The Health Care Aide Conundrum

Medical science can keep us alive well beyond our expiration date. That was what my father told me when he was in his 90s, a message I understood. He was alive, as long as breathing was all one wanted from life, but he struggled to walk, to remember names, to manage his personal hygiene. The problem was that he knew he was failing, his life pretty much sucked, but there he was, waking up every morning anyway. He wasn’t about to do anything to change the status quo, but when it came, he was ready and it was fine with him. He remembered what it was like to be able to enjoy life.

As the population ages, and it is indeed aging thanks to medical science’s ability to keep blood pumping if no other part of our anatomy, the need for care becomes increasingly problematic. First, caring for the elderly isn’t exactly a fun job, even if they can be cute at times. Their needs are constant. Senile dementia isn’t as adorable as they make it look in the movies. They can be downright unpleasant and demanding, often quite offensive without being entirely responsible for what they say and do. Who wants a job like that?

That could be about to change: In his address to Congress last month, President Biden highlighted the $400 billion he proposes to spend on home- and community-based services for older adults and people with disabilities. It’s part of his $2 trillion American Jobs Plan to shore up infrastructure. The plan, he said, could make all care jobs good jobs, with “better wages and better benefits,” no matter where workers happen to live.

We tend to categorize jobs based on some normative notion of what the job “deserves” to be paid. There’s a strong argument to be made that the aides who care for the elderly deserve a lot. It’s not an easy job. But that’s not how wages are determined, and as much as caring, tolerance, honesty (there’s a lot of opportunity for taking advantage of the elderly for obvious reasons) and, dare I say it, empathy are critical to the service they provide.

Despite the demand for home care workers, wages are low: a median $11.52 an hour in 2018 (the average went up in 2020 because of temporary Covid-19 hazard pay increases). More than half of home care workers qualify for public benefits. And the people who make up the work force for these jobs are often vulnerable and marginalized: Nine in 10 home care workers are women and nearly two-thirds are people of color.

This profession of mostly women and women of color was left out of the Wagner Act in 1935 and the Fair Labor Standards Act in 1938 — exclusions that many  scholars believe  were  designed to reinforce white supremacy and patriarchy.

The unfortunate framing is unfortunate, false and misleading. Home health aides aren’t a profession. There’s no educational requirements, no licensure, no ethical code and no organization to enforce ethics. Pretty much anyone can get the job for the asking, making it a job of last resort for people unqualified for any other job.

But it wasn’t left out of the Wagner Act for nefarious reasons. Rather, domestic workers were not covered because they didn’t fit into the paradigm of craft or industrial employees. They were one person working in a home, not assembly line workers unionized to negotiate with a big corporation. Then again, most domestic workers were black women, and this is one of the times when reinforcing racist and sexist divisions applies pretty well.

As a result, home care workers were denied the federal right to organize and collectively bargain, and the right to a minimum wage and overtime pay.

But in recent decades, home care workers have won important victories. In 2001, home care workers in Washington won the right to collectively bargain. One necessary tool for enabling independent providers to come together is designating an “employer of record.” Without one, each worker is simply an independent contractor, unable to force the state to negotiate.

Washington State created a Home Care Quality Authority to serve as the employer of record, and in 2003, the workers represented by the S.E.I.U. negotiated their first contract with the state. Since then, they have successfully renegotiated their contracts several times with the state.

This reflects a mechanism to work around the exclusion of domestic workers from laws that would otherwise apply, but it comes with a lot of baggage that goes unmentioned. It turns domestic workers into public employees, whereas the Wagner Act only applied to private sector employees because nothing about labor relations dynamics makes any sense in the public sector. It removed the ability for the employers of health care aides to have a say in the negotiations, as their employees now work for the state which will negotiate their terms and conditions of employment on behalf of the people paying for it.

Given the growing need for home health care workers, this could ironically work to the disadvantage of some, whose experience and skills could command a higher salary than the union would negotiate. On the other hand, people get older but not necessarily wealthier, and may get priced out of the market for an aide by the negotiated increases. And Olds’ needs and circumstances vary widely, even as unions negotiate one-size-fits-all agreements with the state.

Do home health aides “deserve” to earn a decent wage? Sure, like anyone doing good, honest work and providing a valuable and necessary service. What that wage is, however, isn’t so easily fixed and will produce the usual unintended consequences born of solutions that ignore realities. No one wants home health aides to work for “starvation” wages. No one wants the elderly to be left alone without the help they need due to their inability to afford, or find, care.

5 thoughts on “The Health Care Aide Conundrum

  1. John Barleycorn

    Since you are doing math again, esteemed one, isn’t it about time you started posting up some exacta, trifecta, and superfecta predictions on the game of life?

    P.S. Before the lawyers fuck everything up, for a fantasy cut, do you think I should I tear up my my Mandaloun to win ticket or frame it? I was also wondering if the topic of this entire conundrum of a post, not to mention guilded fantasy math, couldn’t both be solved for good if the FDA just allowed the purchase of betamethasone over the counter?

  2. James

    Given the history (Washington State and Illinois), these laws are designed to classify family caregivers as SEIU dues paying members. Not sure how much it helps these families giving the SEIU a cut of the welfare.

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