Objectives: Our study investigates unionization trends among direct care workers (DCWs) in the United States and examines the association between unionization and their wealth outcomes.

Design: This is a cross-sectional study using data from the Current Population Survey and Annual Social and Economic Supplement from 2009 to 2023.

Setting and Participants: Our study is based on US representative household surveys. The sample includes 17,522 DCWs (eg, personal care aides, nursing assistants, home health workers).

Methods: The prevalence and trend in labor unionization among DCWs and the association between their union status and wealth outcomes (hourly wage, employer-sponsored health insurance, pension plans, and poverty status) were analyzed. Union status identified by formal union membership or coverage by a union without formal membership.

Results: The sample was composed of mostly women (87%); they had a mean age of 41.8 ± 14.5 years, 38.1% were non-Hispanic White, 30.4% were non-Hispanic Black, 21.6% were Hispanic, and 9.9% were Asian and other. Overall, 12% (n = 1850) of DCWs were unionized. The Cox trend test showed decreasing in unionization rates over the study years. In fully adjusted models, unionized DCWs earned more than nonunionized DCWs ($1.2; 95% CI, $0.8-$1.6; P < .001). They were also more likely to have employer-sponsored health care insurance (odds ratio, 2.0; 95% CI, 1.8-2.3; P < .001) and pension plan (odds ratio, 1.8; 95% CI, 1.6-2.0; P < .001), with higher employer's contribution to health insurance ($561.2; 95% CI, $303.1-$819.3; P < .001). Also, unionization was negatively associated with DCWs' poverty status (odds ratio, 0.7; 95% CI, 0.6-0.9; P < .001).

Conclusions and Implications: Unionization is an effective means of improving the financial well-being of DCWs, a workforce that is currently facing challenging working conditions and high levels of turnover.