Nearly two million Americans work as home health aides and personal care aides — a number that is projected to climb above three million by 2020.

This is low-paid, low-status, exhausting work. A typical shift might include helping a client bathe, preparing her meals, changing her linens, helping her walk safely to the store, sweeping her floors, and helping administer medications (even though in many cases these aides aren’t licensed to do so). There is also a complex burden of emotional labor: comforting, cajoling, making small talk.

Most home aides are hired and paid by third-party agencies, which are often hugely profitable, in part because domestic workers have lacked minimum-wage and overtime protections under the so-called “companionship exemption” to the Fair Labor Standards Act.

After years of organizing by the National Domestic Workers Alliance, the Paraprofessional Healthcare Institute, and other groups, the Obama administration issued a preliminary regulation late last year that might finally bring an end to that exemption.

But that fight is far from settled. The administration still has not issued a final version of its rule, and Senate Republicans introduced a bill in June that would block the rule from taking effect. Meanwhile, California’s ever-charming Governor Jerry Brown has just vetoed a state-level Domestic Workers Bill of Rights.

Clare L. Stacey, an assistant professor of sociology at Kent State U., looked at the lives of domestic workers in her 2011 book The Caring Self: The Work Experiences of Home Care Aides (ILR/Cornell University Press).

One of the themes of Stacey’s book is that domestic labor blurs the conventional understanding of the line between “real” wage work and the unpaid time we spend caring for family members and friends. She quotes a woman who was paid for five years to care for a neighbor with multiple sclerosis:

She really did depend on that daily contact with me. Several of her friends kept in touch by phone, and that helped a lot. But I found that I actually had to play the big sister a lot of times, and get bossy, and tell her what to do. You know, ‘You have to take your meds. You have to eat.’ She would go days without eating . . . . It was much like a sibling relationship in that she would take so much motivation from me, and then shut me down. ‘That’s enough!’ Which I loved; I really enjoyed that part.

Clare Stacey recently answered a few questions by e-mail.

Q. How closely have you followed the Obama administration’s rulemaking process? Do you have any criticisms of the language the Labor Department has proposed? Do you think their approach goes far enough?

A. I have followed the rulemaking process fairly closely and I submitted a comment on the draft regulation. The only criticism I have of the proposed rule is really an academic one (one I did not raise in my comment but is in my book): The flawed basic premise of the companionship exemption remains intact under the new rule.

The Obama administration’s justification for removing the exemption in the case of home care aides is based on the proposition that aides are “more than companions” and therefore are “real workers.” In my view, part of what aides provide is emotional labor, which of course is the very thing the Department of Labor does not want to protect under the FLSA. Until we recognize that listening to someone, being with someone, managing someone’s worries, fears, emotions, etc., is in fact work, then I think home care will continue to be a socially devalued job.

That said, I do think that the proposed rule represents an important policy change that gets us moving in the right direction. In an ideal world, though, I’d like companionship to be recognized as labor and compensated accordingly, rather than building a case around home care work as “more than companionship” and therefore deserving of labor protection.

Q. As a nurse-in-training, of course I’m interested in the relationships between RN’s and home care aides. What kinds of dynamics did you see in your field work? What should nurses understand about these workers?

A. The public health nurses who worked with clients at [one of the agencies in Stacey's book] were actually pretty disdainful of home care aides and viewed many of them as unscrupulous and unreliable. There were a few nurses who really respected the work of home care aides, but for the most part they kept their interactions with aides to a minimum.

Q. State governments are moving toward giving medication-administration rights to home health aides. (Connecticut, for example, passed a new law this summer.) You mention in your book that a certain amount of this already goes on, on a don’t-ask-don’t-tell basis. How do you see this question? Are home aides competent to give meds safely? Could it change the informal character of their work by bringing them under a new regime of state supervision?

A. This is a tricky one. I know that nurse practice acts in several states preclude aides from doing this work, but my findings suggest that they often have to do it anyway since they are the only ones around to help clients. A good policy would recognize that workers are doing this work anyway and find ways to train and protect them. But aides may also paradoxically find themselves without the same kind of autonomy in states where policies/laws like this become codified. But since client health is at risk if we don’t train workers appropriately, I think the best way to go is to acknowledge that aides are well-suited to administer meds in many circumstances and that they should be trained to do the work properly.

David Glenn is a student at the University of Maryland School of Nursing and author of the blog, Notes On Nursing, where this post originally appeared.

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7 Responses for “The Wages of Home Care”

  1. Matthew says:

    Very interesting article; we have similar problems over in the UK in this area

  2. Peter1 says:

    “Most home aides are hired and paid by third-party agencies, which are often hugely profitable, in part because domestic workers have lacked minimum-wage and overtime protections under the so-called “companionship exemption” to the Fair Labor Standards Act.”

    Allowing these workers (mostly women) access to fair wages and working conditions will cost their patients/clients more money. As usual there are those who can pay more and those who can not. From what I’ve read getting care at home is a cost saver for the system, but in a capitalist health care world there is no “system” there is only a separation of income groups.

    For example where will Medicaid recipients fall in a higher wage, better working condition home care world?

  3. sadat says:

    Allowing these workers (mostly women) access to fair wages and working conditions will cost their patients/clients more money. As usual there are those who can pay more and those who can not. From what I’ve read getting care at home is a cost saver for the system, but in a capitalist health care world there is no “system” there is only a separation of income groups.

  4. Sandra says:

    There are a lot of jobs like this. Low pay, little gratitude, hard work. Its sad, but…such is life.

  5. Marilyn Swenson says:

    Visiting Angels is indeed a blessing. I needed someone to care for my mom who lives in Palm Beach Gardens, FL. She suffers from Alzheimer’s and I live in England. I was able to choose the right caregiver for my Mom. The person was experienced and had excellent credentials. I have peace of mind knowing that Mom is in capable hands. You should check them out at http://www.visitingangels.com/palmbeaches (561-328-7611) if you need senior care services.

  6. Erica Hathway says:

    I was looking on the internet to find some options on how to care for my elderly parents in West Palm Beach, FL. I found a great website with lots of pertinent info. Check it out at http://www.seniorhomecareadvice.org maybe it can help you too.

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