After fracturing her hip in 1981, Ethel Hunter, an 80-year-old stroke survivor, just "needed somebody to take care of [her]" so she could remain in her Forest Hills, New York apartment. She gained that aid through the minimum wage labor of Haitian immigrant Maryse Williams, who was paid by the city to "help her bathe and dress, cook the broiled chicken that she likes, clean her house and take her outside in a wheelchair." Williams was one of what was then 28,000 New York City home attendants providing personal care and undertaking household chores for frail elderly and non-elderly disabled persons who qualified for Medicaid. Such "domestic workers," as the press and public officials called attendants like Williams, allowed people to avoid institutionalization by substituting for absent family members. Their "humane and vital service" also saved the government the cost of "more expensive nursing homes"—but only because of minimum wages and lack of benefits that kept workers poor despite state promotion of such jobs as an alternative to welfare dependency.[1] From the early 1990s until 2005, home care and health care jobs accounted for the most employment growth in New York City.[2]

Personal attendants and home health aides like Maryse Williams are America's front-line caregivers. Predominantly Latina, Black, and immigrant women, they labor without health insurance, paid sick leave and vacations, or worker compensation.[3] Because of their location in client homes and the dense network of state contracts to private agencies, both the public nature of the job and the employment status of the worker are obscured. With workers employed by a municipal or proprietary agency, private charity, public hospital, or family, home care has existed in a clouded netherworld between public and private, employment and family labor, health care and household service.

As the population in the U.S. ages and family members are less available to care for elders, we have come to rely on this vast 'invisible' workforce to provide long-term care. But the U.S. has never implemented a social insurance or dedicated program for long-term care at home. Instead, it has relied primarily on means-tested social services available only to the poorest people. This financing of care through the welfare system has fundamentally shaped the entire labor market for care, whether "public" or "private." State policies have made it difficult for even middle-class people to go out and hire someone to look after their loved ones because it has turned home care into a low-paid job.

Home care emerged as a modernized form of domestic work when state policies transformed intimate labor, performed by wives and mothers, into a social service authorized by state bureaucracies and financed by taxpayer funds. State policy both mirrored and facilitated the restructuring of domestic labor from an informal agreement between mistress and maid to a formal labor market in which a third party—a non-profit, proprietary, or government agency—functioned as the employer, standing between worker and client. This 'modernization' was never complete; a gray market expanded to offer attendants to those ineligible for state services. This largely affected the vast middle class, which otherwise has to spend down its assets to qualify for publicly funded care. By the late twentieth century, home aide was one of the fastest growing occupations in America; yet the occupation had no clear-cut employer, common workplace, or recognition under the nation's primary labor law, the Fair Labor Standards Act (FLSA).[4]

Home care, as a distinct occupation, emerged in the Great Depression both as work relief for New York's unemployed Black women who had previously worked as domestic servants, and as an alternative to fiscally strained public hospitals.[5] The New Deal employed what at the time were called visiting homemakers directly through the Works Progress Administration (WPA) to help poor families and individuals with medical emergencies, chronic illness, and health problems surrounding old age, while curtailing the costs of institutionalization. The WPA also initiated programs to move such people out of hospitals and give them the necessary assistance to become 'independent' at home.

While New Dealers developed home care as a form of relief for both providers and receivers, they ignored it as an occupation. When the Democratic Congress passed old-age insurance, unemployment benefits, collective bargaining, minimum wages, and other labor standards, it excluded nurse companions, homemakers, and in-home workers from coverage.[6] Even when Congress amended the FLSA in 1974 to include domestic workers, it specifically exempted home care workers from coverage. The Supreme Court reaffirmed this exclusion in 2007.

After World War II, New York City's Department of Welfare offered the most successful model of a public program for home health care services. It directly employed home aids, still called homemakers, worked closely with private social welfare agencies, secured federal funding, and extended the service from child to elder care. Home care further grew as both an expansion of the hospital and as an attempt to alleviate the number of charity and chronic cases overburdening hospitals. The Great Society, the domestic programs initiated by President Lyndon B. Johnson in the 1960s, enhanced home care through new services for the aged and poor, especially Medicare and Medicaid. Specifically, War on Poverty training programs sought to channel poor women into these jobs. Recruited from families on public assistance, homemakers cared for others from the same social class.

From 1945 until the 1970s, these workers belonged to a booming municipal public sector, despite their actual workplaces being private homes. New York defined them as public employees able to receive benefits with limited Civil Service protections. Unlike a typical domestic, city homemakers officially worked a forty-hour week and received health insurance, sick leave, and paid vacation. In the early 1960s, the City employed 263 full-time workers, covered by a collective bargaining contract with the American Federation of State, County, and Municipal Workers (AFSCME).

In the late 1960s, however, New York State started to change course as it sought to counter militant public sector unionism, the welfare rights movement, and growing public welfare spending. After 1969, it began to privatize the home aide workforce, reclassifying workers as independent contractors. A new part-time and casualized employment structure emerged. Renamed home health attendants, their numbers soared to over 12,000 by the mid 1970s.

The contractor strategy resulted in marked deterioration of both the conditions of labor and the care received. Repeated investigations found egregious problems for both workers and clients. As a consequence of not being covered for over-time, some home attendants ended up making less than minimum wage. Audits found "inordinate delays and errors in payment," with workers waiting weeks or even months for wages. Attendants often called the mayor's office to complain of utility shut-off notices. Elderly and disabled clients reportedly drew upon "their own Supplemental Security Income checks" to help attendants. The Division of Home Attendant Service and its vendor agencies also seemed to exploit the caring part of home health care.[7] For example, there were weeks in which housekeepers received no paychecks at all, yet they continued working, since they could not abandon their clients. Despite these known problems, policymakers continued to insist that welfare recipients be pushed into these jobs to end their "dependency" on the state.

Workers began to organize and fight back in the late 1970s, especially as they came to recognize that they were largely serving clients of the Division of Home Attendant Service. During August 1977, a grassroots organizing effort emerged in the South Bronx amongst disgruntled home care aides who had not been paid for weeks. With guidance from a grass-roots neighborhood organization, La Raza Unida, a core group of Afro-Caribbean, African-American, and Puerto Rican women organized a union. Although employed through the Morrisania Community Corporation, a vendor agency, they went to the city government to demand redress. After waging an eight-day strike, with help from the Teamsters the women won union recognition. The City, however, had no intention of bargaining and instead terminated its contract with Morrisania and reassigned the women to other agencies. While not an individual success, this was just the beginning of a new social struggle.

Other unions started paying attention. The civil rights movement had begun to emphasize the status of domestic workers, pushing New York State to pass collective bargaining legislation for household workers. In response, New York's flagship local of the Service Employees International Union (SEIU), 32B-32J, launched an organizing campaign among household workers "to organize and to free you good people from slavery."[8] When SEIU sought to win bargaining rights for household workers as public employees, the city outmaneuvered them by shifting all clients to agency vendors. Thus, the union had to organize each agency, whatever the size, one at a time. The initial response was tremendous, but this strategy soon succumbed to the hassle of having to define bargaining units piecemeal, and to an ever-shifting labor force while state budgets constrained agencies from negotiating real wage increases.

New York's hospital workers' movement, Local 1199, however, knew how to turn workplace drives into political campaigns. In 1987, it launched (with AFSCME) the Campaign for Justice for Home Care Workers, joining forces with non-profit vendor agencies to press for greater appropriations from Albany. It mobilized significant community pressure, as well as support from clergy, including Cardinal John O'Connor, and political leaders, such as Jesse Jackson. In 1988, after unprecedented negotiations between Governor Mario Cuomo's office and the unions, the state allocated more funds to home health care and agreed to a major wage increase, health insurance, guaranteed days off, and prescription drug coverage.

This political deal was not enough to resolve the ambiguities of employment that hampered long-term rights and job security. Workers still lacked the protection of the nation's basic employment law. The intimacy of the work and its location in private homes continued to obscure care work as labor in multiple ways: through ideological and discursive dismissal of such labor as real or worthy work; through the service ethos of some care workers that leads them to work beyond their paid hours; and through legal classification that refuses to recognize the home as a workplace and the care worker as a worker. Home care workers and their disabled and senior clients and allies have both had to challenge pervasive stereotypes and representations. Home care workers are characterized as self-sacrificing workers, while their clients are stigmatized as helplessly dependent on others, as well as on the state.

Our forthcoming book, Caring For America, traces the various stories of home care workers. We follow home care's political trajectory in both New York and other cities, such as Chicago, Los Angeles, and San Francisco, to see how workers and community organizers experimented with strategies that would make unionism in this sector succeed for clients and caretakers. Successful strategies include organizing in the community, direct action tactics, mass visits to the legislature, female rank and file leadership, and a new kind of steward system that could meet the needs of workers who often could not leave the home. We also write about social movements among the disabled and the elderly, which became crucial to home care workers organizing. Not only did workers organize on their own, but they cultivated political strategies and relationships at the state level. They too sought public benefits that would enable them to live with security and dignity. Together, they took labor that seemed private and projected it into the public sphere, turning the welfare state into their terrain of social struggle. They have also had to build concepts and strategies reflective of the increasingly complex inter-personal relations essential to care work.

Before the current recession, New York's home care aides made less than those in California, where unions more successfully gained higher wages through bargaining with the state. Many still had to rely on the strategies of the poor—turning to welfare or Medicaid, living with relatives, and taking on extra jobs. One of these retired workers, Jamaican immigrant Evelyn Coke, became the plaintiff in a high-profile lawsuit initiated by SEIU to challenge their exclusion from FLSA. Coke spent twenty years cooking for, cleaning up after, and bathing clients on Long Island, sometimes working twenty-four-hour shifts but rarely paid for overtime.[9]

Coke v. Long Island Care at Home exposed the limits of the search for care on the cheap. In its brief to the Supreme Court, New York City rationalized the exemption on the basis of expense. In contrast, civil, women's, and immigrant rights groups stressed the need to correct prior discrimination against household workers and revalue domestic labor. In foregrounding the concerns of receivers of domestic and personal services, Associate Justice Stephen Breyer erased the presence of providers. The Court unanimously ruled against Coke in 2007.[10] However, it left open the door for Congressional action or administrative rule changes. Long-term care could be added to social insurance, so that it becomes a right of citizenship.

Yet as our historical research has found, it takes personal and social transformation to tackle the more fundamental challenge: revaluing the labor of care. Trade unionism or other forms of collective organization, as with Domestic Workers United in New York, enables home-based caregivers to find others doing the same labor, recognize it as real work, form cultures of solidarity across race and ethnic lines, and become active political agents who put in the forefront the most urgent needs of our society. Such care worker unionism pleas for larger social benefits, advocating better care and better jobs. It not only seeks to make the home a place of dignity and respect for all those who labor there, but to recognize our fundamental human connection.

Endnotes

1. Robin Herman, "Demand for Home-Care Workers Is Rising in City," New York Times 2 October 1981. [Return to text]

2. Patrick McGeehan, "For New York, Big Job Growth in Home Care," New York Times 25 May 2007. [Return to text]

3. Rhonda J.V. Montgomery, Lyn Holley, Jerome Deichert, and Karl Kosloski, "A Profile of Home Care Workers From the 2000 Census: How It Changes What We Know," The Gerontologist 45: 5 (2005), 593-600. [Return to text]

4. See "Demand Still Rising Fast for Direct Care Workers" on the Direct Care Alliance, Inc. blog (accessed 27 December 2009). [Return to text]

5. This narrative appears in another from in our book, Caring for America: Home Health Workers Under the Shadow of the Welfare State, forthcoming from Oxford University Press. [Return to text]

6. Mary Poole, The Segregated Origins of Social Security: African Americans and the Welfare State (Chapel Hill: University of North Carolina Press, 2006). [Return to text]

7. "Report on the Quality of Care and Operating Practices of the Home Attendant Program: Summary of Significant Observations," Oct. 25, 1978, unpublished manuscript, New York State Library; Metropolitan Regional Audit Office, "Audit of Home Attendant Services, New York City, Department of Social Services, #76-835-S-029-58," Aug. 1977, McMillan Library, NYC, 8, 14-18; Joan Shepard, "Payroll Foulup Angers Home Health Attendants," New York Daily News, 16 December 1977; Peter Khiss, "Program to Aid Elderly Sick Poor Marked By Fraud, State Audit Says," New York Times, 15 December 1977; Richard Severo, "Troubled Program for the Disabled," New York Times, 27 December 1977. [Return to text]

8. "Union Steps up Drive to Organize Household Workers," 32B-32J Newsletter, 46 (May 1978), 1. [Return to text]

9. Steven Greenhouse, "Justices to Hear Care on Wages of Home Aides," New York Times 25 March 2007. [Return to text]

10. Long Island Care at Home, Ltd. v. Evelyn Coke, 127 S.Ct. 2339 (2007). [Return to text]