Essential Work, Disposable Workers: Why Home Care Workers Need Labor Protections

A home care worker leaves her home in Cambridge, Massachusetts, to care for an elderly woman in Watertown on March 26, 2020.

This Labor Day, as the coronavirus crisis continues to grip the United States, it is more important than ever to stop and pay tribute to the contributions of workers by enacting policies to increase wages, provide benefits, and ensure labor and employment protections. In the past six months, the nation has seen societal and economic transformations previously not thought possible. And yet, in the face of new and unique challenges brought on by the COVID-19 pandemic, millions of essential workers continue to provide the services the country needs most.

Among these individuals are more than 2 million home care workers—home health aides, personal care aides, and nursing assistants—who provide in-home and community-based support to older adults and people with disabilities. This low-wage workforce is overwhelmingly female and is disproportionately made up of Black women and other women of color; moreover, nearly 1 in 3 home care workers are immigrants. Yet despite the vital services they provide, home care workers are excluded from a variety of worker protections, so they often lack the collective power needed to demand better wages and working conditions and to stay safe during the pandemic. Policy interventions are needed to ensure that these workers receive the compensation and protections they deserve.

Home care workers’ compensation and protections do not reflect the importance of their work

Home care workers provide essential services to Americans across the country: They assist clients with a variety of everyday tasks, ranging from bathing and cleaning to arranging health care and managing finances. Millions of American rely on these workers for their basic health and well-being. Moreover, with the population of older adults set to nearly double by 2050, demand for home care workers’ services will only continue to increase. Indeed, home care workers have the most projected job growth of any occupational category, according to the U.S. Bureau of Labor Statistics.

However, despite their essential role, home care workers—like too many others in the service and care industries—are often treated as disposable. The average home care worker earns a meager $13,300 per year and is more likely than other workers to be uninsured or underinsured. Because of low wages and inconsistent schedules, a quarter of home care workers live below the federal poverty line. Federal and state governments—more so than individual clients—bear the primary responsibility for driving this low-road employment. Home care services are primarily paid through Medicaid and Medicare reimbursements. However, there are limits to how much home care agencies can be reimbursed for this work, which suppresses wages even in the face of increasing demand and worker shortages.

Importantly, home care workers typically lack the labor rights and protections afforded to other American workers. In the 1930s, Southern lawmakers upheld their racist exploitation of cheap, Black labor by predicating their support for the National Labor Relations Act and the Fair Labor Standards Act on the exclusion of domestic workers—understood to include home care workers—who were, as they are now, predominantly women and people of color. Another hallmark piece of labor legislation, the Occupational Health and Safety Act, provided only limited protections for domestic workers; and the Civil Rights Act of 1964 also failed to protect them from racial discrimination or sexual harassment. Furthermore, while most home care workers gained federal minimum wage and overtime protections in 2015, “fissured” employment structures and employee misclassification continue to complicate efforts to hold employers accountable, with some home care agencies converting employees to independent contractor status in order to avoid regulation. Unfortunately, since home care workers still don’t have a federally guaranteed right to collectively bargain, they are often unable to join a union. And last May, the Trump administration further attacked home care workers’ ability to organize by making it harder for them to pay union dues.

Lack of protections have made home care workers even more vulnerable to COVID-19

Now, as COVID-19 spreads across the nation, home care workers’ lack of protections has put them at heightened risk as they continue their essential work providing care to older adults and people with disabilities. Because they work in private homes, there is often an assumption that home care workers are in safe environments. In reality, however, these workers confront many of the same occupational risks as frontline health care workers—but without the protective equipment or workplace safety rights. The intimate nature of home care work has made it difficult for workers to socially distance during the COVID-19 pandemic. On top of this, many home care workers have multiple clients, which requires them to travel between several different households. At the same time, their employers often have lower priority for personal protective equipment (PPE) than hospitals or nursing homes; a March survey found that more than 75 percent of home care agencies faced shortages of masks and hand sanitizer.

The drop in home care employment since the start of the pandemic likely reflects these risks. Even still, research shows that the direct care providers who are most at risk—including those with physical disabilities, those over age 55, and Black and Latinx workers—have continued going to work at disproportionate rates. Due to financial needs, many workers simply do not have the choice to stop working, even when there is a direct threat to their health. Even before the COVID-19 pandemic, only 1 in 5 home care workers were able to take paid time off for medical and family reasons. Now during the pandemic, workers without access to paid leave are forced to make an impossible choice between working to keep their paycheck or staying home to recover from an illness, to quarantine due to exposure to COVID-19, or to care for a sick loved one.

Policy interventions are needed to ensure home care workers have the protections they deserve

Policymakers can take a number of immediate steps to protect home care workers during the pandemic. For instance, they can pass the Coronavirus Relief for Seniors and People with Disabilities Act—introduced by Sen. Bob Casey (D-PA) and Rep. Debbie Dingell (D-MI)—which would temporarily bolster state Medicaid programs to increase worker compensation, provide paid family and medical leave, purchase PPE, and cover travel costs for workers to safely reach clients. State and federal governments should also distribute educational materials in a variety of languages; increase COVID-19 testing; and boost contract tracing for these workers. Finally, state unemployment and workers’ compensation systems that exempt or limit coverage for home care workers should be reformed and strengthened. In addition to these vital safeguards, home care workers ultimately need livable wages, quality health insurance, paid days off, affordable child care, and retirement security far into the future.

Treating home care workers as the essential caregivers they are begins with giving them the same legal protections as other workers—including the right to a union. Unions give workers a voice in raising industry safety standards, ensuring that protections are followed, and providing training. In doing so, they can also help improve the response to the pandemic.

While organizing home care workers who are paid directly by clients can be complicated, states can give agency-based workers—who make up the majority of the home care workforce—the right to unionize. With advocacy by home care unions such as Service Employees International Union (SEIU) Local 503 and SEIU 775, several states, including Oregon and Washington, already allow home care workers paid by public funds such as Medicaid to unionize and negotiate with state agencies for wages and benefits, even if they are hired directly by individual clients. Furthermore, a number of cities and states have passed Domestic Workers Bill of Rights legislation aimed at establishing minimum standards and portable benefits for all caregivers, regardless of employee status. Meanwhile, the California Senate recently passed a bill to include domestic workers under the California Division of Occupational Safety and Health (Cal/OSHA), which would give state agencies authority to establish workplace protections under OSHA to address the COVID-19 pandemic. In tandem, state agencies could adopt an airborne infectious disease standard, something the proposed Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act would mandate for the federal OSHA.

Policy solutions to boost worker voice also exist at the federal level. Last summer, Sen. Kamala Harris (D-CA) and Rep. Pramila Jayapal (D-WA) introduced the national Domestic Workers Bill of Rights Act, which extends common workplace rights and protections to all domestic workers—including home care workers—while also incorporating fair scheduling practices and creating a wage and standards board.

Conclusion

Measures to protect home care workers would be a win for both the workers themselves and the public. At the end of the day, protecting home care workers also protects their clients, many of whom are particularly vulnerable to complications from COVID-19. As the United States celebrates the contributions of workers across the country this Labor Day, it is past time that we afford home care workers with the respect, recognition, and economic dignity they deserve.

Malkie Wall is a research associate for Economic Policy at the Center for American Progress Action Fund.