The Culture and Politics of Health Care Work

the work experiences of home care aides

Clare L. Stacey

• Publisher: ILR Press
• Year: 2011
• ISBN:
  9780801463327
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

According to the Bureau of Labor Statistics, there were approximately 1.7 million home health aides and personal and home care aides in the United States as of 2008. These home care aides are rapidly becoming the backbone of America's system of long-term care, and their numbers continue to grow. Often referred to as frontline care providers or direct care workers, home care aides—disproportionately women of color—bathe, feed, and offer companionship to the elderly and disabled in the context of the home. In The Caring Self, Clare L. Stacey draws on observations of and interviews with aides working in Ohio and California to explore the physical and emotional labor associated with the care of others.

Aides experience material hardships—most work for minimum wage, and the services they provide are denigrated as unskilled labor—and find themselves negotiating social norms and affective rules associated with both family and work. This has negative implications for workers who struggle to establish clear limits on their emotional labor in the intimate space of the home. Aides often find themselves giving more, staying longer, even paying out of pocket for patient medications or incidentals; in other words, they feel emotional obligations expected more often of family members than of employees. However, there are also positive outcomes: some aides form meaningful ties to elderly and disabled patients. This sense of connection allows them to establish a sense of dignity and social worth in a socially devalued job. The case of home care allows us to see the ways in which emotional labor can simultaneously have deleterious and empowering consequences for workers.

1

THE COSTS OF CARING

LETE

Lete came to the United States in 1992 from Sinaloa, Mexico, at the age of twenty-six, to join her sister and aunt living in California. Soon after emigrating, Lete found herself caring for her aunt, who had fallen ill with a terminal form of cancer. In addition to providing care at home, Lete secured a part-time job in a factory at night, assembling computers for $9.50 an hour. Lete eventually earned her GED from a local community college and then enrolled in a few night courses—mostly nursing and computer science related—to try to identify a new career path. After her aunt died, Lete decided she could no longer justify the expense of community college, so she quit to find full-time work. She secured a job as a packer in the warehouse of a big-box chain store, making fourteen dollars an hour with health benefits.

Several months into her packing job, Lete heard through a friend that IHSS was hiring home care aides with no training required. Within a matter of days, Lete was assigned to work with a frail ninety-two-year-old white woman, Mavis, who lived alone and required help with bathing, dressing, cleaning, and cooking. Although Lete made decent money working the night shift at the warehouse, she felt drawn to Mavis. Having “prayed for a purpose” on her arrival to the United States, Lete believed God led her to caregiving, first for her aunt and now for Mavis. She took the job with Mavis but continued to work nights at the warehouse, in need of the higher wages and health benefits offered with the packing job.

Mavis proved to be a demanding and difficult woman to care for—insulting Lete for being overweight and accusing her of theft, for example—but Lete feels they now have a close bond. Lete wants to work full-time caring for Mavis, but such a change would require her to leave the night shift at the warehouse, which pays six dollars an hour more and offers insurance. Between the two jobs, Lete works nearly seventy hours a week. She says that the hours are required to ensure that she can pay her rent and send small sums of money back to family in Mexico. Even though Lete essentially works around the clock to make ends meet, she still takes care of Mavis on Saturday “for free.” Lete feels Mavis needs the care and it is her “calling” to do so, saying that “caregiving is what God has put me on this earth to do.”

Lete comes from a family with a strong commitment to the care of elders, and she spent time as a young adult caring for her grandfather, alongside her mother and other sisters. Lete’s sister, Alicia, works as a child care provider and hopes to open her own day care; Lete describes her sister as “another me,” referring to their shared proclivities for caregiving. Lete tells me that her talent for caregiving comes, in part, from spending her formative years in Mexico. She contrasts Mexico with the United States with respect to the care of elders and says that “[U.S.] culture lacks an interest in elders . . . young people don’t think they are important.” She adds, “We don’t appreciate what they’ve done . . . we are losing what’s important in life, values.” When I ask Lete to compare her caregiving job to her work in the warehouse, she tells me that the caregiving job is harder because there “[you] feel pressure, because you don’t know how she [Mavis] is going to be.” This work is more difficult, she tells me, than trying to meet the piece rate in her eight-hour shift at the warehouse. Even so, Lete would leave the packing job if, as she put it, “the money weren’t so bad” in caregiving.

Providing Care in the Context of Poverty

As Lete’s story illustrates, many nursing aides provide ongoing care to others in the context of serious economic hardship. The job of home care aide (or any direct care worker for that matter) is an entry-level health care occupation that requires little formal education, offers minimal training, and generally carries very little promise of vertical mobility (Crown, Ahlburg, and MacAdam 1995; Stone and Wiener 2001; Yamada 2002). As such, nursing aides, whether they work in a private home or a facility, are part of the very same low-wage service sector that has become the focus of attention for a growing number of sociologists of inequality (Edin and Lein 1997; Leidner 1993; Munger 2002; Sherman 2007).

Home care is a growth industry, especially in the areas of personal care and homemaker services (Paraprofessional Healthcare Institute 2008b; Stone and Wiener 2001). Unlike institutional care (i.e., nursing home or convalescent care), home care is a largely unregulated industry composed of a complex array of publicly funded and proprietary agencies (Benjamin 1993; Stone and Wiener 2001). Some aides work for private, for-profit agencies (such as It’s For You or Maximum Care), while others work for state agencies like IHSS, under what is called a “consumer-directed” model. In such a model, clients theoretically hire, train, supervise, and fire aides, while the organization overseeing care (e.g., IHSS) administers payment to workers. In consumer-directed care, agencies label aides “independent providers,” a misnomer that allows the state to distance itself—at least in name—from the responsibilities and liabilities that agency employers face in the private sector. Certainly for aides in the field, the distinction drawn between consumer-directed and agency-based care is overstated, since in either context workers provide care to clients and are paid a wage by a third party (either an agency or state entity).

In California and Ohio, few agencies require advance training of aides (and minimal on-the-job training), although some agencies mandate CPR certification and evidence of basic first aid skills. There is also evidence that the scope of work radically varies from state to state, from agency to agency, and even from client to client, depending on whether that client’s care is paid for by public monies or private insurance (Institute of Medicine of the National Academies 2008). In real terms, this means that an aide working multiple jobs, which is often the case, can go from being a “housecleaner” in one context, to changing bandages or Foley catheters in another. Many of the aides interviewed expressed frustration that job descriptions and scope of work change so radically by agency, with often no obvious rationale for the discrepancy.

With respect to pay and benefits there is little standardization, but successful organizing campaigns in California, New York, and Oregon represent an important shift in the bargaining power of home care workers in the United States (Mareschal 2006, 2007). In Northern California in 2004, average wages for an IHSS worker after unionization rose to ten dollars an hour, from the minimum wage of only seven dollars a few years earlier (Howes 2006). Bracketing the issue of unionization, and taking real wages into account, a bleaker picture emerges. In 2006, the real median hourly wage for personal and home care workers was $7.96 in California, and $7.40 in Ohio. These numbers are slightly higher than the national average real wage for aides of $7.17. The more distressing reality is that real wages for aides have actually declined, from $7.50 in 1999 to $7.14 in 2006. Geographic variation is apparent as well. In 2006, Texas reported a real wage of $5.41 for aides, while in the same year real wages in Alaska were $11.38 (Paraprofessional Healthcare Institute 2008c). Whether an aide can garner a living wage from home care appears highly dependent on geographic location and the extent to which the labor force is organized. One thing is certain: higher wages positively impact worker turnover (Howes 2006), which suggests that the material inequality associated with direct care is a considerable constraint for aides. Ample evidence now exists to support the claim that raising wages would indeed help address the perennial problem of workforce turnover (Howes 2006; Kemper et al. 2008).

Addressing turnover, however, is no small task, as rates of attrition are high for personal and home care aides, as well as for aides working in nursing homes. Estimates of turnover range between 45 and 100 percent for the general population of direct care workers, depending on study sample size and different formulas for calculating turnover (Ejaz et al. 2008; Harris-Kojetin et al. 2004). A majority of aides working for IHSS, the largest employer of home care aides in California, leave the job within three years (Benjamin, Matthias, and Franke 2000). While turnover is the scourge of the industry, resulting in annual losses totaling over $2 billion (Ejaz et al. 2008; Seavey 2004), the constant hemorrhaging of caregivers also reflects uncertainties workers face as they traverse service jobs in the new economy (V. Smith 2001). As the accounts of workers in this book demonstrate, aides move in and out of home care work—sometimes for personal reasons, often for financial reasons—but tend to return because there are few other options available to them. This movement in and out of care work, while common, takes a toll on workers who wish for a more predictable occupational path.

Beyond poor wages, there are many reasons why turnover is so high among nursing aides, including lack of benefits, insufficient training, workload stressors, and the high emotional demands of the work (Brannon et al. 2002). As the women and men in this book attest, health, sick leave, and retirement benefits are generally unavailable to them, although organized workers usually have better access to benefits beyond wages (Howes 2004). It is a cruel reality that many aides, who spend their days tending to the health care needs of others, go without care themselves, sometimes for the duration of their careers. Many of the “veterans” interviewed for this study, some with job experience that exceeds fifteen years, have never had health insurance. When asked what they do when they get sick, almost all responded with the eerie refrain, “I don’t get sick.”1 Data on the insurance status of direct care workers supports this anecdotal evidence. In fact, advocates for the direct care workforce refer to the insurance crisis among aides as the “invisible care gap,” worthy of the same kind of attention (and investment of resources) as the care gap confronting the elderly (Paraprofessional Healthcare Institute 2008a). Estimates published in 2008 suggest that nearly 30 percent of direct care workers in the United States lack health coverage, making them twice as likely as the general public to go without insurance (Paraprofessional Healthcare Institute 2008a). Among the ten aides I interviewed in Ohio, only two of the women have health insurance (through their partners); among the California aides, one-third of the twenty-three aides have insurance. Aides working for It’s For You and Maximum Care were the least likely to have insurance, whereas aides working for IHSS were more likely to be insured, due in part to the successful organizing campaign of publicly employed aides in California (Boris and Klein 2006; Delp and Quan 2002; Howes 2004).

While there are very few formal job requirements for nursing aides, working as a paid caregiver to an elderly or disabled person does necessitate a set of informal skills, including emotional intelligence, physical strength, and work flexibility. Aides receive very little training from agencies to help foster these skills, although, now organized, IHSS workers are offered regular, voluntary training sessions on a range of topics. Some home care aides begin their careers as certified nursing assistants (CNAs) or state tested nursing assistants (STNAs). Among the workers interviewed, however, only those who work simultaneously in nursing facilities and home care renew their license each year (most nursing homes now require CNA or STNA certification). While half of the aides began with a license, only five renew annually. This is not surprising given that the difference in pay between a certified aide and a noncertified aide is usually negligible. Predictably, poor training seems to go hand in hand with lack of career advancement: a statewide study in California found that only 5 to 12 percent of IHSS workers experience vertical mobility and go on to train as a licensed vocational nurse (LVN), arguably the next step on the career ladder (Ong et al. 2002).

Inadequate training and poor job mobility, combined with low wages and high turnover, mean that aides who find themselves in this line of work tend to face ongoing economic uncertainty. A majority of aides in the sample described working multiple jobs for multiple clients to ensure enough weekly income to simply pay their own bills and housing costs. While I did not ask respondents to reveal their monthly gross income, aides talked at length about relying on public assistance for health care and, occasionally, for food (i.e., food stamps). Nine of the aides interviewed have one or more children under the age of eighteen. The sample roughly mirrors national trends that suggest 40 percent of home care workers have a child under the age of eighteen and must therefore juggle paid and unpaid caregiving responsibilities (Smith and Baughman 2007a; D. Stone 2000b). Wages for home care workers in California and Ohio range between eight and ten dollars per hour and hardly constitute a living wage, especially in situations where the caregiver is a single parent, which is true for roughly 22 percent of home care aides nationally (Smith and Baughman 2007a). Although some economists argue that recent improvements in wages and benefits make home care a “good” job financially (Howes 2006), the individual aides in this study would beg to differ. Respondents, especially those with dependent children, report that they often work multiple jobs or their kids “go without” from time to time because the wages, although a drastic improvement from the minimum wage of a few years ago, are inadequate to sustain a family.

It is not surprising, given these working conditions, to learn that three in ten direct care workers live in households that have poverty or near-poverty income levels (Paraprofessional Healthcare Institute 2008a). In California, 25 percent of all IHSS caregivers received welfare at some point between 1995 and 2000 (Ong et al. 2002). The number dropped to 10 percent in 2000, but it is not clear whether this reflects successful transition to full-time employment and the benefits of increased wages or if this drop in the welfare rolls reflects the simple fact that many Temporary Assistance to Needy Families (TANF) recipients have “timed out” of income support and are no longer counted on the welfare rolls.

It is important to keep in mind that aides are not the only social actors grappling with poverty in this story. In both Ohio and California, Medicaid waiver programs allow low-income residents to opt for state-subsidized personal care in lieu of institutional care.2 As a result, most agencies cater to both privately and publicly insured clients. With the exception of one aide, each caregiver introduced in the book serves at least one low-income person (some care exclusively for low-income clients). As we will see in subsequent chapters, when both sides of the caring dyad are poor, aides are sometimes quick to overextend themselves both emotionally and financially to clients with whom they share similar conditions of poverty.

Racial Formations in Direct Care Work

It is clear from the above discussion that the working poor—those with low socioeconomic status (SES)—provide the bulk of low-skilled care to the elderly and disabled in the United States. Taking an even closer look at the demographic profile of workers, we see that race and ethnicity further compound the link between paid care work and social inequality. In the words of Evelyn Nakano Glenn (1992), there is a clear “racial division of paid reproductive labor” associated with personal and home care work, meaning that women of color are overrepresented in occupations like nanny, maid, and home care worker. Nearly half of all home care aides nationally are white women, but black women and Latinas are disproportionately represented in the occupation, representing 24 percent and 21 percent of the workforce respectively (Smith and Baughman 2007a). Of all home care aides, 22 percent are foreign-born, further evidence that the world is witnessing a transfer of caring labor from the global South to the global North (Ehrenreich and Hochschild 2002; Smith and Baughman 2007a). Direct care, not surprisingly, is female dominated: 89 percent of the workforce are women (Smith and Baughman 2007a). To the extent that men enter the occupation, it is men of color who are disproportionately represented, a trend that reflects the historical presence of black, Asian, and Latino men in certain realms of reproductive labor (Duffy 2007).

The men and women interviewed for this book possess demographic characteristics that roughly mirror the general population of home care aides. Of the thirty-three aides interviewed, twenty-eight are women and five are men. The sample is half white (sixteen respondents) and the remaining racial/ethnic breakdown is in line with the general population of aides in the United States. Six of the interviewees are African American, four are Asian American, five are Latino, and one person identifies as “mixed race.” Ten of the aides are foreign-born, and two are recently naturalized. To my knowledge, none of the workers are undocumented, although I did not discuss immigration status extensively with participants. The diversity in the interview sample comes almost entirely from the California portion of the study. In Ohio, all of aides interviewed were white women. This in part reflects the demographic differences between the two states, but not entirely. Ohio has a sizable population of African American direct care workers, but recruiting these workers to participate in the study proved challenging. Methodological constraints notwithstanding, Ohio provides an important point of contrast to California, as a state that has concentrated pockets of racial and ethnic diversity in urban areas—largely composed of African Americans—but is otherwise a very white, politically conservative, and economically drained region (Lopez 2004). California stands in contrast to Ohio, as a state with a sizable immigrant population and a rejuvenated labor movement in some areas of the service sector (Mitchell 2004). As I discuss later, the core components of aides’ identity formation (i.e., the caring self) appear to transcend geographic region. However, there are also observable differences in the way in which aides of different racial and ethnic backgrounds conceive of and narrate their care work, based largely on their own experiences with discrimination. In this regard, there are important varia...

Table of contents

• Acknowledgments
• Introduction: On the Front Lines of Care
• 1. The Costs of Caring
• 2. Doing the Dirty Work: The Physical and Emotional Labor of Home Care
• 3. The Rewards of Caring
• 4. Organizing Home Care
• Conclusion: Improving the Conditions of Paid Caregiving
• Appendix: Methods
• Notes
• References