Organizing Home Care

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

1. Robin Herman, “Demand for Home-Care Workers Is Rising in City,” New York Times 2 October 1981.[↑]
2. Patrick McGeehan, “For New York, Big Job Growth in Home Care,” New York Times 25 May 2007.[↑]
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.[↑]
4. See “Demand Still Rising Fast for Direct Care Workers” on the Direct Care Alliance, Inc. blog (accessed 27 December 2009).[↑]