Coming to and Caring in America

We don’t care about care in America.

This was made clear most recently by New America’s Care in America report, which demonstrated the ways in which every state in the country has failed to provide care that is simultaneously low cost, high quality, and accessible. A conversation about care more generally will inevitably turn toward elder care (as the convening to discuss the report at New America did). Assisted/direct care for the elderly is related to but distinct from child care, and is provided primarily by immigrants. In both cases, however, those providing the care deserve the respect and dignity that they try to provide our loved ones—and that we do not currently afford them.

The People Who Should Be Talking about Direct-Care Reform Are Not

Assisted/direct care is care involving elderly, disabled and mentally/physically impaired individuals. Direct-care workers are an alternative for families who refuse or cannot afford assisted/long-term care facilities. Direct-care workers are primarily immigrants working in high-stress conditions making menial wages.

However, recent conversations about immigration and care reform are not seen as inextricably linked, leaving direct care workers to fall by the wayside. In the recent Care Index launch, Katie Hamm of the Clinton campaign and Dan Kowalski of the Trump campaign indicated their respective candidate’s plan for care in America. Donald Trump’s plan emphasizes a tax based component for the individuals that pay for child care. Hillary Clinton proposes a tax based system that caps at ten percent of a family’s income, but offers greater benefits to lower income and middle class families through free pre-kindergarten. Hamm and Kowalski were speaking of child care, not elder care, but no policy on caregiving in America can be divorced from the conversation and rhetoric on immigration reform that is taking place in America today. But because we do not see the situation as such, and despite efforts of individuals like Ai-Jen Poo of Caring Across Generations to unionize health care workers and bring these issues to the forefront, care policy as it pertains to immigrant direct care workers remains a niche issue.

Not All Direct-Care Workers Are Illegal

It should not need to, but indeed does need to, be said that not all direct care workers are undocumented immigrants, even if some hope to use the job as a pathway for citizenship. However, the presumption of “illegal immigrants” to some may allow for lower wages and longer hours. “Increasing Pathways to Legal Status for Immigrant In-Home Care Workers”, a report by the Institute for Women’s Policy Research (IWPR) and Caring Across Generations 52(CAG), highlights the discrepancies between work and recognition. In a conversation with one health worker who asked for her name be omitted from this piece, the relationship between caregiving agencies and their workers is imbalanced. When cases go unfilled, workers who are “off” (time for which, it should be noted, they are not paid) bombarded with phone calls and are pressured to fill-in. Working long hours and receiving low wages decreases the chances that a worker is willing to take time off or to tend to his or her own health. IWPR and CAG’s report acknowledges 28 percent of all direct care workers are immigrants—and 20 percent of immigrant direct care workers are undocumented. Understanding this as an undocumented immigrant issue distances policy makers and fuels exploitative practices.

Underpaid, Overworked, and Overstressed

Direct-care workers are providing a service for which demand outweighs supply. However, because care in America in general is underfunded, their wages do not reflect this reality. The majority of patients receiving elderly assisted care have degenerative diseases or other forms of mental/emotional distress. With few workers in the home care field, direct-care workers fill a void. According to the U.S. Census Bureau, 7.6 million Americans that suffer chronic or acute ailments receiving in-home care are seniors who would have been in assisted living or long-term care facilities had they not been able to receive direct-care.

Direct-Care Work Is Not Directly Defined

The Department of Labor’s definition of direct-care work does not acknowledge the various work levels and training. Direct-care professionals with home care agencies are defined as companions, certified nursing assistants, personal care aides, and caregivers. As of January 1, 2015, the United States Department of Labor required all home care agencies to pay at least federal minimum wage ($7.25/hour) and overtime pay to all direct care workers.

Officially defining all caregivers as the same ignores the various training levels acquired and required by those doing the work. One interviewee, who asked that her name be withheld, has worked in the medical field for 23 years in various nursing homes and assisted care facilities. In assisted care facilities, it was common for her and her peers to get 15 clients to take care of in one shift (i.e. 7am - 3pm). Despite being over assigned, many picked up multiple shifts working overtime to make up for low wages.

We need to define and fairly pay for assisted and direct-care work for the elderly. As a new generation shifts into retirement, the concept of care becomes more relevant. The United States Department of Health and Human Services reports that persons 65+ are expected to represent 21.7 percent of the population in 2040. Investing in effective care for young and old alike highlights important conversations around affordability, ethics, and, yes, immigration. We need to care about all three.