New Opportunities or More of the Same? Health Industry Entrants in the Post-Pandemic Era

Abstract

This cross-sectional study examines shifts in health industry entry and sector choice among women, racially minoritized workers, and immigrants during the pandemic era. Using data from the Annual Social and Economic Supplement of the Current Population Survey (2018–2023), we compare entrant characteristics before and during the pandemic era, focusing on demographic composition and sector choice. Results show minimal shifts by gender, race, or education but highlight a rise in entrants from outside the labor force, particularly among white women and racially minoritized men. There were changes in sector choice: ambulatory care saw the greatest increase in racially minoritized entrants, with small increases for hospitals and a decrease for long-term care. Despite these sector-specific shifts, overall opportunities for minoritized workers did not expand, nor did workforce diversity significantly improve. These findings underscore the need for research that examines how policies outside the workplace shape worker behavior, particularly among marginalized groups.

INTRODUCTION

The health industry has long been considered an engine of opportunity, providing stable employment for workers through economic booms and busts. The pandemic, however, ushered in early indications of a shift in how opportunities were distributed in the healthcare sector. During the acute phase of the pandemic, many healthcare jobs were lost (Telesford et al., 2023), with some workers choosing to leave healthcare due to the risks of infection, high work demands, or competing opportunities in other industries (Lusk et al., 2022). This shift was more acute for women and Black and Hispanic workers. These groups had higher rates of exit from healthcare, raising concerns about the diversity of the workforce that remained (Buerhaus et al., 2022; Frogner & Dill, 2022). Concerns over workforce diversity should focus not only on those who leave or remain, but also on new entrants to the healthcare workforce. However, little research has examined the demographic composition of workers entering the health industry. While the challenges of the pandemic may have deterred some from working in healthcare, new opportunities may have emerged given that demand for healthcare workers rebounded and, in some cases, expanded during the post-acute phase of the pandemic era (Auerbach et al., 2024; Telesford et al., 2023).

We know that for women, immigrants, and racially minoritized groups, the healthcare industry has served as both a source of opportunity and a site of persistent inequities. Women hold 77% of all health industry jobs (Dill & Frogner, 2023), with female-dominated professions like nursing historically providing stable, middle-class careers for generations of women (Trotter, 2017). Over 25% of Black women are employed in the health sector (Dill & Duffy, 2022), and many immigrant workers leverage the industry to establish themselves in the US labor force, finding roles in both low-wage positions and well-paid, stable careers in nursing and medicine (Al Achkar et al., 2023; Chen et al., 2013). However, these opportunities are often constrained. Racially minoritized groups, immigrants, and to a lesser extent, women, are overrepresented in low-wage sectors of healthcare, such as long-term care (Dill & Duffy, 2022; Islas et al., 2023). Even within the same sectors, women earn less than men, and Black and Hispanic workers earn less than comparable White workers (Frogner & Schwartz, 2021; Moore & Continelli, 2016; Williams, 2013).

After the acute phase of the pandemic (March-December 2020), there has been heightened demand for healthcare professionals in hospitals and ambulatory care settings, so women, racially minoritized groups, and immigrants may have gained greater access to higher-wage sectors and improved benefits. This demand may also have incentivized unemployed workers as well as those previously out of the labor force to reconsider employment in healthcare (Telesford et al., 2023). This study aims to examine whether there have been significant shifts in health industry entry and sector choice among women, racially minoritized workers, and immigrants during the post-acute phase of the pandemic era.

NEW CONTRIBUTION

This analysis fills a gap in the existing literature, which focuses on exits from the health workforce during the pandemic, by examining whether entrants are finding opportunities in higher-wage sectors such as acute and ambulatory care, and whether access to these opportunities differs by gender, racially minoritized status, or immigration status. The findings may open future avenues for research into these employment patterns and support efforts to diversify the health workforce while promoting career pathways into high quality jobs.

METHODS

Data and Sample

This observational cross-sectional study used nationally representative data from the Annual Social and Economic Supplement (ASEC) of the Current Population Survey (CPS), a complex, monthly panel survey of 60,000 households conducted by the US Bureau of Labor Statistics. ASEC data for 2018–2023 were extracted using IPUMS, a public data service of the University of Minnesota (Flood et al., 2021). Respondents answer questions about employment status, occupation, and industry for the current and prior year for each adult in the household.

We identified individuals working in the health industry as defined by US Census industry codes (IPUMS CPS; IPUMS USA). Given our focus on settings providing direct patient care, we did not include drug manufacturers, pharmacies, and medical supplies as part of our definition of the health industry (Frogner, 2017). Our sample included civilian workers aged 18 to 75 who reported current employment in the health industry at the time of the survey. Our sample was divided into two groups. The first, designated ‘pre-pandemic’, includes survey responses from 2018, 2019 and 2020. Because the survey occurs in March and the reference period was the week of the month containing March 12th, the 2020 data reflect employment prior to nationwide shutdown orders due to COVID-19 (U.S. Bureau of Labor Statistics, 2020). Responses from 2021, 2022, and 2023 are designated ‘during-pandemic’ indicating that data reflects employment after the acute phase of pandemic onset in March 2020. This study was exempted from human subjects review by an Institutional Review Board as the dataset is deidentified and publicly available.

Measures

Entrants.

We defined individuals as entrants when they reported working in the health industry in the current year and not working in the health industry in the prior year. For example, if a respondent in the 2020 ASEC stated that they worked in a retail setting in the prior year of reporting (i.e., 2019) but worked in the hospital setting as a laboratory technician in the current year, then they were defined as an entrant (Frogner, 2017; Frogner & Dill, 2022). With this definition, individuals are considered entrants even if they worked in a health specific occupation outside of the health industry, for example a nurse who worked in pharmaceutical sales the prior year who reports working in home health in the current year is considered an entrant. To get specificity in where entrants were finding jobs, we used industry codes to categorize the health industry into three sectors: hospitals, ambulatory care (including provider offices and outpatient care), and long-term care (including skilled nursing facilities, residential care, and home health) (IPUMS CPS; IPUMS USA). We compared healthcare industry entrants to entrants in all industries and those that tend to compete with healthcare for workers, including educational services, leisure and hospitality, professional services, and retail (Frogner, 2017).

Prior occupation.

Using information reported by survey respondents, we classified workers’ employment into one of three prior year occupation statuses: healthcare occupation which included specific healthcare occupations such as nurse or health aide held outside the health industry; non-healthcare occupation which includes occupations not specific to healthcare and not in the health industry (IPUMS USA); and out of labor force which included not working due to school attendance, sick/disabled care, retirement, or other unspecified reasons. Unemployed workers, while technically part of the labor force, were grouped with the out of labor force category to represent a state of being without a job in the health industry.

Demographics.

We used individually reported demographics including gender, race/ethnicity, immigration status, and education. We derived gender from the sex variable, which is only available in the dataset as a binary male/female variable. Reported race(s) and ethnicity were used to identify racially minoritized workers via a dummy variable created using the National Institutes of Health’s definition of persons who are underrepresented in the biomedical workforce to include African American (or Black), American Indian and Alaska Native, Hispanic (or Latinx), and Native Hawaiian and other Pacific Islander workers (National Institutes of Health). Immigration status was categorized in the data as native-born, naturalized citizen, or non-citizen; we kept those designations in our analysis. ASEC respondents report the highest level of education they achieved; we collapsed this into a binary variable indicating whether the respondent had less than a bachelor’s degree or a bachelor’s degree or higher.

Analysis

Our descriptive analysis examined trends in the rate of entry into the health industry overall, in specific health sectors, and by gender, racially minoritized status, immigration status, and education levels as described. We analyzed the data using Stata/SE 18 including survey weighting functions. ASEC weights are provided with the data; we used the recommended adjusted weights for 2020 to account for different response rates during COVID (IPUMS, 2023). In addition to the descriptive analysis, we performed chi-square analyses with significance at 95% to examine differences in pre- and during-pandemic entrant characteristics.

RESULTS

The study sample included 674,110 unweighted observations of individuals aged 18–75, representing a weighted estimate of 1.4 billion US workers over the 6-year study period. Of these workers, 107.4 million individuals reported working in the healthcare industry. The annual percentage of workers entering healthcare declined during the pre-pandemic period, reaching a low point in 2021 and then increasing in the next two years (Figure 1). A similar pattern was found in most of the industries that compete with healthcare, with the exception of the retail industry that did not show a consistent decrease or increase in entrants.

Figure 1.

Percent of Entrants Among all Employed Workers in Healthcare and Competing Industries, 2018–2023.

Demographics

When comparing health industry entrant demographics from pre- to during-pandemic periods, few significant changes were noted. The overall gender composition of the health workforce remained stable, with a trend toward increased representation of entrants who are women (73.5% pre- to 74.6% during-pandemic, chi²=1.02, p=.40; Table 1). This trend was not reflected in overall job entrants, where the percentage of women dropped slightly from 47.9% pre-pandemic to 47.8% during the pandemic. Representation of racially minoritized workers among healthcare entrants grew from 32.8% to 34.0% (chi²=1.32, p=.33), consistent with a slightly increased percentage of these workers among job entrants overall (31.8% to 32.7%; χ²=12.65, p=.00). Figure 2 displays the annual rates of both women and racially minoritized workers entering healthcare compared to all industries showing no large spikes or variations between years across the study period.

Table 1.

Demographics of Healthcare Industry and All Industry Job Entrants, 2018–2023

	Healthcare Entrants		All Industry Entrants
	Pre	During	Pre	During
N	7,058,899	6,916,110	82,430,646	81,875,591
Gender (female)	73.5	74.6	47.9	47.8
Age (average)	41.1	41.3	40.3	40.5
Education
Less than BA/BS	61.7	61.5	66.0	64.5*
BA/BS or higher	38.3	38.5	34.0	35.5
Racially minoritized (including Hispanic)	32.8	34.0	31.8	32.7*
Immigration status
Native born	85.2	85.8	84.1	83.7
Naturalized	8.8	8.5	7.5	7.4
Not citizen	6.0	5.6	8.4	9.0

Note. Pre- = pre-pandemic, 2018–2020; During = post-peak-pandemic=2021–2023. Due to rounding of estimates, some columns may not add to 100.

^*Chi-squared analysis showed significant differences by education (χ²=5.16, p=.02) and racially minoritized status (χ²=12.65, p=.00) among all industry entrants pre- to during pandemic.

Figure 2.

Percentage of Female and Racially Minoritized (RM) Entrants to Healthcare and all Industries, 2018–2023.

Unlike entrants across all industries, where the share of native-born entrants decreased from 84.1% to 83.7% and the share of non-citizen immigrants increased from 8.4% to 9.0%, in the healthcare industry the share of non-naturalized immigrant entrants decreased slightly from 6.0% to 5.6% (chi²=.35, p=.88; Table 1). During the pandemic, there was also a small insignificant increase in entrants with a bachelor’s degree or higher (38.3% pre- to 38.8% during-pandemic; chi²=.08, p=.78), while among overall entrants there was a significant increase in entrants with a bachelor’s degree or higher (34.0% pre- to 35.5% during-pandemic; chi²=12.65, p=.00).

Entrant Characteristics by Health Sector

Compared to the pre-pandemic period, during the pandemic years, entrant rates into different health sectors shifted significantly (chi²=9.31; p=.01; Table 2). Entrants into long-term care declined from 25.9% to 23.1%, while entry into the ambulatory care setting increased by over 2 percentage points (38.8% to 41.0%). Hospitals experienced a small increase in entrants overall (35.3% to 35.9%).

Table 2.

Distribution of Entrants by Health Industry Sector and Racially Minoritized Identity

		Pre-pandemic N=7,058,899	During-pandemic N=6,926,673
Ambulatory Care
	All entrants	38.8	41.0
	Racially minoritized	29.3	33.4
	Not racially minoritized	60.7	56.6
Hospital
	All entrants	35.3	35.9
	Racially minoritized	32.1	33.2
	Not racially minoritized	67.9	66.8
Long-Term Care
	All entrants	25.9	23.1
	Racially minoritized	43.6	41.9
	Not racially minoritized	56.4	58.1

Note. Pre-pandemic=2018–2020; During-pandemic=2021–2023. N=category estimates using survey weighting. Numbers represent the percentage of entrants into each individual sector per period. Chi square analyses showed a significant difference in the sector distribution of all entrants from pre- to during-pandemic time periods (χ²= 9.31, p=.01) and a trend toward a significant difference in the percentage of racially minoritized entrants into ambulatory care (χ²=3.7, p=.06).

Entrant diversity.

The increase in overall entrant diversity varied by sector (Table 2). The ambulatory care setting saw the greatest increase in entrant diversity, with an additional 4.1 percentage points of racially minoritized entrants, which was the only trend approaching statistical significance (29.3% pre- to 33.4% during-pandemic; chi² =3.7, p=.06)). Hospitals saw a 1.1 percentage point increase (chi²=1.77, p=.18) and the long-term care setting saw a 1.7 percentage point decrease (chi²=0.32, p=.57) in entrant diversity. Among racially minoritized entrants, there was a significant shift in entrance sectors from nearly equal distribution (33.9% ambulatory, 33.6% hospital, and 32.5% long term care) to 39.2% entering the ambulatory sector, 34.8% entering hospitals, and 25.9% entering long-term care (chi²=12.65, p=.00).

Citizenship status.

Rates of workforce entry among non-citizens also varied by sector (Figure 3), with a 0.4 percentage point increase in non-citizen entrants to ambulatory care, a 0.2 percentage point decrease in non-citizen entrants to hospital settings, and a significant 1.2 percentage point decrease in non-citizen entrants to long term care (chi²=6.84, p=.02). Otherwise, there were no significant pre- to during-pandemic changes in the overall distribution of entrants by immigration status alone or combined with racially minoritized identity.

Figure 3.

US Immigration Status of Health Industry Sector Entrants, 2018–2023.

Prior Year Occupations

We found an overall increase in workers coming from being out of the labor force into the healthcare industry from pre-pandemic to during the pandemic (14.0% and 16.0% respectively, chi² 4.78, p=.09). Among these workers, there were notable increases in workforce entrance by women who did not belong to racially minoritized groups (3.3 percentage points) and men from racially minoritized groups (5.1 percentage points). Women from racially minoritized groups had a 2.2 percentage point increase in healthcare industry entrance from non-health occupations that was not shared by any other group. Table 3 shows more detail on source occupations.

Table 3.

Prior Year Employment Status of Health Industry Entrants by Sex and Race

	Women		Men
	Pre	During	Pre	During
Racially Minoritized Identity
N	1,697,756	1,767,083	616,902	583,879
% Overall entrantsa	24.1	25.5	8.7	8.4
Prior year employment status
Out of labor forceb	18.1	17.4	11.6	16.7
Non-health occupation	67.0	69.2	80.6	75.9
Health occupation	14.9	13.4	7.9	7.4
No Racially Minoritized Identity
N	3,489,457	3,394,018	1,254,783	1,171,130
% Overall entrantsa	49.4	49.1	17.8	16.9
Prior year employment status
Out of labor forceb	12.9	16.2	12.8	13.0
Non-health occupation	70.0	69.9	75.2	74.8
Health occupation	17.1	14.0	12.1	12.2

Note. Pre-pandemic=2018–2020; During-pandemic=2021–2023. Numbers indicate % entrants from each employment status in the specific category and time period.

^aIndicates percentage of all entrants in the pre- or during-pandemic time period.

^bIncludes statuses of being sick, disabled, or caring for others.

DISCUSSION

From the years before to the years during the pandemic, we found little significant change in the proportion of healthcare industry entrants by gender, racially minoritized status, or immigration status. Several subtle shifts were present, such as changes in the healthcare sectors where workers entered jobs and increased numbers of some entrants coming from out of the labor force. The significant increase in racially minoritized entrants moving into the ambulatory care setting suggests that some jobs were more available or desirable to this group of workers than jobs in other health sectors. These and other subtle shifts in entrants must be viewed in the context of the US labor market, policy, and health services overall during the study period.

After the initial shock of the pandemic and a spike in unemployment, national unemployment rates were low and the health sector, like other industries, continued to report high job vacancy rates (Telesford et al., 2023). Our findings reflect these conditions, with a general trend toward decreased entrants in the health industry and several other sectors that typically compete for workers from 2018–2021, followed by an uptick in entrants in the years following the onset of the pandemic. Within the healthcare industry, the demand for services dropped significantly at the onset of the pandemic due to closures but has slowly increased and continued to grow in the ensuing years. Demand in different healthcare sectors changed throughout the pandemic. For example, the demand for hospital workers increased while demand for nursing home services declined due to longer hospital stays and a shift toward home- and community-based services (McGough et al., 2023; Segelman et al., 2024).

Increased demand and accompanying improved incentive structures may have acted as a pull factor, drawing workers who were previously out of the labor market into healthcare jobs. Our findings highlight the increased number of entrants who were previously out of the labor force (including unemployed workers) during rather than before the pandemic. This trend was particularly noticeable for women who did not belong to racialized minority groups and men who did, suggesting that, for these two groups, either the barriers to entry had lessened or the incentives to reentering the paid labor force had significantly increased. But in addition to demand acting as a pull factor, the thinning of the social safety net may have pushed workers into employment. The end of pandemic-era policies such as eviction moratoriums, the child tax credit, and accessible Medicaid enrollment have increased childhood poverty rates due to the loss of these financial supports (Parrott, 2022; Williams & Rudowitz, 2024), which could force workers to back into the workforce. There may be parallel trends in family- and individual-level poverty that have reshaped individual decisions about employment.

In addition to changes among racially minoritized workers, workers who are not native-born had different experiences entering the healthcare industry. There was a significant decrease in non-native workers entering long-term care jobs accompanied by smaller decreases in these workers entering hospital or ambulatory care work. These changes were likely influenced by policy shifts during this time period, as the pandemic and other sociopolitical factors impacted immigration rates. At the same time, immigrant workers were more likely to be in frontline, high-risk jobs, increasing rates of illness and potentially changing employment patterns and decisions (Allen et al., 2023; Butcher et al., 2023).

Our study did not explicitly examine workers who may have re-entered the health sector after stepping away, but other studies suggest that this type of movement is not equally likely for all demographic groups. A previous analysis of CPS data showed that over 30% of health industry workers in jobs such as direct care aides or other roles with similar entry requirements did not return to the industry after displacement related to COVID-19 (McCall et al., 2021). This study indicated that low re-employment was heightened among women and racially minoritized workers and was likely related to low wages, lack of targeted recruitment, and inadequate job supports for workers. These and other factors that shape movement into and out of healthcare suggest complexity in employment decisions that bears closer examination for specific groups of workers in different settings.

In general, job shifts during the pandemic era have tended to preference White workers over racially minoritized workers, sustaining or worsening existing inequalities in the labor market (Cortes & Forsythe, 2023). Our findings do not show a worsening of opportunity for racially minoritized workers or women, but they also did not indicate a substantive change in opportunity for women or racially minoritized workers in the healthcare labor market as a whole. Focused effort on eliminating barriers to entry and supporting pathways to health career development for workers from racially minoritized groups may help improve workforce diversity. Future work should investigate the relationship between rollback of state and federal support and labor market reentry rates broadly while also assessing the impact on labor market disparities specifically.

Limitations

This study was limited by several factors. During the pandemic, the CPS survey received a decreased number of responses, requiring the use of COVID-specific weighting in our estimates (McIllece, 2020). Because our analysis focuses on all health industry workers, findings may not be applicable to specific occupations (e.g., RNs or home care aides), and instead speak to health industry workforce dynamics more broadly. We analyze health industry entry in the year prior to survey participation, which may mask previous entrance to and departure from the health sector. Our use of broader race categories and the definition of ‘under-represented’ that we used (National Institutes of Health) may miss important differences for some groups of workers. Finally, we do not describe all possible intersecting demographic characteristics, so may have missed critical differences for subpopulations of workers. This analysis therefore provides a high-level view of health industry entrance among workers rather than a granular view of specific groups of individuals or occupations.

CONCLUSION

The pandemic sparked a cascade of changes in the health workforce, from job loss and instability to stabilization and increase in available opportunities. However, we largely did not find that the pandemic and during-pandemic economy created an increase in opportunities for racially minoritized workers, nor did the demography of during-pandemic entrants substantively improve workforce diversity. It may be that forces outside the labor market, such as immigration policies and changes in the social safety net, may impact subpopulations of industry entrants in unique ways. Future work aimed at understanding the flow of workers into the health industry should not only be concerned with intersubjective factors such as burnout or worker satisfaction, but also events and policies outside the workplace that shape worker preferences and behavior, particularly among marginalized or underrepresented groups of workers.

Data availability:

Data used in this study is publicly available at https://cps.ipums.org/cps/.