Standards and Training

“Through our union we have really been able to negotiate contracts that help our caregivers make a decent living – if we go through training, we can earn a wage increase. But the training also helps us increase our wisdom and take better care of clients.” – A home care worker and member of SEIU 775

Both home care workers and family child care providers lack clearly defined career pathways. In many states, a 20-year veteran of one of these jobs might earn the same or only marginally more than a new worker. While training is necessary for providing higher-quality care and education to clients and children, increased training does not necessarily translate to higher wages.

In California, for example, many providers of home care services have received extensive training for which multi-million dollar grants have provided the initial funding. There is no clear relationship between this level of training and additional pay or mobility for workers, however. The Center for Medicare and Medicaid Innovation set aside $11 million to provide additional training to home care workers in an effort to reduce rates of hospitalization and emergency room use. Despite the importance of this training, workers who participated in the training received only a $1 per hour stipend during the training and no ongoing wage increase.¹ Similarly, the Center for Caregiver Advancement in California received funding to provide three months of training to home care workers in Los Angeles County. While workers who completed it received a certificate and were deemed eligible to make a bit more money providing backup care if other workers are not available, the only immediate financial benefit was a $300 stipend per worker, which translates to about $1 per training hour completed; there was no change to the base hourly wage of the workers.²

Despite the general lack of connection between training and wages among care workers, Washington’s home care workers succeeded in connecting increased training to higher wages. Washington home care workers were able to elevate training standards as a means to support career progression, secure increased wages for advanced home care workers, and improve quality of care.

History of Home Care in Washington

The elderly population in Washington, as throughout the United States, has been increasing and so has the demand for care services. In response, Washington embarked on reforming its long-term care system to maximize consumer choice and flexibility, improve the qualifications and compensation of home care workers, and reduce long-term care costs, beginning in the late 1990s. In line with recommendations from the elderly and disability communities, Washington shifted to a consumer-directed model to support aging in place. Individuals who would ordinarily be cared for in a skilled nursing facility could access Medicaid and/or Medicare funding to acquire in-home care and support, a long-term care delivery approach that is far less costly.

The prioritization of in-home care presented several challenges for policymakers and implementers. To be successful, the state needed many more home care workers and an infrastructure for ensuring they were adequately trained to provide high-quality care. This was a challenge considering that home care was increasingly delivered in consumer homes rather than in care facilities like nursing homes, where workers had limited access to on-the-job training and mentorship.

The new long-term care model also presented a challenge to workers. The decentralization of home care services made it impossible for most workers, many of whom were independent providers, to organize and collectively bargain for improved wages and benefits. Beginning in the early 2000s, SEIU helped solve these problems by organizing workers, making them easy to find and contact, and by creating a training infrastructure and set of training standards to improve the quality of care.

Workforce Demographics

The home care workforce in Washington is 84 percent female, 62 percent white, 18 percent Asian/Pacific Islander, 9 percent Latinx, and 7 percent Black. The average home care worker is 48 years old. Two-thirds of the home care workforce has completed some college or more advanced education and training, while 34 percent have a high school diploma or less.

Facilitating Conditions for Worker Organizing

In 2001, home care workers affiliated with SEIU advocated for legislation that would establish the state as the employer of record for state-paid independent provider workers and allow them to form a collective bargaining unit for the purposes of union representation. When that failed, SEIU helped get Initiative 775 on the ballot later that year, which voters passed, giving independent home care workers the right to organize and collectively bargain with the newly created Home Care Quality Authority (HCQA). By 2002, 26,000 home care workers voted to form SEIU 775.

In Washington and other states in which independent home care providers have managed to form a union and collectively bargain, the presence of a Medicaid consumer-directed program has been the common thread. Before establishing the state as the employer of record, these workers essentially functioned as independent contractors and therefore lacked protection under state and federal labor laws.

The unionization of home care workers in Washington laid the groundwork for a series of improvements to their compensation, benefits, and training.

In 2004, SEIU 775 negotiated its first contract with the state, which included health benefits for home care workers. By 2006, SEIU 775’s second contract with the state included a wage scale with step increases for hours worked by home care aides, paid vacation time, workers’ compensation, and mileage reimbursement.

Despite these gains, home care workers had few pathways for career advancement and were not valued or compensated as a professional workforce. Under the advice of PHI and SEIU 1199 New York Training and Upgrade Fund, SEIU 775 sought to improve home care worker qualifications and training standards as a means to secure better wages for workers. Prior to 2007, Washington had some of the most minimal licensing and training requirements for home care workers. That year, the legislature passed HB 2284, establishing a work group to recommend new training requirements and requiring that training for state-paid independent provider home care workers be provided through a joint labor-management training partnership. The SEIU Healthcare NW Training Partnership created a statewide training system, becoming the second-largest training provider in Washington. In 2010, voters passed Initiative 1163, which required most home care workers to complete 75 hours of entry-level training within 120 days of hiring; pass a certification exam through Washington’s Department of Health within 200 days of hire; and complete a federal and state background check. Some caregivers are exempt or have lower training requirements because of their relationship with the client or other factors.

Successes

With increased training standards in place, SEIU 775 negotiated additional wage increases for home care workers who obtained advanced training. Currently, new home care workers earn between $16.72 and $18.25 an hour, above the state hourly minimum wage of $13.69.³ However, individuals who earned a home care certification or Certified Nurse Assistant license are eligible for a $0.25 per hour wage increase, and those who complete advanced home care training earn an additional $0.75 an hour. Wage increases apply to both independent home care providers and those employed by Medicaid-contracted private agencies because of legislation passed that created parity within the Medicaid home care system. The universal applicability of home care worker benefits is unique to Washington.

Future of Home Care in Washington

Washington serves as a model for how to secure improved benefits, as well as training and career advancement opportunities for essential home care workers. Yet home care services, although critical, remain underfunded in Washington. In 2019, it became the first state to pass legislation to fund a long-term care insurance program.⁴ Under the Long-Term Care Trust Act (LTCTA), employees must begin paying 0.58 percent of their wages into a fund that will help cover the cost of long-term care services for individuals who have met work history requirements starting in January 2022. SEIU, in collaboration with AARP, the Washington Health Care Association, and the Washington Association of Area Agencies on Aging, championed the LTCTA as a means to expand access to home care services and reduce the need for consumers to spend down into poverty to become eligible for Medicaid-funded long-term care. If successful, this initiative could set an example for how to adequately fund and expand access to long-term home care. What remains to be seen is how the new long-term care system will impact workers.

Child care providers, including family child care providers, face similar pressures to gain additional training without the reassurance that such training will lead to a higher wage. The Institute of Medicine and the National Research Council’s 2015 report, Transforming the Workforce for Children Birth Through Age 8: A Unifying Foundation, recommends a transition to a minimum bachelor’s degree requirement for all lead educators working with children from birth to age eight.⁵ But, while additional knowledge and skills for teachers would likely lead to higher quality care for young children, there is little evidence that this additional training leads to higher wages for the workforce. In fact, child care workers with a bachelor’s degree earn about half as much as the average earnings of individuals with a bachelor’s degree overall.⁶ Child care workers who are able to complete coursework and earn a bachelor’s degree are likely to consider leaving the field entirely, since they can earn a much higher wage teaching in the elementary school system.⁷

In theory, the quality rating and improvement systems (QRIS) put into place by many states should reward family child care providers who earn higher credentials. Partly to incentivize training, many states have instituted tiered reimbursement systems through which providers who meet specific quality standards, such as increased training for staff, receive higher reimbursement rates from the state. While this system connects provider training to higher subsidy rates from the state, moving up the levels of the tiered system is a time-intensive process that does not typically end up translating to higher pay for the provider because the extra money often goes straight back into the program to keep it running effectively.

New models for career preparation are emerging to provide workers with high-quality and affordable training options that lead to higher pay. Apprenticeship is a promising method for linking training to wage increases for entry-level workers as well as incumbent workers looking to gain skills. Apprenticeships combine paid, on-the-job training with related classroom experience; apprentices complete their programs with work experience, higher skills, and no student debt. They also earn progressively higher wages as they advance through the program.

As of 2018, at least eight states have early childhood educator apprenticeship programs.⁸ One of the leading organizations supporting these apprenticeships is Early Care & Education Pathways to Success (ECEPTS) in California. ECEPTS was developed in partnership with the SEIU Early Educator Training Center and intends to change entry-level early care and education jobs from being seen as dead-end jobs to being the first step towards a well-paid career in this field. ECEPTS has apprenticeship programs specifically designed for incumbent center-based and Head Start workers as well as licensed family child care providers.⁹ By September 2021, ECEPTS will have enrolled over 600 apprentices. family child care providers who participate in the apprenticeship program participate in no-cost college coursework to help earn California Child Development Permits and receive wage enhancements throughout their time in the program.¹⁰

However, while apprenticeships are a promising method for linking training to wage increases for care workers, even the higher wages earned by apprentices who complete the ECEPTS program often fall short of a living wage, suggesting the need for more systemic change around the funding of jobs in early care and education in the United States