There are few industries as rife with inequity and occupational segregation as health care, where 79% of workers in low-wage health services jobs are women and more specifically, Black women, Latinas, and immigrants. These entry-level healthcare workers are paid poverty wages and are ineligible for benefits, including paid sick leave. One organization is trying to change this.

The Healthcare Career Advancement Program (H-CAP) is a national labor management organization comprised of healthcare employers and Service Employees International Union (SEIU) locals that provide programs, trainings, and educational opportunities to healthcare workers historically locked out of higher paying union jobs. Of particular interest in enrolling Black and brown healthcare workers into registered apprenticeship programs that provide the skills and training needed to be considered for management positions.

According to Daniel Bustillo, a former unionized healthcare worker and H-CAP’s executive director, almost all of the healthcare industry’s major inequities fall across race and gender lines. The ED recently spoke to Prism about dismantling institutional barriers, the importance of apprenticeship programs, and the fight for long-term care workers. Our conversation has been condensed and edited.

Tina Vasquez: I have to say, I was particularly interested in speaking to you because I’ve never heard of a pipeline program and education fund like H-CAP that specifically works to dismantle institutional barriers for Black and brown healthcare workers.

Daniel Bustillo: It’s very different from traditional workforce development narratives that you might hear about, and what we do is especially needed right now. The pandemic has really brought a heightened level of awareness regarding structural inequities within healthcare, for both patients and workers. They are not new inequities, of course; they are the result of historical policy and current practices. Health care is a heavily raced and gendered field and that has a particular impact on Black and brown women. This is why we center our work explicitly at the intersection of racial and gender equity. It’s not just about training or skills or educational attainment. Without centering racial and gender equity, you’re not getting to the heart of job inequality. Most people tackle one or two of these things and in workforce development narratives, you’re really just tackling skills attainment.

Health care is the fastest growing job sector in the U.S. and it is the largest sector in terms of employment in the U.S., and it’s rife with huge inequities. Occupational segregation is a real problem and you see an overrepresentation of Black and Latina workers in entry-level, lower paying, lower quality jobs like direct care work. There are major inequities in wages, working conditions, and job security—and you see how it plays out across race and gender lines.

Vasquez: Based on what I’ve read, apprenticeship programs are really central to H-CAP. Tell me why.

Bustillo: If you boil it down, apprenticeship programs are a way to remove some of the institutional barriers for entry into the higher paying positions. Registered apprenticeship traditionally has been a very white male-dominated field. We wanted to use the institutional power and ability that we have, and the partnerships that we have, to flip the traditional registered apprenticeship paradigm.

Within H-CAP, 65% of our registered apprentices are Black or brown, primarily Black and Latina. Over 86% of our apprentices are women. Nationally, the figure for apprentices for women is around 8 or 9%. I don’t care what anyone says: In health care, lived experience is really important. Most of the members that we work with live in the communities where they provide care, so helping women of color move up in the healthcare field also has an impact on the community.

Vasquez: I imagine that disrupting the demographics of registered apprenticeship also has an effect on the kind of occupational segregation you mentioned earlier.

Bustillo: It does, and it matters a lot in this moment because we are without a long-term, robust job stimulus program. We’re not going to get to pre-COVID levels of employment in this country again until 2023 or 2024. We have a massive job crisis and in health care and broadly, there is always a lot of focus on entry into a profession, but we have to think about supporting the existing workforce with opportunities for progression. More than 60% of direct care workers are BIPOC and they spend their careers segregated in lower paying entry-level roles that are really difficult. These are the same workers who have carried us through the pandemic and who have suffered severely. Creating a pipeline for workers to advance imbalances power in a good way, and allows workers who have been sidelined to aggregate power.

Vasquez: When Black and Latina women in the healthcare industry are relegated to specific kinds of jobs, or they’re locked out of union jobs or better paying jobs, what does that look like in practice?

Bustillo: Here is where it’s important to talk about adult learners. The typical thinking is that you need to create structures that support a progression to higher-paying, good union jobs. You have a lot of Black and Latina women in health care who have a lot of experience and if they want, they should be able to progress in the industry. On paper, you can map out how to progress along a career path, but it’s actually really difficult to actualize because there are multiple breakages along the path and frankly, existing systems are not really designed to support people along the path—especially if you are older. The median age of the workers that we work with is mid-40s and depending on the geographic location, 80% of these workers are immigrants.

Here is a tangible example from the perspective of an immigrant adult learner. Say you’re a certified nursing assistant (CNA) and you want to progress in your career and become a licensed practical nurse (LPN). Oftentimes, LPN programs are five days a week. What happens if you have kids and other family to support? You still have to work while you do this program. How do you go to school five days a week while still making a wage that enables you to support your family? Usually, it means people are pulling double shifts on the weekends. That’s a seven day work week for years. That is overwhelmingly difficult. There’s no way that I could do that right now.

Vasquez: I don’t even have kids and there’s no way I could do that.

Bustillo: Right? Really think about what that would be like and understand that you’d be doing all of it without the support of a union or an organization like H-CAP that would provide the support that is needed, even basic stuff like getting an employer to accommodate your schedule or provide funding support or supportive services. Without that, you are setting people up to fail from the beginning.

Vasquez: Talk to me about the National Center for Equity and Job Quality in Long-Term Care. I understand it’s a new initiative that H-CAP is launching for long-term care workers, who are overwhelmingly Black and brown immigrants that experience some of the worst wage standards and working conditions in the healthcare industry.

Bustillo: Dismantling inequity within long-term care is really essential to the future of healthcare. We were fortunate enough to get a three-year foundation grant to launch something really groundbreaking. The National Center for Equity and Job Quality in Long-Term Care will focus on the narrative and policy changes needed to help raise the floor on standards across the field. This is a really opportune moment to do this because of the Biden administration’s caregiving plan, which is centered on raising the floor of occupations as opposed to telling people they have a skills gap, which is something that always really bothers me. That basically says: “It’s up to you to acquire the skills that you reportedly don’t have, in order to proceed to this higher paying occupation.”

Vasquez: I don’t want to just flatten this to “diversity,” but what you’re saying has me thinking about reporting I did on the American Nurses Association and the overwhelming whiteness of the organization and their refusal to speak out against the Trump administration during the pandemic, even as healthcare workers were dying. In doing that reporting, I thought a lot about what it must be like for women of color nurses navigating the healthcare industry. But I also thought a lot about what it means for patients. If Black and Latina women can’t move along in the healthcare industry, what does this mean for patients?

Bustillo: I think that’s an important question to ask. In nursing, an occupation where the requirements to become a nurse have just increased, a two-year degree used to be sufficient. Now that is no longer the case. In many places, it’s a four-year degree. If you look at the demographic breakdown as you transition up the traditional nursing ladder, you see an overrepresentation of Black and brown workers at the entry level among CNAs. The higher you move up, it becomes overwhelmingly white. This is an occupational segregation issue—and it clearly makes a difference. We have so much evidence that when you have patient-provider concordance, it makes a difference in patient care outcomes.

This is why a core part of our work to lessen occupational segregation. There’s still a lot of work to do. There’s a general understanding in our industry that this is a serious issue, but few are attempting to tackle it in any real substantive way. COVID has absolutely put a spotlight on disparities experienced by both caregivers and patients that are not new, and we’re seeing it play out with vaccinations as well. Whites are overwhelmingly vaccinated compared to other groups. We see disparities everywhere in the healthcare system.

Vasquez: President Joe Biden has already signaled that federal worker protections are going to be important to his administration. How are you thinking about the next four years under this administration, is there an opportunity here for healthcare workers?

Bustillo: I do think this is an interesting moment, one where we can potentially increase quality of jobs, access to good benefits, access to unionization, and access to training opportunities for direct care workers. This is the work we’ve been doing, but now we are looking forward to playing a part in supporting that work nationally. There is clearly also an opportunity around registered apprenticeship. At the end of the last legislative session, the House re-authorized the National Apprenticeship Act and it’s going to be introduced again.

The big thing I’m really thinking about is building back better. I don’t want to go back to what existed before because that clearly did not work for so many people and so many communities. We have an opportunity to move the needle. I’m feeling hopeful that we can do things differently. Is it going to be everything we want? No. But it’s our job to continue to push for as many healthcare workers as we can and to make sure we’re doing it in a way that explicitly focuses on racial equity and gender equality in the industry.

In part two of this series, hear directly from Trinidad Garcia de Ochoa, a former hospital housekeeper who participated in an H-CAP program and is encouraging other Latino immigrants to do the same.

Tina Vásquez is the editor-at-large at Prism. She covers gender justice, workers' rights, and immigration. Follow her on Twitter @TheTinaVasquez.