In California, it pays little to take care of the aged in want at residence • Sacramento Information & Overview
Home care is becoming increasingly important nationwide. When will the districts treat it like this?
By Mark Kreidler, Capital & Main
This story is produced by the award-winning non-profit journalism organization Capital & Main and is co-published here with permission.
Sydney O’Connor’s customers have different needs. One, a nearly blind double transplant survivor, needs help with most of the critical transactions in his life, including paying bills and managing his finances. The other, a woman in the early stages of dementia, needs help with the basics: getting out of bed, making food, moving around the house, going to the bathroom.
The first is O’Connor’s partner, the second her neighbor. As an In-Home Supportive Services (IHSS) provider, O’Connor is part of California’s response to its population of residents who need day-to-day assistance, lack financial resources and want to age in place.
This number keeps growing. According to the State Department of Social Services, more than 666,000 Californians were eligible recipients of IHSS coverage as of last December. In the coming decades, researchers say, that number will skyrocket as California’s graying progresses.
But the state is already lagging behind in its ability to provide IHSS services, which it created almost half a century ago. In 2020, the state auditor found that more than 32 million hours of estimated IHSS needs across California were unmet, a gap that is almost certain to widen.
A reason? Money.
O’Connor, 27, is paid just $15 an hour for her services. It’s a minimum wage figure driven by an oddly constructed system in which each of the state’s 58 counties sets its own rate for IHSS work. Kern County, where O’Connor lives, has stubbornly stuck to the lowest payment it can authorize.
“It’s often medical work, or at least paramedical work,” O’Connor said. “I’ve operated dialysis machines, done IVs, made adult diapers — I do a lot of things that people in long-term care facilities do, and at a much lower cost to the county than someone who’s taken to a hospital or nursing home. But it’s not just minimum wage, it’s not even full-time.”
Instead, each patient is assigned hours at home by a county social worker who attempts to learn the patient’s needs and then estimate how many hours per month it would take to meet them. Since the pandemic began in 2020, O’Connor said no social worker has personally visited any of the people in her care. She is authorized to work 94 hours a month for her partner and 72 for her neighbor; In reality, she often works all day and well into the evening to take care of both, hours well beyond county estimates.
The low pay and stressful job demands discourage people from considering IHSS, and a growing number of workers, including O’Connor, have joined the unions, which negotiate better wages for them. But it’s also part of a long-standing trend in the care industry, and researchers suspect decades-old prejudices — against women and minorities, who make up the bulk of the workforce — are still at play.
“Gosh, that’s the heart of the problem,” said Marokey Sawo, a government economic analyst at the Economic Policy Institute. “What we see manifested here is part of a larger picture of systemic oppression, and it’s tied to three things: who is doing the nursing work, what type of work is it, and who is receiving it?”
Last year, an EPI report co-authored by Sawo found that nursing work, including home care, was paid nationwide at a rate about half the average wage for the workforce as a whole. Women make up 88.6% of home health workers, with 54.6% of workers being women of color and more than a quarter being immigrants. (Although the term “primary care” often refers to professional medical assistance, the EPI’s use of the term encompasses many home care job descriptions, Sawo said.)
“What would these wage levels be like if these factors – racism, sexism, xenophobia – were reduced in relation to the harm they cause? This is a specialized workforce and it is difficult to attract and retain the labor force required,” Sawo said.
Established in 1974, the IHSS system was designed to provide home care to blind, elderly and disabled California residents who meet income requirements. Essentially, those who qualify for Medi-Cal can also request IHSS. More than half of the estimated $18.5 billion cost of running the program in fiscal year 2022-23 will be borne by the federal government, with the remainder being funded by the state.
Counties pay only about 10% of the total cost, but it is the county supervisors that set the rates for IHSS workers in their areas. This has led to huge wage disparities – up to $3 an hour depending on the region. In general, wages do not reflect the importance of the work, especially considering that home care means less strain on other county and state health services.
“People really need to be compensated and recognized for the care they provide,” said Anthony Wafer, who commutes about 60 miles a day from his home in Encino to Lancaster, where his sister is struggling with debilitating knee and back injuries. After caring for her for most of the day, he drives another 65 miles to his night job as a housekeeper at West Los Angeles Veterans Affairs Medical Center.
His IHSS hourly wage from Los Angeles County is $16. His sister is entitled to 109 hours of care per month. Wafer is logging slightly closer to 200.
“I was raised to take care of family, but we’re not just talking about one family member. We’re talking about a patient,” Wafer said. “These people need care. Those are working jobs, period. It’s tough.”
For decades, the jobs have been offered with low pay and no benefits. While the EPI’s report highlights the gender and ethnicity of home care workers as a reason, others note that family members are often the ones providing the necessary care, leading to a devaluation of the service.
“Some county regulators have expressed in the past that IHSS providers can be happy to be paid at all, as if providing full-time care to an elderly person or a person with disabilities isn’t work if you’re related to them,” Cherie said Parker, information officer for the United Domestic Workers of America (UDW). “Low pay is leading to a care crisis of alarming proportions.”
Although firm numbers are hard to come by in California because people are constantly moving in and out of the IHSS, officials estimate that 50% or more of this care is provided by family members. (In another twist on the system, IHSS recipients choose their own caregivers, while the district sets the rate and allocates hours.) For many, choosing a family member is a matter of comfort and trust, caregivers say.
Tracy Mills Jones has extended this care to several family members dating back to the 1990s when her mother was diagnosed with Alzheimer’s. Jones was at home caring for her mother and later her husband with cancer, and is now caring for a brother who has suffered a stroke and is also on dialysis.
“When the pandemic hit, I really noticed the wage issue more clearly,” said Jones, who lives in Palmdale, in north LA County. “I always knew I was underpaid, but I’d made up for it with a couple of odd jobs, night cleaning and stuff like that. During the pandemic those jobs all went away and I could see I just couldn’t make it on IHSS pay. It’s a horrible feeling.”
What should she pay? In a just-released report, the EPI examined what home care wages would look like if factors such as “penalties” related to the type of care work and the demographics of the workers themselves were removed. While the estimates apply to all types of home care, including medical, the results are startling: California’s recommended hourly rate is more than $25, or about $10 more than the current average.
Increasingly, home care providers in California are turning to labor organizations to advance the wage issue. The approximately 570,000 IHSS providers in the country are represented in contract negotiations by either the SEIU 2015 or the UDW, regardless of whether they choose to join the union. (Disclosure: Both organizations are financial supporters of Capital & Main.)
SEIU 2015 made efforts to establish a wage floor of $20 per hour for home care workers. “That’s a great place to start,” Wafer said, “because then this can become a more competitive career field and we could have more nurses who are open to IHSS work.” But those efforts are ultimately local, with unions dealing with each county separately have to negotiate.
In the absence of a government mandate to increase homecare workers’ wages, this 58-piece puzzle will remain in place. “It’s a necessary program that should be developed further,” O’Connor said. But with wages this low and work so undervalued, the massive gap in IHSS coverage in the state is sure to grow. It’s a nursing crisis waiting to happen.
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