There are two million home care workers in the United States. They change diapers, administer medications, bathe and dress people and transfer the immobile from one place to another. They also take care of tasks that are mundane annoyances to most of us — doing the dishes, cooking, vacuuming — but that make a world of difference to an elderly or disabled person who hopes to maintain a sense of dignity and security as they age at home.
And they do this without overtime pay or minimum wage protections. That is because home care workers are not covered by the Fair Labor Standards Act. This legislation has historically excluded them (and other domestic laborers) from its purview because of something called the “companionship rule.” Believed to be “casual” companions to the elderly rather than laborers in the conventional sense, home care workers — even those working at for-profit agencies — have long been denied the security of a living wage. And this is despite the fact that they are on the front lines of care provision for a rapidly expanding population of elders - by 2025 there will be over 65 million Americans over 65. The profession is expected to grow, with one million more home care workers by 2022.
As many Americans struggle to piece together care for their elderly or disabled loved ones, it’s time to look at how we value home care work.
The fight for better conditions
In 2013, home care workers received a glimmer of hope when the Department of Labor narrowed the companionship rule. Under the new regulations effective January 2015, home care workers were to be covered by the Fair Labor Standards Act, granting them access to overtime pay and minimum wage protection.
But on January 14, 2015, US District Court Judge Richard Leon overturned the Department of Labor regulations, arguing that the DOL overstepped its bounds and must leave the issue of the companionship rule to Congress.
This ruling certainly works to the advantage of home care franchisees who perceive regulation as a threat to their US$90 billion industry. In fact, the case against the DOL was led by the Home Care Association of America, an organization that supports and promotes for-profit home care agencies. It is expected that the DOL will appeal the ruling and that the case will eventually make its way to the Supreme Court.
While this legal wrangling goes on, home care aides work while living in poverty. The median hourly wage for a home care worker in the US is $9.38, with considerable variation across states. What does that mean over the course of year? In terms of Median annual wages in 2012, the lowest ten percent of home care aides earned less than $16,330 whereas the top 10 percent earned $27,580.
According to the Paraprofessional Healthcare Institute, over half of aides live in households whose income puts them at 200% below the poverty line. One in three have no health care coverage and 56% rely on public assistance, including Medicaid, Supplemental Nutritional Assistance or child care subsidies, to make ends meet.
High turnover is a problem in home care and there is increasing evidence that higher pay is associated with a greater likelihood of aides staying on the job. Further studies are needed to confirm the benefits of home care with respect to expense and health outcomes, but existing evidence suggests that for many seniors, aging at home is both cost effective and psychosocially beneficial.
Some aides work informally for neighbors and friends, some for private for-profit companies, while others work as independent contractors in consumer-directed programs. Some states in the US require agencies to provide orientation or in-service training.
This is not just companionship
Home care aides take on the paid care work that few others are willing or able to do. They attend to bodies and minds to help ensure that other human beings — many of them in the last years of life — are well cared for and able to live in their homes.
As more of us face the realities of aging, or caring for aging parents, we can no longer afford to ignore the inequities associated with our system of paid care. We have to connect the dots between our personal crises — a dying father, a sister with cancer, a child with a severe disability — and the crises faced by the millions of home care workers who help us manage the daily realities of caregiving.
Caring is work
The time is ripe for a new conversation about care. To begin, we should reconceive of care as not only an act of love or altruism, but also as a form of labor, worthy of fair compensation.
We have to rethink our understandings of paid work. We may have little trouble conceiving of housecleaning as work, but we are less sure whether the emotional and relational dimensions of caregiving constitute labor. Is it work to listen to someone telling stories of days gone by? Is it work to hold a dying person’s hand so they feel less afraid? Is it work to wheel an elderly person to the park so she can feed the birds?
While we lack clear answers to these questions, most people acknowledge that there would be real consequences if aides weren’t paid to perform these tasks: the elderly and disabled would suffer both physically and emotionally, families would be burdened financially, and the costs of care would likely rise as people leaned disproportionately on institutional care.
We seem to understand on some level that home care should be compensated, but we are conflicted about how much value – or money – we should assign to the labor.
As the struggle for fair working conditions for care workers continues, Americans should begin to look carefully at their own care arrangements and ask themselves this question: What is care worth?