We Get What We Pay For

Dear Leading Ladies,

A dear friend is moving her husband to a memory care residence because he can no longer function at home with only her loving care and part-time help. Another dear friend just lost her husband after negotiating his treatment through an acute care hospital, then a rehab, and finally a hospice facility. And yet another close friend recently was discharged from a rehab hospital following a fall and two serious bone breaks that left her temporarily unable to walk or even turn over in bed unassisted.

What have all these patients and their loved ones faced, besides suffering, pain, loss, and the frustrations of medical paperwork?

A serious shortage of care providers.

The results for my friends and others? Sometimes having to wait days or weeks for a bed in a facility equipped to handle a patient’s needs. Sometimes being placed in a facility far from home, making it difficult for family and friends to visit. Sometimes waiting in a room for hours to have one’s toilet needs met and then longer still to have soiled sheets changed. Sometimes not getting medications on time. Fortunately, there are some skilled and generous caregivers as well. Needless to say, however, an environment where patients are sick, unable to move, and worried that their calls for help could go unheeded is not good health care in anyone’s book.

What has caused this staffing shortage crisis? And what’s all this got to do with social justice?

To understand why the caregiving business is such a mess in this country and what it has to do with social justice requires a look back at history.

History

State Senator Pat Jehlen wrote a revealing overview of the situation to her constituents, based on a recent report from the Boston Foundation. Not surprisingly, the care of children and people with disabilities was generally done at home by women until the Industrial Revolution. Women of means did the entertaining and house management, while actual caretaking fell to enslaved women who were not paid at all or other women considered of a lower class. As white women began to enter the workforce in clerical and sales roles, women of color continued to be domestic workers, underpaid, undervalued, with no union representation or reform law advancements. These domestic workers were only included in federal minimum wage and overtime protections in 2015. In 2014, Massachusetts passed a Domestic Worker Bill of Rights, according to Jehlen’s overview.

So, there’s the connection with social justice, or lack thereof. Workers, mostly of color, are asked to do demanding work in exchange for little pay that hardly covers the cost of transportation, food, rent, and childcare.

Since the pandemic, jobs in caregiving have gone unfilled.

Researchgate.net

Why is Demand Up?

COVID put monumental stress on caregivers. They were asked to work more and exposed to COVID non-stop. Their children were home from school, often without anyone to watch them. Just getting to work presented challenges and risks. Many wondered if returning to work made financial sense. If they couldn’t make enough to cover their basic expenses, should they stay home, cobble together some side hustles, or work in a different field?

Add to that the fact that the demand for caregiving is rising quickly as life expectancy keeps going up. The need to care for the elderly in nursing homes, rehab hospitals, hospice facilities, and at home is rising quickly and will continue to do so.

And then there’s child care. Many centers closed permanently during the pandemic, particularly in neighborhoods of color, leaving parents stuck between a rock and a hard place — unable to work without child care, unable to stay home and pay the rent. The report says that "affordable child care would lead to an increase of over $100,000 in lifetime net income for Black mothers, the highest of any racial or ethnic group." But too many child care providers, as with other care workers, can’t afford to go back to work.

Demand is up also because of the slowdown in immigration during the Trump years. More than half of nursing home workers in the Greater Boston area are immigrants, specifically immigrants of color, so the increase in immigration restrictions has had a significant effect on the care in these facilities.

The Painful Irony

As we recall, direct care providers were called essential workers during the early days of the pandemic. Yet, as Jehlen points out, their wages are near the bottom of all occupations. Overwhelmingly women of color, these workers are less likely to have pension plans; more likely to qualify for SNAP benefits; less likely to receive employer-paid health insurance, and more likely to rely on Medicaid. While minimum pay in Massachusetts has increased and personal care assistants are now unionized, wages have still not kept pace with inflation.

Beyond the low wages, these workers face significant challenges: working in situations that can be physically demanding; often losing pay when a patient cancels; exposure to illnesses; and shouldering the transportation costs to different work addresses when caring for multiple patients. In addition, with the shortage and subsequent high turnover of workers, those who stick around have unusually large workloads, adding to their stress. Working 16 hours straight is not uncommon for long-term care aides, according to Jennifer Nazareno, assistant professor at Brown University School of Public Health, as cited in an article in Politico by Alexandra Moe.

So, we appreciated these care providers when they were putting their lives on the line, but now it is all too easy to lambast those who don’t want to return to their poverty-level jobs. And white men and women? They’ve never wanted these jobs. Who can blame them?

Detroit Free Press

Solutions

“Finding more workers to do these jobs is only half the solution: Higher pay and opportunities for career advancement are critical for retention,” writes Moe in Politico. Low wages are the root factor of the shortage of workers, Charlene Harrington, professor emerita of sociology and nursing at UC San Francisco told Moe. Most aides live below the poverty line and are responsible for 12-25 patients in a facility, instead of the recommended seven, says Moe.

Many of these jobs do not require extensive training – child care workers, personal care aides, home health aides, nursing assistants, even psychiatric aides. But to get people interested in entering the fields requires incentives such as money for schooling and advancement and to cover expenses for the break in earning while in school; a living wage; and benefits once licensed in their field. Nazareno adds that a path to citizenship should come with the job, too.

The Boston Foundation’s report, as referenced by Sen. Jehlen, recommends that we continue to raise the minimum wage; license home care agencies; strengthen career ladders; expand the Earned Income Tax Credit to unpaid family caregivers; and improve care workers' ability to unionize. Offering free training, as mentioned above, is another positive initiative. Payment for at-home caregivers, including spouses, should also be on the docket.

It is notable that Massachusetts is among a handful of states that have set “direct care ratios,” which ensure a limit on profits so that more expenditures are directed to care. This is significant since 70 percent of nursing homes are for-profit. Massachusetts is also among the five states that adopted permanent increases to nursing home staffing requirements during the pandemic. In September, the Biden-Harris Administration awarded $225 million in American Rescue Plan funds to train over 13,000 Community Health Workers (CHWs), with the goal of investing more than $1.1 billion for 40,000 community health, outreach, and health education workers over the coming years

This is all good news, and clearly can’t come soon enough, since we all have stories of inadequate care in facilities in this state, usually due to understaffing and fatigue. And underneath it all? The devaluation of work performed usually by women, women of color.

From cradle to grave, we and our loved ones will need care. If we value the care, we need to value the caregivers. It’s as simple as that.

Happy New Year! We are taking next week off. Look for our next newsletter in 2023!

Therese (she/her/hers)
Judy (she/her/hers)
Didi (she/her/hers)
Mackenzie (she/her/hers)
Leading Ladies Executive Team
Leadingladiesvote.org
ladies@leadingladiesvote.org