On June 30, the Supreme Court ruled that a key strategy used by unions to raise the earnings and professionalism of home-care workers was illegal. Since the 1990s, the labor movement has worked with states and countries to get laws or executive orders to allow home-care workers to be treated as employees of public authorities rather than as individual contractors. The result has been to allow these workers to form unions and to bargain collectively with government for better wages and working standards.
In the Harris v. Quinn case, however, the Court held that workers could still unionize, but that they were not true public employees. Unions thus could not collect dues from workers who choose to remain outside the bargaining unit. The Service Employees International Union, which pioneered the strategy, took the ruling as a temporary setback but also as a challenge to redouble organizing of home-care workers. This campaign may yet succeed, but in the short run these workers will have a harder time bargaining for decent wages.
Less visible, but perhaps equally damaging, is the harm this ruling will cause an increasingly vulnerable group of elderly and disabled care “consumers.” In theory, the interest of workers can be at odds with that of consumers, because higher wages typically mean higher costs, whether for taxpayers footing Medicaid bills, middle-class families paying out of pocket, or long-term care insurance companies calculating premium costs. When higher costs hit limited budgets, care needs are likely to go unmet. By this reasoning, cheaper care means more care and more benefits for consumers.
But the care “market” (if you can call it that) doesn’t work that way. Care isn’t something you just pour into a measuring cup and sell by the ounce. Its quality matters—and varies enormously, affected not only by the motivation, experience, and skill of the care provider, but also by empathy with a client who is not just a consumer.
Home-care workers are paid to help people with basic activities of daily living in their homes. They are among the fastest-growing segments of the U.S. labor force, not merely because the share of elderly in our population is growing but also because home- and community-based care is a cost-effective—and widely preferred—alternative to nursing-home care. Many states have figured out that Medicaid funds targeted for people with disabilities and the low-income elderly needing assistance are best spent helping those who can get by at home.
Yet policymakers—and probably many other people who have never needed to hire a caregiver—continue to make the outdated assumption that this is menial, low-skilled work. Until recently, federal labor law put home-care workers on a lower tier than domestic servants, exempting them from the minimum wage and overtime requirements of the Fair Labor Standards Act on the grounds that they were merely providing “companionship.” (This provision was revised by the Obama administration in 2013, potentially benefiting some 2 million home-care workers.)
Mere companionship may have been an expectation fifty years ago, when most people could rely on a mother, wife, or daughter to meet most of their care needs, and hired a “sitter” to help fill in for family members. But today, many women are constrained by demands of paid employment, and more elderly people (including many widows who have outlasted their husbands) are living alone. Cost pressures tend to shove people quickly out of hospital care, leaving them to manage their own treatment for ongoing illnesses such as cancer or the chronic diseases of old age, such as diabetes, congestive heart failure, and dementia.
Often a paid caregiver is the only person left standing between a needy client and a hospital emergency room. In our focus groups and interviews with fifty Personal Care Attendants (PCAs) in Massachusetts, we learned a lot about what that takes. Twenty-one of the PCAs answered detailed questions about their time use and we found that 62 percent of their clients lived alone. Many needed time-consuming help with meal preparation and housework, but a large majority (86 percent) also needed help with medication. About 76 percent needed help with bathing, and at least half needed assistance transferring out of bed and/or going to the bathroom.
People who rely on home- and community-based care are, almost by definition, people who need personal, individualized, customized attention. Reflecting that, virtually all the PCAs we talked with emphasized the emotional demands of the job. They embraced the responsibility of giving affection and many described incidents in which they willingly went far beyond their specific job description.
In one instance, a disabled child got lost on his way home from school, and his family turned first to the PCA who worked with him. She had to stop what she was doing at home, talk to the police, and go pick him up when he was found. She seemed cheerful, even proud that she was able to provide such effective assistance. But she also felt her work was undervalued, asking: “How do you put a price tag on something like this?” In fact, the price was zero because rescue was not on her list of assigned tasks.
Another home-care worker described getting a call at 2 a.m. from a client who cried, “I fell and can’t get up.” The PCA told her she should call an ambulance, but the elderly woman seemed terribly anxious, explaining, “No, I don’t want to do that, I’d rather wait for you.” This PCA went over, on her own time, to help with the ambulance transfer. Another PCA described paying out-of-pocket for a cab to the hospital with a client who wanted her to accompany him. She spent the night there in his room, also “for free.”
PCAs deliver care in skilled and mindful ways, rather than simply doing whatever their clients ask. One explained that her client, a disabled teenage girl, needs to learn greater independence to improve her future. “I am very patient," the careworker explained. "She needs to do things for herself and her family maybe does a little too much for her. So …I just take time.” Some of her strategies to help this teen have been learned at meetings at the union office with other experienced PCAs. She said she is grateful for this “chance to talk it over.” Isolated in clients’ homes, these workers have little opportunity to learn from one another or gain access to training opportunities. They describe their union as a source of information as well as advocacy.
Most home-care workers try hard to connect with their clients. They recognize that people who need care at home come in all kinds of packages, and with all kinds of needs. To ask for assistance with basic activities of daily living is to relinquish both privacy and pride. Most clients would strongly prefer to hire a family member or someone who closely shares their cultural or religious background. Above all, clients and their families seek home-care providers who practice concern and compassion. Having found a good match, they hope and pray for continuity of care, a long-term relationship.
But home-care workers have a hard time achieving the stability they need to turn their calling into a decent job, much less a career. And they deserve some reciprocity from a society that relies heavily on their commitment. In 2012 their median national hourly wage was only $9.57 per hour. That adds up to about $20,000 per year for those members of this predominantly female and disproportionately black, Latino and immigrant labor force who are able to find full-time employment. Since few people who need care qualify for that much assistance, many workers are forced to spend considerable unpaid time on the road, juggling part-time jobs in other households.
The stresses of dealing with physically and emotionally needy clients are compounded by the difficulty of paying their own bills. PCAs are often caught between the demands of their work and their own family needs. The conflicts can be wrenching. As one woman put it, “I’d hate to quit after five years of taking care of her.” But quit she might if her wages don’t rise and she continues to be denied any sick leave. This kind of turnover is a hidden cost to clients and their families.
Another home-care worker told us of trying to find a job parking cars because the hourly rate was better than taking care of his elderly clients. “You hate to just up and quit but…my kids have to eat.”
Home and community-based care requires a labor force that has incentives to remain on the job and to develop new skills. This helps explain why states like Illinois (where Harris v. Quinn was filed) and Massachusetts have applied the “public authority” model that allows home-care workers authorized by the state’s Medicaid program to be paid directly by the state and collectively bargain with it. This model is good not only for the workers, but for the citizens who rely on them, because it produces better compensated workers. That, in turn, improves morale, motivation and professionalism.
Economist Candace Howes conducted a detailed statistical analysis of the impact of the public authority and collective bargaining approach in California. She found that turnover for new workers over a six-month period plummeted from 70 percent to 35 percent. Because public authorities were set up on the county level, with variable success in union bargaining, the wage effects varied considerably. But in the San Francisco and Sacramento areas, union efforts raised wages as high as $12.34 an hour compared to $8 an hour in counties with no contract.
The Service Employees International Union has won significant wage gains for unionized workers in states with a public authority model (see SEIU's Overview of Homecare Collective Bargaining) as well as major improvements in job training and career ladder development.
In her California research, Howes found that the higher wages and health insurance that workers gained through unionization made it easier for families to hire the care providers they preferred, rather than whoever might be available at a wage barely above the minimum.
Many studies show that high-quality care at home helps reduce emergency room and hospital visits, as well as lessening the likelihood of entering costly nursing home facilities.
These benefits are relevant not just for states trying to minimize health care costs, but also for families who may need to hire someone to help them care for a loved one.
Unionization improves the stability, reliability and experience of the care labor force, benefiting consumers as well as workers. What labor economists term a “high road” strategy costs more up front, but leads to a safe destination. The low road may seem cheaper, but the monetary savings are outweighed by the costs both to workers and to their clients. When the Supreme Court ruled that home care workers enjoying the benefit of a democratically chosen union under a public authority model don’t have to pay dues, it harmed those needing home care, as well as those providing it.