One rather important healthcare job is developing into a flashpoint of what ails workforce development, the labor market, and much, much more.

One day I came home from school to find out my mom was going to become a nurse.

Mom had always been smart—about 20 years earlier, she had finished high school early—and she had told me she had wanted to be a nurse ever since she was very small. It just required a college degree. For some reason, that wasn’t for her, although I’m not sure if anyone ever told her that out loud.

Regardless, at 17, she went to work at one of the garment factories that pocked Northwest Alabama. She did that until my father died suddenly when I was eight. When she had crawled out of the shock and despair from his death, NAFTA had gone into effect, and those factories were gone.

So one day, after dropping me off at school, she enrolled at the University of North Alabama to major in nursing and got a job as a nursing assistant. We had mostly lived off Social Security survivor’s benefits after my father’s death. College cost extra, and she wanted to go ahead and get into scrubs, so it made sense she would try to work her way through school.

She started when I was in middle school. She finished around my sophomore year of college.

She was working 12-hour overnight shifts as a nursing assistant, going to school 45 minutes from our house during the day, and sleeping when it was possible. (It often wasn’t.) There wasn’t give in our household budget for her to do anything else, and her fear was that the unavoidable human things—someone getting sick, the car breaking down—would derail a train clinging to the flimsiest of tracks. Those fears often came true and kept her in school for much longer than she ever intended.

By the time she got to the actual nursing part of her nursing program, she was golden, although it remains grimly hilarious to me that she had to pay for her clinicals. She’d been working in patient care for most of a decade by the time she got her license. It just cost her financial security for the rest of her life to get it.

I don’t share this story as much as I used to because I see only so much utility in trying to solve today’s problems with yesterday’s grief. But I was recently talking to someone who trains around the healthcare industry, and they emphasized to me—in bold, underlined, all-caps—that the problems my mother faced then are almost precisely the same today.

Since then, I haven’t gone a week without talking about a job category that’s becoming a flashpoint for conversations around where we’ve been, and where we’re headed, in American workforce policy: certified nursing assistants, or CNAs.

CNA training can be a popular offering within publicly funded workforce programs, including those under the Workforce Innovation and Opportunity Act, America’s most consistent source of workforce funding, and Workforce Pell, where multiple nursing or medical assistant programs were among the

The problem is that CNA certification has become, in the words of a workforce official I spoke with a couple of months ago, “a terminal credential.” In effect, what that means is that while the problems my mother faced remain commonplace, her outcome is not. An Urban Institute study on a federal grantmaking for CNAs found that only 3 percent went on to train as a registered nurse or a licensed practical nurse, both fields in seemingly perpetual need for more qualified talent.

CNA training, then, has become a collision of several major challenges that will shape the workforce conversations to come: talent shortages created by poor working conditions, workforce programs routing people toward the easiest and cheapest option, and policymakers reluctant to talk about the most obvious problems, let alone try to fix them.

Let’s be clear: I’m not trying to beat up on CNA programs or nursing assistants. Nursing assistants do the highly intimate, frontline patient care that can be just as vital as what nurses do, and their ability to do that work with grace and empathy can be the difference between care that helps someone recover and care that leaves them feeling more miserable.

That makes it an increasingly vital occupation as the American population grays. Here in Michigan, we have a projected unmet need of more than 56,000 nursing assistants in the next decade.

It’s a hard job—a harder one in the burnout-heavy aftermath of COVID and the recent spike of violence against healthcare workers—but it’s also a relatively easy job to get hired into. You’ve probably seen ads like this one, which I spotted in Philadelphia about a month ago.

That access is not necessarily a bad thing, particularly when it comes to the part of workforce development that has to rollback decades of conditioning that a worker is les than. Public school systems and other social structures can ruggedly beat down lower-income workers’ belief that they belong in any workplace, let alone one of any importance. CNA programs can be great for bringing people into healthcare who, like my mother, needed a paycheck and a set of scrubs to believe they could work in a medical facility.

But also has a get-rich-quick kind of impact on policymakers and political leaders. When you talk to policymakers about CNAs, the first thing they will tell you is that nursing-assistant jobs are important gateways into healthcare—then half a breath later, they’ll note those jobs don’t pay particularly well. In some policymakers’ minds, that disparity between pay and importance is justifiable. From where they sit, CNA training is like planting a seed that might eventually grow into an LPN or an RN.

What those policymakers don’t consider is that there really isn’t a clear or easy pathway for CNAs to make that jump. Here’s what my friends at Work Shift wrote when they picked apart this issue nearly a year ago:

Among policymakers, there also remains a reluctance to address the obvious: that whole “It doesn’t pay enough” part.

I get why. Employers tend to be the ones who hire people for all the jobs, in my experience. Very rarely have I met an employer who’s willing to say they can pay people more, and nurses look like an expensive line item to healthcare companies.

That said, I also get economics, namely the part that at some point you have to pay what an asset is worth to the market if you want it to solve a problem. In many parts of the country, a majority of CNAs don’t earn a living wage.

At the same time, CNA programs very frequently are sold to people like my mother, older workers with kids who need to earn something while they’re clawing their way into healthcare. That means those wages aren’t just inadequate—they’re grossly inadequate for the people whom we’re trying to recruit into the role.

And it’s indicative of a problem with nursing overall. We’re at a point where, to pull a quote from a recent Wall Street Journal piece, “[t]here is no shortage of nurses in this country,” but rather “a shortage of nurses that want to work in the current environment”—a calculation that very much involves pay.

One, this isn’t the most immediately practical advice, but I’m saying it first because it’s important: my read of the next Congress is we’re about to have some deep conversations about healthcare—maybe the deepest we’ve had since the Obamacare fight nearly two decades ago.

If those conversations are being had without considering what it takes to recruit, compensate, and keep the workers needed to deliver healthcare, they’re incomplete thoughts. And if we really are talking about a single-payer healthcare system, any such proposal needs to use that single payer’s financial leverage to improve pay for vital roles like nursing assistants.

More immediately, we also need more complete thoughts when it comes to …preparing people to meet healthcare workforce needs. People won’t just figure out how to get from Point A (a CNA) to Point B (a job that requires more training than a CNA) unless there are clear, explicit pathways for them to travel. Those are very rare at present.

There are some understandable concerns that have held up development of some alternatives to traditional higher education that could weave around some of the problems my mother faced. For example, I’ve heard worries from labor about starting more apprenticeship programs for nurses because nursing apprentices could be used to undercut the pay of more experienced nurses. Given the entirety of the pay discussion above, that’s completely fair.

At the same time, it makes no sense to ask capable healthcare professionals to balance night jobs with day classes and pay for clinicals when they’re already working in a healthcare facility on a daily basis. Integrating that work and education into an apprenticeship program—with apprentices’ pay and working conditions shaped by nurses’ unions—seems better to me than halting their development entirely. (Although I admit that with my mother’s story, it’s hard for me to believe anything else.)

Finally, we shouldn’t be shy about talking with employers about pay. You pay people to show up, and the shortages we expect among CNAs in the near future suggest that they’re not being paid anywhere near enough.

That being said, pay isn’t necessarily security against the unexpected, as highlighted in my interview with the Escalate crew a few weeks ago. For those older and “nontraditional” students trying to get a healthcare job, we need more resources to help cover childcare and transportation—needs that have nothing to do with talent but can keep capable people from filling important jobs.

It’s an area where I quite literally put my money where my mouth is: if you’ve bought a subscription or clicked an ad on this newsletter, a portion of that revenue has supported an endowed barrier-removal fund for students like my mother at her alma mater, the University of North Alabama.

When I talk to employers and employer-aligned policymakers, the workers they imagine filling their shortages often sound younger—and cheaper—than the second-career workers who’ve lurked around a living wage but never gotten one. Given the workers these programs are often marketed to, that’s a mistake, and they’re losing capable talent due to the kind of human concerns that held up my mom.