Beyond “care deserts”: a new metric for mapping formal care employment equity in the United States

The formal care economy, including paid labor in health care, education, and daily living support, is essential to individual well-being and national productivity. Yet access to these services remains geographically unequal across the United States. Existing approaches commonly measure either within-area inequality (e.g., Gini coefficient) or regional specialization/adequacy (e.g., location quotient (LQ)), but rarely integrate both dimensions in a way that supports consistent classification and comparison across places, sectors, and time. Here, we develop the Care Resource Equity Score (CaRES), which integrates the Gini coefficient and the Location Quotient to quantify the joint distribution of care employment across internal regions and its regional concentration. Using U.S. census tract data aggregated to all counties from 2009–2021, we classify counties into four care-employment typologies using common thresholds: low inequality (Gini < 0.5) vs. high inequality (Gini > 0.5), and below-average concentration (LQ < 1.0) vs. above-average concentration (LQ > 1.0, relative to the national average). The resulting categories are Equitable Coverage (low Gini, high LQ), Concentrated Access (high Gini, high LQ), Even Desert (low Gini, low LQ), and Unequal Scarcity (high Gini, low LQ). Applying CaRES across health care, education, and daily living sectors, we found that most counties fall into either Unequal Scarcity or Concentrated Access, indicating that care employment is typically either under-supplied and unevenly distributed or abundant but spatially concentrated. Nonmetropolitan counties, especially small-town and rural areas, disproportionately exhibit Even Deserts, whereas metropolitan areas more often exhibit Concentrated Access, reflecting localized inaccessibility despite overall resource abundance. Over time, average within-county inequality declines, but this trend is often accompanied by a decline in relative care-employment concentration, suggesting that more even spatial distribution can coincide with growing scarcity. The resulting typology provides an interpretable, scalable tool for identifying distinct types of care-access challenges and for targeting policy responses that differ between places facing scarcity and those facing concentration.