A new report from the Paraprofessional Healthcare Institute describes home-care workers as personal aides, independent providers, home health aides, nursing assistants, and even informal networks of family members that provide living assistance, housekeeping chores, medication management, and a host of other services for elderly people and people with disabilities. About 1.4 million of these workers fulfill the kind of formal roles tracked by the Bureau of Labor Statistics—working for firms or insurance companies—while almost a million more are ad hoc “independent providers” who are employed directly by patients or their families. Almost three-quarters of the payment for services provided by home-care workers comes from public-insurance programs Medicaid and Medicare.
The millions of home-care workers operate in one of the fastest-growing fields in the country—one that will add more jobs over the next decade than any other occupation. The American population is aging and the number of elderly people will double over the next 40 years, a spate of growth that will require even more people to enter the home-care workforce.
While the field is rapidly expanding and funded by insurance programs that have been reformed by Obamacare, in many ways it resembles the domestic work that for so long dominated employment options for women of color in the United States. Almost a quarter are immigrants, most did not receive a college degree, over a third are covered by public health insurance themselves, and a quarter have no insurance at all. That point deserves emphasis: A quarter of these people who toil to make the health-insurance system function do not have health insurance themselves. According to a 2008 study, workers across domestic services and home care are subject to exploitation and instability. For many, that exploitation includes assault and abuse, and women of color and recent immigrants often find reporting abuse or seeking legal protection too risky to attempt.
The big problem for home-care workers appears to be the same one that has plagued domestic workers since the days of black in-house “help”: that in-home service work has been subject to a gendering and racialization of labor that has largely carved it out of the labor movement, creating barriers to the kind of protections afforded to unions and industries mostly comprised of men. While organizations led by women of color have a strong history of organizing to advance the interests of in-home workers, domestic workers are still exempt from many provisions of the Fair Labor Standards Act and the National Labor Relations Act. Home-care workers—as members of a more regulated industry where strikes and labor shortages directly endanger lives—are afforded more protections than domestic workers, but still lag far behind others in the health field. While home-care workers are much more likely to have health insurance than domestic workers, their wages often still fall well short of living wages. Home-care workers were only just granted full federal overtime and minimum wage protections in October 2015.