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Caring for Workers Who Care for Our Loved Ones

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Michelle ChenFor many seniors, growing older means facing new kinds of stress—such as fragile health, a tight budget on a fixed income, or the travails of living alone.

And for the people who care for the aging, the stress can be just as severe. When her client is going through a rough time, one domestic worker says she lives through every minute of it, too: “Sometimes we stay there for five days…and we don’t know what’s outside…You cannot leave the job.”

Stories like this one, recorded as part of a survey of New York’s care workers, form the invisible pillar of an evolving industry that is making the private home the center of public health, and in the process, reshaping our relationships of family, work, community and social service. Yet the home care workforce, which is driven largely by poor women of color, mirrors inequities embedded in the low-wage economy. At work, caregivers manage the lives of our loved ones while often facing exploitation and abuse, and after a long day of delivering comfort to vulnerable clients, many struggle themselves to cope with ingrained poverty their communities.

To open a conversation about the economics and ethics of caregiving, ALIGN (Alliance for a Greater New York) has partered with the national advocacy campaign Caring Across Generations, along with various community and labor groups, to study New York City’s more than 150,000 home care workers. The surveys and investigations published by ALIGN reveal structural problems in the industry and identify potential for reforms that work for those who give and those who receive care.

In New York, the home care industry is booming as more seniors opt to live at home rather than in institutions. Thousands across the city earn their living by taking care of seniors and people with disabilities. Overall, according to the study, the sector “will be the single biggest driver of employment in the city in the coming years.”

On a typical day in New York, these workers, mostly women of color and immigrants, act as both therapists and companions, managing medications, bathing and feeding, and helping seniors feel dignified even on the days they can’t get out of bed. On top of this, the workers have to negotiate with stressed families about hours and pay–and typically take home low wages that keep them and their families mired in poverty.

And yet it turns out that consumers and providers of care want the same things. ALIGN’ssurveys of New Yorkers, including both caregivers and care “consumers,” show strong concern about decent pay for workers, along with retirement and healthcare benefits. These labor conditions are many cases dictated by insurance companies and Medicaid, not by the families receiving care.

The fact that consumers and caregivers both recognize that labor should be fairly valued “really does challenge this zero-sum notion that good jobs and affordable care can’t coexist,” says ALIGN policy analyst Maya Pinto. “And it suggests that people understand the connection between the quality of care and the quality of jobs.”

The converse is also true: When workers are miserable, it shows up in their work. Nearly 40 percent of people receiving care complained that the quality of services was “fair” to “very poor.”

But from a workers’ standpoint, this is the consequence of a job that treats them poorly. One worker described her situation bluntly: “It is a very difficult job at times because there are patients who think the home care workers are slaves.” Workers reported being subject to verbal and physical abuse, sometimes racial slurs, on the job.

Nonetheless, many care workers feel deep devotion to their job—they just want to their labor to be appreciated and duly compensated. “I do my work well…and the person I care for is very satisfied with my work,” said one worker. “It is very dignified work but it needs to be paid better.”

A priority across all respondent groups was providing appropriate training and monitoring–indicating that workers, contrary to stereotypes, are not instinctively resistant to greater accountability and oversight, and that all stakeholder groups realize the depth and complexity of responsibilities involved in caring for vulnerable seniors.

One area of divergence between consumers and workers was the importance placed on career advancement. The issue was a higher priority for caregivers, especially domestic workers who serve seniors but lack the official credentials of “formal sector” workers—a category that includes certified “home health aides” and “home attendants,” and who are generally employed through an agency. Lacking the formal qualifications associated with specialized, better-paying positions, domestic worker-caregivers (who are disproportionately low-income immigrant women, both documented and undocumented) often remain stuck in the most grueling, precarious jobs.

Some of New York’s privately employed home care workers benefit from a recently enacted domestic workers’ “Bill of Rights” that provides stronger workplace protections and wage standards than does federal labor law. However, domestic workers overall, who include nannies and housekeepers as well as direct caregivers in private households, still suffer from poverty, discrimination and exploitation. According to ALIGN’s survey of caregivers’ household incomes, about nine in 10 domestic workers earn less than $25,000 annually, compared to six in 10 formal sector workers. That is, despite the strides that domestic workers made with the Bill of Rights, in material terms, they still lag behind those employed through agencies or with more formal credentials.

ALIGN recommends several reforms to ensure dignity for both caregivers and people receiving care. More training and certification options–such as programs equipping domestic workers with emergency medical skills–would expand workers’ access to more formal and higher-paying positions and lift up standards for the workforce overall. On a policy-making level, the report calls for a expansion of publicly funded insurance programs so care workers, many of whom cannot afford medical coverage, can safeguard their own health as they care for others.

Since so many families struggle to pay the cost of community-based elder care, especially if they fall outside the income-eligibility bracket for Medicaid, the report recommends a more comprehensive publicly supported insurance program as an alternative to private long-term care plans. Noting that the current rollout of the Affordable Care Act and Medicaid overhaul present an opportunity for fudamental reforms in home care funding, ALIGN suggests creating a broadly accessible long-term care benefit that would be funded through payroll contributions, like Social Security.

The report also highlights why workers need not just laws but organization and collective bargaining power. In recent years, SEIU and the National Domestic Workers Alliance have organized tens of thousands of workers to win fairer contracts for workers and to press for reforms to extend labor protections for care workers. Meanwhile, some workers are changing how care is delivered in their communities by forming their own cooperatives.

ALIGN cites the worker-owned cooperative model as a system that can empower caregivers, by enabling them not only to share in the ownership and profits of the enterprise but also to access training, negotiate better working conditions, and “improve compensation for workers while keeping the cost of care relatively low.” One impressive case study is New York’s Cooperative Home Care Associates, one of the country’s leading cooperatives with about 2,000 workers, half of whom own a part of the business.

Despite the sometimes harsh conditions, Vilma Rozen, a 52 year-old home care worker, remains unshakably devoted to her job and embraces the challenges. “If you want to take care of elderly people, you have to keep your feelings very in touch [with] the person, because the elderly people in some cases are very alone and very depend[ent],” she says. At the same time, she adds, many seniors “suffer so much, because the home-carers, they have a very sad life, very underpaid… They don’t have happiness.” Rozen, a native of Costa Rica, says that if Americans want to place their elders in the care of attentive, dedicated people, “they need to change the system.”

Whether they give or receive care, everyone wants dignity–both seniors and their aides want to look forward to seeing each other every day in a relationship of mutual respect. The labor issues in senior care show the consequences of neglecting shared needs, but also open space for creating a fairer system of care, by making the home a more welcoming workplace.

This article originally appeared on Working in These Times on August 17, 2013.  Re-posted with permission. 

About the Authory: Michelle Chen is a contributing editor at In These Times, a contributor to Working In These Times, and an editor at CultureStrike. She is also a co-producer of Asia Pacific Forum on Pacifica’s WBAI.


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Florida Governor Inflates Cost Of Medicaid Expansion By 2,500% To Avoid Implementing Obamacare

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Internal email messages uncovered by Health News Florida reveal that Gov. Rick Scott (R-FL) is knowingly citing inaccurate cost estimates to justify his refusalto expand Florida’s Medicaid program. Though the governor’s office is fully aware that the numbers are wrong, Scott continues to use them anyway, the documents show.

Florida, which has one of the highest rates of uninsurance in the nation, could extend health coverage to about one million low-income residents by accepting Obamacare’s optional Medicaid expansion. But the governor — an ardent Obamacare opponent — has repeatedly said that expanding Medicaid would just be too expensive, claiming it would cost the state $26 billion over the next 10 years.

As Health News Florida reports, however, that figure from Florida’s Agency for Health Care Administration (AHCA) is inflated because it doesn’t take into account the full amount that the federal government will reimburse states for choosing to expand Medicaid. A more accurate analysis found that expansion would cost the state around $1 billion:

But those numbers are based on a flawed report, state budget analysts say. A series of e-mails obtained by Health News Florida shows the analysts warned Scott’s office the numbers were wrong weeks ago, but he is still using them. […]

The Act says the federal government will pay the lion’s share of the cost for new Medicaid eligibles if a state agrees to expand its program — a decision the Supreme Court left up to the states. The federal contribution for the new eligibles would be 100 percent between 2014 and 2016, then would taper after that to 90 percent by 2020 and stay there.

But the AHCA report assumes the federal match for the new patients would be much lower, about 58 percent. It came up with that by averaging the match amount over the past 20 years. The report doesn’t say why the authors made that assumption. […]

As Health News Florida reported on Dec. 21, the AHCA estimates were huge in comparison to a study released by the Urban Institute and Kaiser Family Foundation, two neutral research groups that specialize in Medicaid studies. Their study estimated that if Florida agreed to expand Medicaid, about 1 million uninsured people would gain coverage at a 10-year cost to the state of around $1 billion.

According to the email chain that Health News Florida obtained, state officials began calling the AHCA’s $26 billion cost estimate into question as early as December 20. One member of the House Health Care Appropriations Subcommittee even pointed out that, since the health reform law specifies that the federal government will help fund Obamacare’s Medicaid expansion, it would actually break Florida state law to expand Medicaid without using the federal dollars mandated for that purpose.

Nevertheless, Scott has continued to repeat his false claim that Florida can’t afford to provide its low-income residents with the health coverage they need. Scott met with U.S. Health and Human Services Secretary Kathleen Sebelius on Monday to express his concerns about what expanding Medicaid would mean for his state’s bottom line. “Growing government, it’s never free,” Scott explained to reporters. “It always costs money.” Just not as much money as Scott says it does.

This article was originally posted on Think Progress on January 8, 2013. Reprinted with Permission.

About the Author: Tara Culp-Ressler is an editorial assistant at ThinkProgress.org. Before joining Think Progress, Tara deepened her interest in progressive politics from a faith-based perspective at several religious nonprofits, including Faith in Public Life, the National Religious Campaign Against Torture, and Interfaith Voices. Tara first came to D.C. to study Communications and Spanish at American University, where she also wrote for the student newspaper and advocated for women’s issues on campus. She is originally from Lancaster County, Pennsylvania.


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Hey, Let’s Fix Health Care

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Written by CEPR

Former White House adviser Ezekiel Emanuel offered in a recent New York Times column his bipartisan solution to Medicare, Medicaid and Social Security reform: Graduated eligibility for Social Security and Medicare, or linking “the age of eligibility to lifetime wealth.” The idea, according to Emmanuel, is that “[t]he richer you are, the older you would have to be to be eligible for Social Security and Medicare.”

As Dean Baker notes over at Beat the Press, there are two problems with this approach. First, the budget deficit is a health care problem, not a Social Security problem. Lumping Social Security in with Medicare and Medicaid certainly makes it look like a problem, but if you replace “Social Security” with “muffins,” suddenly we are experiencing explosive growth with muffin costs.

Second, Emanuel’s proposal states:

People in the bottom half of the lifetime earnings distribution would become eligible for normal retirement benefits at age 65 for Medicare and 66 for Social Security, just as they are today. But people in the next quarter of the lifetime earnings distribution would become eligible for the respective programs at 67 and 68, and those in the top quarter would become eligible at 70 and 71. All eligibility ages would increase over time, as they are scheduled to now.

Dean points out that “Emanuel’s proposed cuts in these programs would hit people with average lifetime earnings of $40,000 and above.”* Dean and Hye Jin Rho wrote a paper about means testing last year, which you can find here.

* See Social Security data on Average and Median Amounts of Net Compensation.

This blog originally appeared in Center for Economic and Policy Research on May 22, 2012. Reprinted with permission.


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The Senate Has a Health Care Bill. What’s in It?

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Last night, the Senate unveiled their health care bill. You can read the full bill here [pdf], or the summery documents here.

On the whole, the Senate bill looks very much like the House health care bill. It ends insurance company abuses like denying care for those with pre-existing conditions and it sets benefit standards to make sure the coverage people receive – both on their own and through their employer – actually covers the care they need. It gives people the choice of a public health insurance option like the one in the HELP bill, though states would be able to opt-out of the public option if they passed a law saying so. And it sets up a health insurance “Exchange” that would provide tax credits (subsidies) to make health care affordable, as well as helping business afford health care for their employees.

On the budgetary front, the Senate bill would cost $849 billion over 10 years, and reduce the deficit by $127 billion over the same period. You can read the CBO’s projections on the bill here [pdf].

Of course, there are major differences. Igor Volsky at the Wonk Room has a handy comparison chart:

Senate Bill ($849 billion/10 years) House Bill ($894 billion/10 years)
Individual Mandate Yes, penalty of $750 by 2016 for those don’t purchase coverage. ($95 penalty in first year) Yes, penalty of 2.5% of income for those who remain uninsured
Employer Mandate Free rider provision. Employers would have to pay whichever is lower: $3,000 per every employee who receives a subsidy in the Exchange, or $750 for every employee (not just the subsidized worker). Yes, employers who don’t’ offer coverage would pay a fee equal to 8% of their payroll
Medicaid Expansion Up to 133% FPL. 100% federal funding for the first 3 years, then revert to Senate Finance language. Up to 150% FPL
Subsidies Between 133 – 400% FPL on sliding scale; spend 2%-9.8% of income on premiums Between 133 – 400% FPL on sliding scale; spend 2%-12% of income on premiums
Public Option National public plan, states can opt-out by 2014. Co-ops are also available. Yes, HHS secretary negotiates rates
Financing Excise tax on policies above $8,500 (individuals) and $23,000 (families), increases the payroll tax by .5% (increases to 1.95%) on individuals who earn more than $200,000 and families earning more than $250,000 a year, tax on insurers, pharmaceuticals, and medicare devices; Medicare savings 5.4% surtax on individuals earning > $500,000, couples earning more than $1 million; Medicare savings

The New York Times also has a great comparison.

Overall, the fact that Majority Leader Harry Reid did the right thing and listened to the American people by including things like a public health insurance option and a tax credit level that goes a long way towards making health care affordable means that this bill deserves a debate and a fair, majority up-or-down vote.

Republicans and the insurance companies will try to block this bill any way they can, even going so far as to recommend the Senate not even talk about this bill, let alone vote on it. These tactics only preserve the status quo. The American people deserve health care reform – reform that delivers affordable coverage, a choice of a public health insurance option, and fair financing – and this bill deserves a fair vote by the full Senate so it can meet the House bill in conference.

*This post originally appeared in Health Care for America Now on November 19, 2009. Reprinted with permission from the author.

About the Author: Jason Rosenbaum is a writer and musician currently residing in Washington D.C. He is interested in the intersection of politics and culture, media consolidation issues, and making sense out of our foreign policy disasters. He currently works for Health Care for America Now and he is also the webmaster for The Seminal.


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