Zulma Torres felt deflated watching legislators on the evening news celebrate the Senate’s bipartisan passage of the $1.2 trillion infrastructure bill this week — for her, it was just further proof of the country’s disrespect for home health aides.
“When are they finally going to say that we’re doing good? That we’re providing a service? That we’re essential?” said the 48-year-old. “When everybody else was home quarantining we were out there working — without bonus pay and without hazard pay. I just want to be respected — and we haven’t been respected at all.”
President Biden’s original $2.6 trillion infrastructure proposal in March included $400 billion for home- and community-based care, which aimed at providing better training and pay for the country’s 2.3 million home health aides (a population that doubled between 2008 and 2018).
That funding, however, was excised during a partisan fight over the size of the bill and whether caregiving counted as infrastructure at all, with Republicans blasting the inclusion of care work in the bill.
“President Biden’s proposal is about anything but infrastructure,” tweeted Sen. Marsha Blackburn (R-Tenn.) in April.
“Now the care economy is infrastructure,” said former New Jersey governor Chris Christie on ABC News. “I don’t even know what the hell the care economy is.”
Health-care advocates are still hopeful that their sector will be included in the $3.5 trillion budget resolution Senate Democrats began pushing for this week that would, in addition to health care and education, invest in home care. However, care being left out of the infrastructure bill felt like a slight, Torres said: “It’s like a ladder, and we’re all the way at the bottom of the ladder.”
Home health aides provide in-home care for older people and those living with disabilities. They’re part of the fastest-growing workforce in the United States, according to projections by the Bureau of Labor Statistics. Their job responsibilities range significantly — from administering medications and checking vital signs, to assisting with daily life tasks such as eating and bathing, to helping clients get in and out of bed, to running their errands and taking them to doctor’s appointments.
America’s aging population and a growing distaste for institutional care — particularly after 10 percent of nursing home residents died of covid-19 — means that well over a million additional jobs will be needed in the sector by 2026. It’s also one of the most poorly compensated professions. According to the Economic Policy Institute, the median wage for home-care workers at an agency is $20,337 — a salary that drops to $18,111 for independent workers. And like a lot of low wage work right now, they’re hard jobs to fill. More than 800,000 Americans are on a waiting list to receive home-based care through Medicaid.
The poor compensation has a lot to do with the demographics of the profession, experts say. Women make up almost 90 percent of home-care workers, with some 62 percent of the industry made up of people of color, according to research by the direct-care nonprofit PHI. Almost a third are immigrants.
“The notion of the home as a workplace is an oxymoron to people — it doesn’t make sense to them. What we do in the home is associated with love, not money,” said Eileen Boris, a professor of feminist studies at the University of California at Santa Barbara and co-author of “Caring for America: Home Health Workers in the Shadow of the Welfare State.” “Then there’s a double devaluing, because it’s work that’s associated with the legacies of slavery and Jim Crow and discrimination of immigrants in the low-wage labor market.”
One in 6 home-care workers live in poverty, and more than half depend on some kind of public assistance, according to PHI. Almost 1 in 5 of these workers have no health insurance.
“I’m disappointed that they still don’t want to acknowledge us,” said Torres, who testified in front of the Senate in July about the need for increased training, funding and worker protections. For her, the urgency has increased dramatically since the pandemic put home-health aides in the line of fire — often without even the basic protections available to better compensated health-care workers such as paid sick leave, PPE and health insurance.
“I think it’s impossible to overstate how challenging the last 18 months has been for this workforce,” said Kezia Scales, director of policy research at PHI. “In many cases, they were making the almost impossible choice to continue doing their job while putting themselves and their families at risk — while also being responsible for the lives of their clients — or staying home and forgoing their paycheck. Since many of these workers are earning poverty-level wages, they’re not in a position to do that.”
Like many home-health aides, Torres has had jobs with multiple companies, juggling extra clients to make financial ends meet with such low pay. However, she downsized her client load during the pandemic because she worried about exposure to the virus, she said.
At the beginning of the pandemic, she scrambled to buy gloves and sanitizer from dwindling grocery store supplies, knowing the three buses she took to work put her at additional risk. At one point, she said, she paid $25 for a bottle of Lysol because she was so nervous about sanitizing at work.
At the end of the day, her son and husband would meet her on the back porch armed with Lysol and towels, ready to sanitize her before she entered the house. Once inside, Torres said, she’d meticulously remove her uniform before showering and sanitizing all over again.
“It was overwhelming. It was very scary. And it still is — it’s still out there,” she said.
Unlike many home-health aides, Torres is part of a union, giving her protections that many of her colleagues lack — she recently ran into a woman who lost her job when she got sick and says some women she knows haven’t received any personal protective equipment during the pandemic.
Still, her finances are so precarious that if any unexpected expenses come up, she knows they’ll likely be short on food in the house, she said.
“God forbid I get sick and I can’t work anymore,” Torres added. “I think what we do is awesome. I think it’s a blessing that we can provide these services for others that need us. I just wish that they’d pay us fairly for it.”
An extra challenge, according to PHI’s Scales, is home-health aides’ “relative invisibility”: “Their workplaces are largely hidden, so whatever goes on is also hidden: the challenges they face, the complex skills they bring to bear, the risks that they encounter; all of that is largely unseen.”
The fact that it’s hidden means it can also be dangerous work.
A 2015 study in Oregon found that more than 23 percent of home-health-care workers reported experiencing violence in the past year, and more than 25 percent reported experiencing sexual harassment.
The creation of this shadow workforce didn’t happen by accident. The roots of the home-care sector go back to the end of slavery, when the only work available to the formerly enslaved was sharecropping or domestic work.
In the 1930s, legislators cut farmworkers and domestic workers — made up of mostly Black people and immigrants — out of the Social Security Act and the National Labor Relations Act in an attempt to preserve the racist order of the Jim Crow South, kneecapping their ability to organize into unions or to receive a minimum wage.
It took until 2013 for the Fair Labor Standards Act’s minimum wage and overtime protections to finally be extended to all home-care workers.
Many advocates hope that the pandemic’s spotlight on unpaid care work, given that women have left the workforce in droves to provide at-home child care, could be a watershed moment for a long disrespected industry.
Properly compensating care workers could have a multiplying effect on women’s work. Recent research found that when Medicaid was expanded, for every 2.4-3 daughters whose parents started receiving professional home care as a result, one was able to start working full time.
Despite the final version of the infrastructure bill, there does seem to be widespread support for change. In June, several lawmakers introduced the “Better Care Better Jobs Act,” which would expand Medicaid funding for home-based care as well as increase wages and improve training for direct-care workers.
Boris, the UCSB professor, believes that better labor protections for the workforce, which has been repeatedly targeted by anti-union legislation, is crucial to improving the sector. This includes passage of the Protecting the Right to Organize Act of 2021, which would better protect workers’ rights to organize, particularly for diffuse workforces like home-health aides.
“There’d be more power to do things like include them in raising the minimum wage and including them in occupational health and safety, which would be really important for this workforce,” Boris said.
Torres is hopeful about all of these developments — but in addition to improving her working conditions, she hopes that they mean the country is finally waking up to how vital her work is.
“What home-care workers provide is really important,” she said. “These people need us.”