| Action | Electronic Visit Verification |
| Stage | Proposed |
| Comment Period | Ended on 3/21/2020 |
 |
When the alarm clock went off at 7 am, Angelica Rios had barely gotten four hours of sleep. She rolled out of bed anyway and slipped into her Winnie the Pooh scrubs.
“I have a lot of trouble sleeping,” Angelica said as she combed mousse through her thick brown curls. She picked up two silver hoop earrings and clasped one onto each ear. Then she laced up her sneakers and grabbed a bottle of Gatorade on her way out the door.
Angelica has a lot to keep her awake at night. As a 25-year-old single mom, she worries about how she will afford day care when her 4-year-old son, Elijah, returns from spending the summer with his father. She worries about coming up with $680 to cover the rent for her two-bedroom apartment in Albuquerque if her car breaks down again. She worries about how she will pay back the $150 cash advance she took out from her employer to pay July’s bills.
“I really need to get a second job,” Angelica said. She recently interviewed for a position working the assembly line at a factory, making prepaid phone cards, but hasn’t heard back. “It’s a struggle. But when is it not? Life’s always a struggle if you’re a single mom.
Angelica already works seven days a week as a home health aide, caring for an 89-year-old widow with dementia who lives alone. The $12.50 an hour Angelica earns isn’t enough, so she and her son rely on government assistance, such as food stamps and Medicaid.
On a recent morning, Angelica drove her 2002 Ford Taurus (it has “stage 4 cancer,” she joked) along the dry, dusty foothills of the Sandia mountain range. The sun was still hiding behind the granite peaks, but the temperature was climbing to 90 degrees. She drove past auto body shops, an elementary school, and a go-kart track.
Fifteen minutes later, Angelica turned right into a neighborhood of tidy beige houses with two-car garages — a world apart from the cramped rowhouse where she grew up in Philadelphia. Then she pulled into the driveway of a house with a red-tiled roof.
Her client, who asked not to be identified for privacy reasons, stood waiting at the door to her garage, clutching a walker. She was tall and slender with sharp blue eyes, still wearing her pajamas and bathrobe when Angelica arrived.
“Has Sparky gone out to pee?” Angelica asked, referring to the widow’s 7-year-old terrier. Her client shook her head.
Angelica walked inside and opened the back door to let Sparky out. Dishes were piled up in the sink. The bed was unmade. The refrigerator was nearly empty.
Angelica mostly likes her job, despite the low wages — even though she never gets a day off. Her current client is far less difficult than others she’s had. Her last client masturbated in front of her (she quit), and the person before him soiled herself constantly, leaving Angelica to clean up (that client later died).
“How’s your throat? Do you want me to make you a cup of tea?” Angelica asked cheerfully as she scrubbed a pot in the sink.
“Yes, please,” the woman answered, sitting down.
Her client was in a good mood, but that wouldn’t last long. Later, she would get cranky and yell at Angelica for not following her orders, like failing to get two visiting journalists to leave before lunchtime. None of it ever seemed to faze Angelica.
She carefully wrote down each task she completed. “Left to run errands. Finished dishes. Cleaned dog poop from backyard. Disinfected stovetop and sink,” she scribbled. The list went on for about half a page. Angelica keeps track of each chore she completes to help her stay organized, and for other caregivers and relatives to reference.
This is what it’s like to do one of the most in-demand jobs in the US, a job that has many names, depending on the state and tasks involved: Home caregiver. Personal care assistant. Home care worker. Home health aide. The title doesn’t matter; what’s important is that this is the future of work for millions of Americans.
According to the latest estimates from the Bureau of Labor Statistics, the US economy is expected to create about 1.2 million new positions for home caregivers like Angelica by 2026 — a 41 percent increase from the 2.9 million personal care and home health aides working in 2016.
Aging baby boomers and expanded Medicaid coverage have led to the surge in the need for workers to care for the sick and elderly in their own homes. But these positions, which require minimal training and no college degree, are among the lowest-paid in the country.
Beyond that, home care workers are an easily exploitable workforce. Because of the job’s roots in slave labor, these workers have long been excluded from US labor laws. Live-in caregivers are not entitled to overtime pay or a minimum wage under federal law, or any other labor protections. Neither are caregivers who spend less than 20 percent of their job helping clients do basic tasks. None are protected from racial discrimination or sexual harassment. They have no collective bargaining rights and no right to a safe workplace. One of the fastest-growing jobs in the US is a really lousy one.
It’s no wonder the caregiving profession has one of the highest turnover rates in the country. In interviews, several home health aides described their work as emotionally and physically draining, with few rewarding moments.
“I pray every day for change,” said Deborah Brockington, a 57-year-old home health aide in Raleigh, North Carolina. “We need the work, and [employers] think paying us little money is better than no money. But we still have to pay our rent.”
The stakes are high. The problems health aides face could compromise not only the future of American work but also the state of care for the aging population. If unemployment keeps dropping, and caregivers discover better job options, they won’t stick around for long. Yet few policymakers have attempted to address the problems in a system rooted in racism and sexism.
Aging baby boomers and expanded Medicaid coverage have led to the surge in the need for workers to care for the sick and elderly in their own homes. But these positions, which require minimal training and no college degree, are among the lowest-paid in the country.
Beyond that, home care workers are an easily exploitable workforce. Because of the job’s roots in slave labor, these workers have long been excluded from US labor laws. Live-in caregivers are not entitled to overtime pay or a minimum wage under federal law, or any other labor protections. Neither are caregivers who spend less than 20 percent of their job helping clients do basic tasks. None are protected from racial discrimination or sexual harassment. They have no collective bargaining rights and no right to a safe workplace. One of the fastest-growing jobs in the US is a really lousy one.
It’s no wonder the caregiving profession has one of the highest turnover rates in the country. In interviews, several home health aides described their work as emotionally and physically draining, with few rewarding moments.
“I pray every day for change,” said Deborah Brockington, a 57-year-old home health aide in Raleigh, North Carolina. “We need the work, and [employers] think paying us little money is better than no money. But we still have to pay our rent.”
The stakes are high. The problems health aides face could compromise not only the future of American work but also the state of care for the aging population. If unemployment keeps dropping, and caregivers discover better job options, they won’t stick around for long. Yet few policymakers have attempted to address the problems in a system rooted in racism and sexism.
There’s a lot of hype about the future of work. You may have heard dire warnings about robots taking jobs, or that work will be all digital.
There’s a grain of truth in that thinking, but the reality is that the future of work will also include a lot of low-skilled, unglamorous service jobs, just like the one Angelica does.
Only one industry is expected to grow faster and add more jobs to the US economy than home care work in the coming years: the renewable energy business.
But it’s not just about future growth. The US economy has been adding thousands of jobs each month. Most of the new jobs are in health care. Many are in caregiving.
Last year alone, there were 153,050 new positions filled for home health and personal care aides. That’s three times higher than the number of jobs created for registered nurses, which has been another one of the fastest-growing professions since the Great Recession.
One reason for this is simple: Baby boomers are getting older, and within a few years, the oldest of them will reach the age when they need help to do basic tasks. Right now there are 6.3 million adults over the age of 85. That number is expected to more than triple to 19 million by 2050.
“Demand for home health care workers is growing at unprecedented rates also because people are living longer, and living longer with chronic diseases,” said Adam Seth Litwin, who teaches industrial and labor relations at Cornell University.
The second reason is a cultural shift in how Americans value their independence toward the end of their lives.
Twenty years ago, it was common in many regions for older adults to live in nursing homes. In 2000, there were 1.5 million people who did.
Fast-forward to 2018 and 80 percent of those over the age of 50 said they would prefer to live at home with help rather than move into a nursing home. A lot of the change is related to family guilt about institutionalizing relatives, and part is a desire for personal independence. Federal and state governments now also prefer what is known as “aging in place”: Medicaid, the federally subsidized health insurance program for low-income Americans, is the largest source of funding for personal care for the elderly and those with disabilities, spending about $82 billion a year.
The third reason is that state governments began diverting more money to home care services starting around 2015. It wasn’t just because of patient preference, but because it’s a lot cheaper than institutional care. They also had to comply with a 1999 Supreme Court ruling that required government-run programs to provide health care in the least restrictive environment available. The justices ruled that it was a violation of the Americans With Disabilities Act for the government to send people with disabilities to facilities that limit their freedom if they can continue living at home with some help.
Medicaid now spends far more on home-based care than institutional care. That helps explain why fewer and fewer people are living in nursing homes. By 2016, the number of people living in nursing homes had dropped slightly to 1.3 million, and more than 1,000 nursing homes have closed since 2000, according to the latest data from the US Centers for Disease Control and Prevention. It may not seem like a huge change, but it’s significant when you consider that more — not fewer — Americans are reaching the age when they are more likely to need care.
However, there might not be enough Angelicas willing to provide that care if the pay means they can barely take care of themselves.
In many ways, Angelica represents the typical American home care worker.
She is a woman (87 percent of home care workers are). She is a person of color (60 percent are). She didn’t go to school past high school (52 percent have a high school diploma or less). She gets food stamps and Medicaid (51 percent get some form of public assistance).
Like many of the professional caregivers interviewed for this story, Angelica said she learned how to do the job by caring for her relatives. She grew up in a rough neighborhood in Philadelphia and raised her younger sister.
Angelica’s parents had issues with alcoholism and were physically abusive. Her eldest sister disappeared for weeks at a time, often leaving behind her four young daughters for Angelica to take care of too.
“By the ninth grade, we had no parents because they were either drunk or in bed,” Angelica explained. So she became the main caregiver. She cooked meals for her nieces and her younger sister. She made sure they bathed and would dress them.
Meanwhile, she worked one factory job after another to help pay the rent — seven jobs in seven years.
During and after high school, Angelica assembled medical syringes, made newsprint, and prepared tortilla chips in an assembly line. But she longed to be an artist. She even enrolled in a fine arts high school, making clay sculptures, drawing with charcoal, and painting with acrylics and oil.
After high school, Angelica moved to Michigan and met Elijah’s father. They dated for several years, but after things ended with him, Angelica decided to start a new life out West. She realized that she didn’t want her son to grow up in the same environment she did, where, she says, she had seen too many shootings and corpses.
So in early 2018, she packed up Elijah and the Taurus and moved to Albuquerque. The first job she got was at a factory. She made solar panels for $11 an hour.
It was a few months after she moved to Albuquerque that she learned about the New Mexico Direct Caregivers Coalition, a nonprofit that was starting a co-op for home care workers. As part of the program, caregivers would own a home care business together, instead of working for an agency that takes a big cut of their pay.
Angelica loved the idea, especially because she didn’t need a professional license in New Mexico. Some states require minimal training, but few states require a license.
“It sounded great,” she said. “I thought, ‘I don’t have to sweat or work in a factory anymore.’”
It’s been a year since she started working as a home health aide, and she’s watched other caregivers come and go. While it’s nice to be part-owner of the co-op, the job is physically and emotionally taxing, and turnover is high. But demand for workers like Angelica isn’t slowing down.
It’s no longer news that the US is experiencing a widespread labor shortage. But the shortage is most severe for unskilled and low-skilled jobs. Home care workers are among those who are hard to find. Not everyone is willing to deal with difficult patients for low pay and no benefits when so many other jobs are available.
Some agencies see 100 percent turnover within a year; 50 percent turnover is considered good, says Bill Dombi, president of the National Association for Home Care & Hospice, a trade group that represents more than 33,000 home care agencies and hospice providers. He says the top complaint he hears from employers is how hard it is to find and keep workers.
The median annual salary for a home health aide was $24,200 in 2018, above the $16,460 federal poverty level for a family of two. That’s about $11.57 an hour. Cooks, janitors, and farmworkers make more than home care workers do, and they aren’t caring for the sick and elderly.
In interviews with Vox, economists shared various reasons wages are so low for such a high-demand job. After all, basic economic theory suggests employers will pay more when they can’t find workers.
However, jobs that require emotional and social skills are valued less in the labor market, some economists say. Another theory suggests that caregiving is a business with low profit margins. One economist believes the labor shortage may be overstated and that there’s actually a bigger pool of low-wage workers than government data suggests.
“Despite an appearance of a tight labor market, it’s probably not that tight for this group,” Michael Carr, an economics professor at the University of Massachusetts Boston, told Vox.
But there’s one underlying problem they all agreed on: demographics. Home health care workers are overwhelmingly women, people of color, and immigrants with low educational attainment. Randy Albelda, who is also an economics professor at UMass Boston, says research clearly shows that occupations dominated by women are lower-paid.