted earnings of workers across key demographic groups, we run a series of models with interaction terms between gender and professional certification, race-ethnicity and professional certification, gender and unionization, and race-ethnicity and unionization. These models are not included in the manuscript but are available on request. The predicted earnings are calculated from regression models, allowing us to control and account for many individual factors, including demographic characteristics, education, and region. We can then interpret the predicted earnings while holding the other factors constant. Finally, an analysis of logged weekly earnings modeled separately by occupation is included in Appendix Table 2. All statistical analyses were conducted using Stata 17.

3. Findings

3.1. Analysis of the likelihood of attaining professional certification among health care workers in low social closure occupations

Table 3 shows a logit model that predicts whether health care workers in low social closure occupations, including personal care aides, medical transcriptionists, medical assistants, or community health care workers, have professional certification. We find that women are 1.261 times more likely to have professional certification than men (p < 0.01), but workers of color, including Black (OR = 0.752), Hispanic (OR = 0.763), and workers who identify as another race-ethnicity (OR = 0.679), are significantly less likely to have professional certification as compared to unionized workers (p < 0.001). Having some college (OR = 1.982), an associate degree (OR = 3.853), or a college degree (OR = 2.568) are all significant predictors of having professional certification among health care workers in low social closure occupations.

Table 3.

Logit models of likelihood of attainment of a professional certification and the likelihood of union membership.

Professional certification Union membership
Odds Ratio SE Odds Ratio SE
Demographics
 Female 1.261** (0.121) 0.792*** (0.106)
 Male Ref Ref Ref
 White Ref Ref Ref
 Black 0.752*** (0.066) 2.189** (0.307)
 Hispanic 0.763*** (0.071) 1.639*** (0.232)
 Other race-ethnicity 0.679*** (0.091) 2.062*** (0.369)
 Born in the US Ref Ref Ref
 Born outside of the 0.898 0.541 0.835 (0.112)
 US
 Age 1.004 (0.023) 1.132** (0.044)
 Age squared 1.000 (0.104) 0.999** (0.000)
Degree
 High school or less Ref Ref Ref
 Some college 1.982*** (0.161) 1.073 (0.363)
 Associate degree 3.853*** (0.319) 0.972 (0.135)
 College degree 2.568*** (0.243) 1.301 (0.187)
Region
 Northeast Ref Ref Ref
0.856 (0.089) 0.546** (0.086)
 South 1.027 (0.096) 0.145*** (0.027)
 West 0.962 (0.089) 0.912 (0.114)
 Constant 0.265*** (0.134) 0.008 (0.007)
 Observations 5185 5185
 R2 0.0554 0.0764
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*

p < 0.05,

**

p < 0.01,

***

p < 0.001.

Notes: Dummy variables for year were included in model but are not shown in Table 3.

Data source: IPUMS-CPS (2015–2020)

For comparison, we also include a logit model of the likelihood of being a union member in Table 3. In contrast to the attainment of professional certification, women are significantly less likely to be a union member than men (OR = 0.792), while Black (OR = 2.188), Hispanic (OR = 1.639), and workers who identify as another race-ethnicity (OR = 2.062) are significantly more likely than white workers to be union members.

3.2. Analysis of weekly earnings among health care workers in low social closure occupations

Table 4 below shows a linear regression model of the natural log of inflation-adjusted weekly earnings for health care workers in low social closure occupations, including personal care aides, medical transcriptionists, medical assistants, or community health care workers. The coefficients can be interpreted as the percent of difference in wages as compared to the reference group. We find that workers who have earned a professional certification have weekly earnings that 4.8% higher than workers who do not have a professional certification (p < 0.001). Workers who are unionized have weekly earnings that are 6.9% higher than workers that are not unionized (p < 0.001).

Table 4.

Linear regression analysis of inflation-adjusted logged weekly earnings.

Coef SE
Social closure mechanism
 Certification 0.048*** (0.013)
 Union member 0.069*** (0.019)
Occupation
 Personal care aide − 0.183*** (0.013)
 Medical transcriptionist 0.024 (0.042)
 Medical assistant Ref Ref
 Community health worker 0.186*** (0.030)
Demographics
 Female − 0.139*** (0.017)
 Male Ref Ref
 White
 Black − 0.046*** (0.016)
 Hispanic − 0.035** (0.017)
 Other race-ethnicity 0.026 (0.024)
 Born in the US Ref Ref
 Born outside of the US − 0.011 (0.017)
 Age 0.011** (0.004)
 Age squared − 9.32e–05** (0.000)
Education
 High school degree or less Ref Ref
 Some college 0.042*** (0.015)
 Associate degree 0.054*** (0.016)
 College degree 0.150*** (0.018)
Region
 Northeast Ref Ref
 Midwest − 0.020 (0.019)
 South − 0.094*** (0.017)
 West − 0.013 (0.017)
 Observations 5185
 R-squared 0.1302
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*

p < 0.05,

**

p < 0.01,

***

p < 0.001.

Notes: Dummy variables for year were included in model but are not shown in Table 4.

Data source: IPUMS-CPS (2015–2020).

Fig. 1 contains predicted weekly earnings for workers with and without professional certification by gender and race-ethnicity. Fig. 1 shows that men who have a professional certification have the higher weekly earnings ($743) as compared to men without a professional certification ($659), which indicates that men who have a professional certification have weekly earnings that are 11.3% higher than those without certification. Women with a professional certification earn $610 per week as compared to $587 earned by women without a professional certification, indicating that women who have a professional certification have weekly earnings that are 3.8% higher than those who do not have a professional certification. White workers with professional certification have weekly earnings of $641 compared to weekly earnings of $599 of those without certification (a difference of 6%), but the earnings difference between workers within and without a professional certification is lower for Black and Hispanic workers (1.2% and 5%). Workers who identify as another race have higher weekly earnings when they do not have a professional certification ($630) as compared to when they do have a professional certification ($623).

Fig. 1.

Fig. 1.

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Predicted weekly earnings for workers with and without a professional certification, by gender and race-ethnicity.

Fig. 2 contains predicted weekly earnings for workers that are and are not unionized by gender and race-ethnicity. Fig. 2 shows that men that are unionized have the higher weekly earnings ($747) as compared to men that are not unionized ($677), which indicates that men who are unionized have weekly earnings that are 9.4% higher than those that are not unionized. Women who are unionized earn $631 per week as compared to $591 earned by women who are not unionized, indicating that women with unionization have weekly earnings that are 6.3% higher than those who do not have a professional certification. White workers who are unionized have weekly earnings of $645 compared to weekly earnings of $611 of those that are not unionized (a difference of 6%), Black workers who are unionized have weekly earnings of $610 compared to weekly earnings of $583 of those that are not unionized (a difference of 4.4%), Hispanic workers who are unionized have weekly earnings of $648 compared to weekly earnings of $584 of those that are not unionized (a difference of 9.9%), and workers who identify as another race and are unionized have weekly earnings of $692 compared to weekly earnings of $620 of those that are not unionized (a difference of 10%).

Fig. 2.

Fig. 2.

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Predicted weekly earnings for union and non-union members, by gender and race-ethnicity.

4. Discussion

The movement towards credentialism in the health care sector – and many other sectors – has been relatively uncontested as positive for both organizations and workers. Health care organizations argue that they need highly trained workers at all levels, and requiring training and certification is one way that organizations try to ensure that the workers they hire have the skills they need to perform their jobs. Proponents of credentialing argue that workers also benefit from certification in that they should be able to demand higher wages from employers, who will be willing to pay more for their more advanced skills (V. Smith, 2010). In addition to health care organizations, professional organizations and advocacy groups have all advocated for additional training, credentialing, and professionalization of many low social closure health care occupations to raise worker wages and improve job quality (Campbell et al., 2021; Hess and Hegewisch, 2019; Fitzgerald, 2006; Scales, 2020). Most of these arguments do not consider the time and money invested by individuals in attaining certification which can reduce the net benefit for workers.

Our findings do, to a certain extent, support the argument that workers will be rewarded for certification with higher wages. We find that workers who have a professional certification have weekly earnings that are 4.75% higher than workers who do not have a professional certification, while controlling for education and other demographic characteristics. The returns on professional certifications range from 5.6% higher weekly earnings for medical assistants, 3.3% higher earnings for personal care aides, and 13.7% higher earnings for community health workers (see Appendix Table 2). However, given the modest wages of most workers in these occupations and in other low social closure health care occupations, the increase in weekly earnings may not be very substantial. For example, the average hourly wage of a personal care is $13.02; a 3.3% increase in earnings is just $0.43 more per hour, or $13.45 per hour. Medical assistants have an average wage of $17.23 per hour, meaning that 5.6% increase in wages for professional certification would result in an hourly wage of $18.20.

As a comparative mechanism of social closure within the labor force, we also examined the relationship between unionization and weekly earnings. We found that unionization was related to weekly earnings were 7% higher than workers earnings who were not unionized. Across occupations, the benefit of unionization ranges from 9% for medical assistants to 5.7% for personal care aides (see Appendix Table 2). These findings are consistent with extensive literature on the wage benefits of unionization, especially for workers without a college degree (Mishel, 2012; VanHeuvelen and Brady, 2021). In sum, our findings suggest that professional certification does lead to higher weekly earnings for low social closure health care workers, but other social closure mechanisms, like unionization, may have similar or greater wage benefits for workers.

This study, along with some past research, also demonstrates that there are a number of reasons why we should be concerned about the widespread proliferation of certification requirements for workers without a college degree. First, our findings indicate that people of color are disadvantaged in earning credentials as compared to white individuals. Certification requirements put substantial responsibility on individuals, who have differential abilities to invest in training and credentials. While organizations may help workers obtain needed credentials, often to even get a foot in the door with an employer, workers need to make substantial investments in training and shoulder all of the costs. It is well established that workers of color, due to generations of discrimination and disinvestment, struggle to participate in higher education and credentialism as compared to their white counterparts (Espinosa et al., 2019). Our findings are consistent with this past research.

A second concern related to certification raised by this paper is that women do not receive the same rewards for certification as compared to white men. As described in the literature review, female-typed degrees lead to female-typed occupations, which tend to be underpaid relative to balanced or male-dominated occupations (Budig et al., 2019; England, 2010; England et al., 2002; Folbre, 2012; Folbre and Smith, 2020). All of the occupations in our study are heavily dominated by women, ranging from 89% of personal care aides to 80% of community health workers. Our findings are consistent with past research that has found that female-typed credentials are devalued by employers in terms of the job-related skills (Ridgeway, 2011; Ridgeway and Correll, 2004).

Past research suggests that men, on the other hand, may experience upward mobility and advantages associated with men when working in female-dominated jobs (Maume, 1999; Price-Glynn and Rakovski, 2012; R. A. Smith, 2012; Williams, 1992). Men are said to ride the “glass escalator” in pink collar occupations because of their higher likelihood of being promoted or to locate themselves in specialties that have higher compensation or prestige (Dill et al., 2016; Price-Glynn and Rakovski, 2012). One of the known contributors of the “glass escalator” effect is that men earn credentials that are related to higher wages (Snyder and Green, 2008). For example, within nursing, men are concentrated in the subspecialty of nurse anesthetist, which is among the highest paid subspecialities within nursing (DATAUSA, 2021). Men may select into these credentials because of higher wages, or these credentials may be more highly valued by employers because of the higher representation of men. In this study, we do not know what certifications are being earned by men and women in the sample, but our findings do suggest that men are more highly rewarded for certification and that certification may be mechanism that supports the “glass escalator” in these occupations.

Our findings also contribute to our understanding of racism in the health care sector. Not only are people of color less likely to have a certification, they also receive lower rewards for certification. While white people with a professional certification have weekly earnings that are 6% higher than their counterparts without certification, the rewards for Black works especially are substantially lower (1.2%) and may contribute to the racial-ethnic wage gap in low social closure health care occupations (Budig et al., 2019; Dill and Hodges, 2019, 2020). In contrast, we find that the rewards for unionization are more equitable across racial-ethnic groups, suggesting that the group bargaining power is more protective of marginalized workers as compared to individualized credentialing and merit (Rodgers, 2019). The increased expectation of occupational licensure or certification is consistent with the literature on the externalization or “responsibilization” of the workplace, where workers are largely responsible for their own career training and development, outside of the organizations for which they work and places responsibility of credentialing largely on the individuals (Vallas and Prener, 2012). Unions, on the other hand, lift the wages and job quality of a collective group and do not rely on individual effort or merit, which may lead to more equitable outcomes for less advantaged groups.

4.1. Policy implications

Our findings have a number of implications for organizational policy and practices, as well as broader practices related to low social closure occupations. First, health care organizations need to be diligent in their evaluation of equity-based pay structures. Within organizations and health systems, administrators need to assess whether men and women, as well as people of color, as being compensated equitably for professional certifications. Further, we argue that health care organizations should take a more activist role in making sure that female-typed credentials and skills are valued at rates that are comparable to credentials and skills that are not gendered or associated with men. The devaluation of women’s work is a broader problem within the labor market, but due to the vast reach of the health care sector, the problem of devaluation and inequitable gender compensation – especially for women of color – is concentrated in the health care sector (Dill and Duffy, 2022). Evaluating and standardizing increases for compensation for professional certification is one way to address the chronic devaluation of women’s work, especially women of color.

Second, credentialing within the health care sector needs to be accessible to workers in low social closure occupations. If earning credentials, including professional certifications, are a pathway to higher wages for workers in low social closure occupations, then training and testing need to be accessible and affordable to workers with constrained resources. Organizations can support professional certification and credentialing through the use of career ladders. Career ladders that make meaningful change within an organization identify pathways or tracks for workers’ advancement (Fitzgerald, 2006). These pathways may involve helping workers locate a training program and credential that will lead to career advancement and upward mobility, such as completing a middle-wage health care credential (Dill and Morgan, 2018). Health care organizations can and should support access to higher education by partnering with community colleges to create tuition remission arrangements, onsite classes, and flexible scheduling to accommodate coursework (Frogner and Skillman, 2016).

Finally, the emphasis on individual attainment of credentials has made individuals vulnerable to for-profit educational institutions. Health care certificates and degrees are the second largest area within for-profit educational institutions, demonstrating the world of for-profit education has invested heavily in health care credentialing (Espinosa et al., 2019). For-profit schools are both more expensive than community colleges and public universities, and students have worse outcomes in terms of graduation, finding jobs, and managing student debt (National Center for Education Statistics, 2021a, 2021b; Shireman and Miller, 2020). Unfortunately, more marginalized students, including both low-wage workers and students of color, are more likely to enroll in for-profit schools. For example, among undergraduate students, about 5% of white men and 7% of white women are enrolled in for-profit schools, but 12.6% of Black men and 17.6% of Black women are enrolled in for-profit schools (Espinosa et al., 2019). Workers who are returning to school as adults have far higher rates of enrollment in for-profit schools; for example, a quarter of Black women above the age of 30 that are enrolled in undergraduate education are at for-profit schools (Espinosa et al., 2019). This raises significant concerns about placing the responsibility of training and credentialing on individuals who want to gain jobs in the health care sector or advance to new occupations. Increasing credential requirements – including professional certifications – pushes workers in low social closure occupations into educational settings that may lead to high levels of student debt and only moderate wage increases or career opportunities.

5. Directions for future research and conclusion

This study has a number of limitations. First, we are unable to track individuals over time to measure the causal impact of earning a certification on subsequent wages. Future research should capitalize on longitudinal data that can more precisely measure the causal link between certification and wage outcomes. Second, the CPS does not include information on the type of professional certification being earned by workers; future research should focus on identifying professional certifications the greatest returns on investment for workers, as well as health care organizations. Finally, we would have liked to have taken an intersectional approach and measured differences in the rewards to professional certification and unionization across both gender and race-ethnicity (e.g., rewards for white men as compared Hispanic women or Black women, for example). Unfortunately, our sample size constraints our ability to measure these differences, but it is likely that we would see even more pronounced differences in rewards across combined racial-ethnic and gender groups.

In conclusion, this paper explores the issue of whether credentialing is an effective strategy for improving low social closure occupations within the health care sector. While we find evidence that having a professional certification is related to modestly higher weekly earnings among workers in our sample, our findings raise concerns about variation in access to professional certification and the equity of rewards for certification. We recommend that policymakers, health care organizations, and advocacy groups consider the equity of access to and rewards for professional certification, and promote and facilitate other mechanisms of social closure, like unionization, in partnership with credentialing to improve job quality in low social closure health care occupations.

Supplementary Material

Supplementary tables

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.

Footnotes

Credit author statement

Janette Dill: Conceptualization, Methodology, Software, Writing – original draft. Jennifer Craft Morgan: Conceptualization, Writing – review & editing. Jane Van Heuvelen: Conceptualization, Writing – review & editing. Meredith Gingold: Software, Validation.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.socscimed.2022.115000.

References

  1. Abbott A, 2014. The System of Professions: an Essay on the Division of Expert Labor University of Chicago Press. [Google Scholar]
  2. Albert K, 2017. The certification earnings premium: an examination of young workers. Soc. Sci. Res 63, 138–149. 10.1016/j.ssresearch.2016.09.022. [DOI] [PubMed] [Google Scholar]
  3. Altonji J, Mansfield RK, 2011. The role of family, school, and community characteristics in inequality in education and labor-market outcomes. In: Whither Opportunity?: Rising Inequality, Schools, and Children’s Life Chances Russell Sage Foundation. [Google Scholar]
  4. Association of State and Territorial Health Officials, 2017. Community Health Workers (CHWs) Training/Certification Standards https://www.astho.org/Public-Policy/Public-Health-Law/Scope-of-Practice/CHW-Certification-Standards/.
  5. Batalova J, Fix M, 2019. Credentials for the future: mapping the potential for immigrant-origin adults in the United States. In: Migration Policy Institute Migration Policy Institute. [Google Scholar]
  6. Becker GS, 2009. Human Capital: A Theoretical and Empirical Analysis, with Special Reference to Education University of Chicago Press. [Google Scholar]
  7. Bettinger E, Soliz A, 2016. Returns to Vocational Credentials: Evidence from Ohio’s Community and Technical Colleges. A CAPSEE Working Paper Center for Analysis of Postsecondary Education and Employment. https://eric.ed.gov/?id=ED571789. [Google Scholar]
  8. Brady D, Baker RS, Finnigan R, 2013. When unionization disappears: state-level unionization and working poverty in the United States. Am. Socio. Rev 78 (5), 872–896. 10.1177/0003122413501859. [DOI] [Google Scholar]
  9. Budig MJ, Hodges MJ, England P, 2019. Wages of nurturant and reproductive care workers: individual and job characteristics, occupational closure, and wage-equalizing institutions. Soc. Probl 66 (2), 294–319. 10.1093/socpro/spy007. [DOI] [Google Scholar]
  10. Budig MJ, Lim M, Hodges MJ, 2021. Racial and gender pay disparities: the role of education. Soc. Sci. Res, 102580 10.1016/j.ssresearch.2021.102580. [DOI] [PubMed] [Google Scholar]
  11. Campbell S, Drake ADR, Espinoza R, Scales K, 2021. Caring for the Future: the Power and Potential of America’s Direct Care Workforce PHI, p. 126. http://phinational.org/caringforthefuture/. [Google Scholar]
  12. Card D, 2001. The effect of unions on wage inequality in the US labor market. ILR Rev 54 (2), 296–315. [Google Scholar]
  13. Carter SD, 2005. The growth of supply and demand of occupational-based training and certification in the United States, 1990–2003. Hum. Resour. Dev. Q 16 (1), 33–54. 10.1002/hrdq.1123. [DOI] [Google Scholar]
  14. Center for Disease Control, 2013. State Law Fact Sheet: A Summary of State Community Health Worker Laws, vol. 3. [Google Scholar]
  15. Cottom TM, 2017. The Troubling Rise of For-Profit Colleges in the New Economy, Lower Ed. New Press, The. [Google Scholar]
  16. Cunningham E, 2019. Professional Certifications and Occupational Licenses: Evidence from the Current Population Survey. Monthly Labor Review 10.21916/mlr.2019.15. [DOI] [Google Scholar]
  17. DATAUSA, 2021. Nurse Anesthetists | Data USA https://datausa.io/profile/soc/nurse-anesthetists.
  18. Department of the Treasury Office of Economics, Council of Economic Advisors, & Department of Labor, 2015. Occupational Licensing: A Framework for Policymakers
  19. Dill J, Duffy M, 2022. Structural Racism and Black Women’s Employment in the US Health Care Sector: study examines structural racism and black women’s employment in the US health care sector. Health Aff 41 (2), 265–272. 10.1377/hlthaff.2021.01400. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Dill J, Hodges MJ, 2019. Is healthcare the new manufacturing?: industry, gender, and “good jobs” for low- and middle-skill workers. Soc. Sci. Res 84, 102350 10.1016/j.ssresearch.2019.102350. [DOI] [PubMed] [Google Scholar]
  21. Dill J, Hodges MJ, 2020. The racialized glass escalator and safety net: wages and job quality in “meds and eds” among working-class men. Soc. Probl [Google Scholar]
  22. Dill J, Morgan JC, 2018. Employability among low-skill workers: organizational expectations and practices in the US health care sector. Hum. Relat 71 (7), 1001–1022. [Google Scholar]
  23. Dill J, Price-Glynn K, Rakovski C, 2016. Does the “glass escalator” compensate for the devaluation of care work occupations? The careers of men in low-and middle-skill health care jobs. Gend. Soc 30 (2), 334–360. [Google Scholar]
  24. Dill J, Morgan JC, Chuang E, Mingo C, 2019. Redesigning the role of medical assistants in primary care: challenges and strategies during implementation. Med. Care Res. Rev, 107755871986914 10.1177/1077558719869143. [DOI] [PubMed] [Google Scholar]
  25. Dill J, Akosionu O, Karbeah J, Henning-Smith C, 2020. Addressing Systemic Racial Inequity in the Health Care Workforce. Health Affairs Blog https://www.healthaffairs.org/do/10.1377/hblog20200908.133196/full/. [Google Scholar]
  26. Ducey A, 2009. Never Good Enough: Health Care Workers and the False Promise of Job Training Cornell University Press. [Google Scholar]
  27. Duffy M, 2007. Doing the dirty work: gender, race, and reproductive labor in historical perspective. Gend. Soc 21 (3), 313–336. [Google Scholar]
  28. Duffy M, 2011. Making Care Count: A Century of Gender, Race, and Paid Care Work Rutgers University Press. [Google Scholar]
  29. England P, 2010. The gender revolution: uneven and stalled. Gend. Soc 24 (2), 149–166. [Google Scholar]
  30. England P, Budig M, Folbre N, 2002. Wages of virtue: the relative pay of care work. Soc. Probl 49 (4), 455–473. [Google Scholar]
  31. Espinosa LL, Turk JM, Taylor M, Chessman HM, 2019. Race and Ethnicity in Higher Education: A Status Report [Report] American Council on Education. https://vtechworks.lib.vt.edu/handle/10919/89187. [Google Scholar]
  32. Fitzgerald J, 2006. Moving up in the New Economy: Career Ladders for US Workers Cornell University Press. [Google Scholar]
  33. Flood S, King M, Rodgers R, Ruggles S, Warren JR, 2020. Integrated Public Use Microdata Series, Current Population Survey IPUMS, Minneapolis, MN. 10.18128/D030.V8.0. Version 8.0 (8.0) [Data set]. [DOI] [Google Scholar]
  34. Folbre N, 2012. For Love or Money: Care Provision in the United States Russell Sage Foundation. [Google Scholar]
  35. Folbre N, Smith K, 2020. Wage of Power vs. Wages of Care Unpublished Paper, Department of Economics, University of Massachusetts Amherst (submitted for publication).
  36. Freidson E, 1988. Profession of Medicine: A Study of the Sociology of Applied Knowledge University of Chicago Press. [Google Scholar]
  37. Friedman A, Hahn KA, Etz R, Rehwinkel-Morfe AM, Miller WL, Nutting PA, Jaén CR, Shaw EK, Crabtree BF, 2014. A typology of primary care workforce innovations in the United States since 2000. Med. Care 52 (2), 101–111. 10.1097/MLR.0000000000000043. [DOI] [PubMed] [Google Scholar]
  38. Frogner BK, Skillman SM, 2016. Pathways to middle-skill allied health care occupations. Issues Sci. Technol 33 (1), 52. [Google Scholar]
  39. Glazer NY, 1991. “Between a rock and a hard place”: women’s professional organizations in nursing and class, racial, and ethnic inequalities. Gend. Soc 5 (3), 351–372. [Google Scholar]
  40. Glenn EN, 2010. Forced to Care: Coercion and Caregiving in America Harvard University Press. [Google Scholar]
  41. Gutiérrez Á, Young M-EDT, Dueñas M, García A, Márquez G, Chávez M-E, Ramírez S, Rico S, Bravo RL, 2021. Laboring with the heart: promotoras’ transformations, professional challenges, and relationships with communities. Fam. Community Health 44 (3), 162–170. 10.1097/FCH.0000000000000286. [DOI] [PubMed] [Google Scholar]
  42. Halpin BW, Smith V, 2017. Employment management work: a case study and theoretical framework. Work Occup 44 (4), 339–375. 10.1177/0730888417720714. [DOI] [Google Scholar]
  43. Hanson M, 2021. Education Attainment Statistics. EducationData https://educationdata.org/education-attainment-statistics. [Google Scholar]
  44. Hess Cynthia, Hegewisch Ariane, 2019. The Future of Care Work: Improving the Quality of America’s Fastest-Growing Jobs. Institute for Women’s Policy Research https://iwpr.org/publications/future-care-work-jobs/. [Google Scholar]
  45. Kim J, 2020. Occupational credentials and job qualities of direct care workers: implications for labor shortages. J. Labor Res 41 (4), 403–420. 10.1007/s12122-020-09312-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Kleiner MM, Krueger AB, 2010. The prevalence and effects of occupational licensing. Br. J. Ind. Relat 48 (4), 676–687. [Google Scholar]
  47. Kleiner MM, Krueger AB, 2013. Analyzing the extent and influence of occupational licensing on the labor market. J. Labor Econ 31 (S1), S173–S202. 10.1086/669060. [DOI] [Google Scholar]
  48. Maume DJ, 1999. Glass ceilings and glass escalators occupational segregation and race and sex differences in managerial promotions. Work Occup 26 (4), 483–509. 10.1177/0730888499026004005. [DOI] [Google Scholar]
  49. Mishel L, 2012. Unions, inequality, and faltering middle-class wages. Econ. Pol. Inst 342 (1), 1–12. [Google Scholar]
  50. Nancarrow SA, Borthwick AM, 2005. Dynamic professional boundaries in the healthcare workforce. Sociol. Health Illness 27 (7), 897–919. [DOI] [PubMed] [Google Scholar]
  51. National Center for Education Statistics, 2021a. Graduation Rates National Center for Education Statistics. https://nces.ed.gov/fastfacts/display.asp?id=40. [Google Scholar]
  52. National Center for Education Statistics, 2021b. Tuition Costs of Colleges and Universities National Center for Education Statistics. https://nces.ed.gov/fastfacts/display.asp?id=76. [Google Scholar]
  53. Price-Glynn K, Rakovski C, 2012. Who rides the glass escalator? Gender, race and nationality in the national nursing assistant study. Work. Employ. Soc 26 (5), 699–715. 10.1177/0950017012451634. [DOI] [Google Scholar]
  54. Ridgeway CL, 2011. Framed by Gender: How Gender Inequality Persists in the Modern World Oxford University Press. [Google Scholar]
  55. Ridgeway CL, Correll SJ, 2004. Unpacking the gender system: a theoretical perspective on gender beliefs and social relations. Gend. Soc 18 (4), 510–531. 10.1177/0891243204265269. [DOI] [Google Scholar]
  56. Rodgers, 2019. Race in the labor market: the role of equal employment opportunity and other policies. RSF: Russell Sage Foundation J. Soc. Sci 5 (5), 198. 10.7758/rsf.2019.5.5.10. [DOI] [Google Scholar]
  57. Rosenfeld J, 2014. What Unions No Longer Do Harvard University Press. [Google Scholar]
  58. Rosenfeld J, Denice P, 2019. What do government unions do? Public sector unions and nonunion wages, 1977–2015. Soc. Sci. Res 78, 41–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Scales K, 2020. It’s Time to Care: A Detailed Profile of America’s Direct Care Workforce—PHI PHI. https://phinational.org/resource/its-time-to-care-a-detailed-profile-of-americas-direct-care-workforce/. [Google Scholar]
  60. Shireman R, Miller K, 2020, May 28. Student Debt Is Surging at For-Profit Colleges The Century Foundation. https://tcf.org/content/commentary/student-debt-surging-profit-colleges/. [Google Scholar]
  61. Skillman SM, Dahal A, Frogner BK, Andrilla CHA, 2018. Frontline Workers’ Career Pathways: A Detailed Look at Washington State’s Medical Assistant Workforce. Medical Care Research and Review, 1077558718812950. [DOI] [PubMed] [Google Scholar]
  62. Smith V, 2010. Enhancing employability: human, cultural, and social capital in an era of turbulent unpredictability. Hum. Relat 63 (2), 279–300. [Google Scholar]
  63. Smith RA, 2012. Money, benefits, and power A test of the glass ceiling and glass escalator hypotheses. Ann. Am. Acad. Polit. Soc. Sci 639 (1), 149–172. 10.1177/0002716211422038. [DOI] [Google Scholar]
  64. Snyder KA, Green AI, 2008. Revisiting the glass escalator: the case of gender segregation in a female dominated occupation. Soc. Probl 55 (2), 271–299. 10.1525/sp.2008.55.2.271. [DOI] [Google Scholar]
  65. Tronto J, 2011. A feminist democratic ethics of care and global care workers: citizenship and responsibility. Feminist Ethics Soc. Pol.: Towards a New Global Political Economy of Care 162–177. [Google Scholar]
  66. U.S. Bureau of Labor Statistics, 2022. Home Health and Personal Care Aides: Occupational Outlook Handbook https://www.bls.gov/ooh/healthcare/home-health-aides-and-personal-care-aides.htm.
  67. Vallas S, Prener C, 2012. Dualism, job polarization, and the social construction of precarious work. Work Occup 39 (4), 331–353. [Google Scholar]
  68. VanHeuvelen T, Brady D, 2021. Labor Unions and American Poverty ILR Review, 00197939211014855. 10.1177/00197939211014855. [DOI] [Google Scholar]
  69. Weeden KA, 2002. Why do some occupations pay more than others? Social closure and earnings inequality in the United States. Am. J. Sociol 108 (1), 55–101. [Google Scholar]
  70. Western B, Rosenfeld J, 2011. Unions, norms, and the rise in U.S. Wage inequality. Am. Socio. Rev 76 (4), 513–537. 10.1177/0003122411414817. [DOI] [Google Scholar]
  71. Williams CL, 1992. The glass escalator: hidden advantages for men in the “female” professions. Soc. Probl 39 (3), 253–267. 10.2307/3096961. [DOI] [Google Scholar]

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