Abstract
Eileen Boris and Jennifer Klein present an in-depth history of the struggles of home health workers to achieve dignity, recognition, and a living wage. They focus on workers who perform personal and body care as well as household labor for the poor elderly or disabled. They examine government policies and the responses and movements of multiple actors beginning with New Deal programs in Chapter One, progressing to an epilogue which chronicles current issues. In order to highlight the complex interplay among federal, state, and local policies and players, the authors ground their study in key programs, primarily in New York, California, Illinois, and Oregon. Their findings are fascinating and illuminate the fragmented nature of the U.S. health care system, the devaluation and ambiguity of home care work, and the lack of comprehensive long-term care policies. Boris and Klein demonstrate how government policy has served to concentrate poor women of color into home health jobs, creating a racialized and gendered work force which is associated with welfare, and in an environment of increased neoliberalism has been repeatedly vulnerable to budget cuts and accusations of fraud.
We are first given insight into WPA programs—a component of New Deal policy—which included a Visiting Housekeeping Program for the poor elderly and ill. According to the authors, employing poor women of color served the policy function of work relief under the premise that training would provide job skills and teach workers how to properly care for their own families. Despite continued devaluation of the work and lack of proof that it truly improved women’s economic status, this “rehabilitation” (p. 35) theme reared its head in government policies throughout subsequent decades, including those in the 1981 Omnibus Budget Reconciliation Act and the 1996 Personal Responsibility and Work Opportunity Act. The early WPA programs also began policy movements toward the deinstitutionalization of the elderly and ill.
The devaluation of home care work is witnessed in workers’ repeated exclusion from labor law protection. They were considered as “domestic servants” and excluded from the 1938 Fair Labor Standards Act (FLSA). In 1975 when FSLA was expanded for domestic employees, they were designated as “elder companions” (p. 132). Boris and Klein note the irony of workers’ exclusion, considering that government sources fund their services. They follow this issue to the epilogue and describe the Long Island Care at Home v. Evelyn Coke (2007) case, in which the Supreme Court ruled that the government had the constitutional right to make the rule. They also describe President Obama’s recent proposal to revise the rule so that workers can be covered.
The authors reiterate that there has been a fundamental misunderstanding of the nature and importance of home health work—work which involves emotionality and interdependency. The work has been associated with both welfare and medical models, and government policies have favored medical ideologies that regard the work as unskilled. The authors show how U.S. policy has reflected ideologies of family independence, and has skirted long-term care, instead providing programs for only its poorest citizens. In Chapter Three, they note the divergent regulations between Medicare and Medicaid. Medicare “beneficiaries” are only eligible for limited homemaking services while they are “homebound” and receiving other “skilled” medical services, while means-tested “recipients” of Medicaid do not have these requirements (p. 86). The authors view these regulations as devaluing and stigmatizing body work and household labor.
Boris and Klein’s use of localities as a locus of analysis exposes multi-level governmental strategies to minimize costs and to shift outlays among federal, state, and local sources. Programs in New York and California increasingly contracted home care to private agencies or independent contractors in order to minimize costs and responsibility for/investment in workers. Analysis at the local level also reveals multiple actors with stakes in home care, which are sometimes at cross-purposes. In Chapter Four, we see how white, educated, disabled activists at Berkeley lead a successful independent-living movement in the 1970s to oppose Governor Reagan’s cuts for attendant services. Although they were able to gain “consumer directed” care, which meant control over hiring/firing/training, the needs and rights of the workers—who were considered to be independent contractors—were essentially ignored. The authors show how this model hindered the future attempts of home care workers to organize.
The work highlights union successes but also shows the difficulties of bringing together workers who are outside labor law and isolated in private homes. Chapter Five describes the civil rights activism in the 1970s which fueled workers in New York City to lead impassioned rallies at City Hall and to build a local union, as well as the formation of the black- and Latino-led UDWA (United Domestic Workers of America) in San Diego, which was successful in organizing through vendor agencies. Chapter Six shows how in the 1980s Chicago SEIU local 880 used grassroots organization, and with its major vendor achieved state increases in reimbursement rates. In Chapter Seven, we learn of the creativity of SEIU’s strategies in California in the 1990s. After court decisions declared workers to be independent contractors, it engineered legislation that allowed the creation of county public authorities to serve as employers under which workers could organize. Most instructive is the authors’ description of worker empowerment in dynamic local union cultures in California. Boris and Klein describe “a social world” (p. 201) of holiday celebrations, training sessions, and storytelling activities which “allowed both consumers and providers to appreciate each other” (p. 205). This picture of parties working together for mutual interests and the dignity of both workers and consumers is a prototype of what can be done right.
Despite reports of much success, the work details the roller coaster ride of victories, and the fits and starts of progress. In the epilogue we see conflict within California unions over organizing strategy. We hear about victories such as passage of the Affordable Care Act (2010), but are reminded of recent responses to economic recession, including state cuts to Medicaid and anti-Unionism. The authors contend that the greatest successes come through worker-led efforts to create and sustain strong local union cultures that allow workers to take leadership roles and be present in bargaining. However, they warn that it will take more than successful unions, it will take an ideological shift away from policies which place care responsibilities on families and devalue workers—a system in which care is “naturalized or stigmatized” (p. 224).
This rich and highly contextualized work will be appreciated by a variety of scholars and is essential reading for those who study home care, care work, and labor and labor movements. The detail and complexity makes for density, yet, this is necessary in light of the multi-level dynamics the authors explore. There are insightful quotes and interesting photos throughout, as well as a table of abbreviations which the reader will find very useful. Boris and Klein make a compelling case that given the aging of the American population, more of us will depend on these workers, and we need to guarantee a quality work force by providing them the recognition, wages, and benefits they deserve. The path they pave through history reveals that the fates of both care receiver and care worker are bound up in each other.