The Caring Class

Home Health Aides in Crisis

Richard Schweid

• Publisher: ILR Press
• Year: 2021
• Print ISBN:
  9781501754104
• eBook ISBN:
  9781501754111
• Topic: Politics & International Relations
• Subtopic: Health Care Delivery
• Index: Politics & International Relations

The number of elderly and disabled Americans in need of home health care is increasing annually, even as the pool of people—almost always women—willing to do this job gets smaller and smaller. The Caring Class takes readers inside the reality of home health care by following the lives of women training and working as home health aides in the South Bronx.

Richard Schweid examines home health care in detail, focusing on the women who tend to our elderly and disabled loved ones and how we fail to value their work. They are paid minimum wage so that we might be absent, getting on with our own lives. The book calls for a rethinking of home health care and explains why changes are urgent: the current system offers neither a good way to live nor a good way to die. By improving the job of home health aide, Schweid shows, we can reduce income inequality and create a pool of qualified, competent home health care providers who would contribute to the well-being of us all.

The Caring Class also serves as a guide into the world of our home health care system. Nearly 50 million US families look after an elderly or disabled loved one. This book explains the issues and choices they face. Schweid explores the narratives, histories, and people behind home health care in the United States, examining how we might improve the lives of both those who receive care and those who provide it.

1

NOT FOR THE FAINTHEARTED

Cherelle Adams was nine years old the first time she saw two men shooting at each other.

“I grew up in the Fort Greene projects in Brooklyn, one of the craziest projects ever. It was bad—like, really bad. I lived in a house in Queens until I was nine, then we moved to the projects. I was an only child. Can you imagine that change? It was like a foreign place to me. I was like, ‘What the heck?’

“The first time I ever witnessed a shooting, I watched it, I didn’t duck. Nine years old. Everybody else around me was getting down, but I’d never seen a man here and a man there shooting at each other. So I was just looking. And a lady pulled me down and said, ‘You have to get down, you don’t look at that.’ And I’m just ‘Huh?’ because I never seen anything like that before. Later, I used to cry at night because it was so much shooting, so much killing.”¹

Cherelle (the names of student trainees are the only ones changed in this book) was thirty-nine years old when I met her, an African American living in the South Bronx with three kids of her own at home: a teenage son and a six-year-old daughter from a previous relationship, and a three-year-old girl with her current partner, a big, easygoing man from Guyana. In the spring of 2017, she was one of sixteen adult students in the month-long English-speaking class of trainees in the classroom on the fourteenth floor at CHCA’s headquarters in the South Bronx. The trainees were all women of color, and they were learning how to assist the elderly in performing ADLs and IADLs. Despite my being an un-pierced, un-tattooed old white male, no one raised a hand when the teacher asked the class if anyone minded my sitting in every day.

Cherelle’s classmates ranged in age from eighteen to forty-nine. It was a free month-long class, from 9 a.m. to 5 p.m. five days a week, taught by a registered nurse and an associate instructor. If the students completed the course, they would be certified as HHAs and would have a guaranteed minimum wage job with CHCA.

The training was free, but class attendance was mandatory, and trainees had to make child care and other arrangements on their own. Thirteen of the sixteen women in my class had kids under eighteen living with them. Nevertheless, an unexcused absence would result in expulsion from the course. Trainees also had to purchase navy-blue scrubs and wear them to class. They could not have acrylic fingernails, could use only a bare minimum of makeup, and had to keep their hair gathered up off their necks. Cell phones were turned off during class.

CHCA began in 1985 with twelve aides. It was a for-profit, cooperative home care agency, training and providing aides to those elderly or disabled people who qualified for Medicare or Medicaid, and it had revenues of more than $60 million in 2016.² Like hundreds of its licensed competitors in New York State,³ CHCA paid only minimum wage, but unlike them, it had always offered aides decent health benefits, sick leave, vacation pay, and maternity leave.

As baby boomers age, home health care is among the top three fastest-growing employment sectors in the nation. In 2013 it generated over $61 billion, nearly half of the direct care industry, which also included personal assistants and certified nursing assistants.⁴ In 1975 only an estimated sixty thousand women were working as home health aides in the United States,⁵ while by 2015, over 2.3 million women were doing so, and paying taxes, while many more who were paid under the table, in what was known as the “gray market,” went uncounted.⁶ In 2018 the federal Bureau of Labor Statistics predicted that millions more HHAs would be needed, and that the field would see a growth of 36 percent over the decade from 2014 to 2024.⁷ Between 2012 and 2050, the number of people in the United States over sixty-five will nearly double from 43.1 million to 83.7 million.⁸

The largest home care agency franchisers employ tens of thousands of HHAs. Home care is a lucrative business, and part of that profitability is based on keeping wages as low as legally possible. Because the job is hard and the salary is minimum wage, the workers—those people we hire to care for our loved ones—are usually women of color, or white women with a limited education, who do not have a wide choice of jobs and are trying to survive on the low end of the income inequality gap. Many aides are African Americans, and many others are first-generation immigrants or their daughters.

Most minimum wage jobs—flipping burgers, washing dishes, lawn care—require little or no preparation, and much of what there is to learn consists of on-the-job training, with someone who is earning maybe fifty cents an hour more than the new employee barking a few directions until a task is mastered. But before they would earn their first paychecks, the sixteen students in Cherelle’s class—and the more than six hundred minority women who trained every year in CHCA’s classrooms—would have to demonstrate that they had mastered a 150-page home care manual during their month-long training.

The infirmities and indignities to which we are prone as we grow old and frail made up the body of knowledge that these trainees were acquiring. They were studying the geography of old age, learning how the years break us down physically and mentally. We watch our parents and their peers cross into that strange land, and then we ourselves become increasingly dependent on care by others. First one bodily function doesn’t work so well, then another. Heart, brain, liver, lungs, and legs begin to fail. Most of us want to go through this aging process in our own homes, but for that to happen, many of us will need a home health aide.

Over 90 percent of CHCA’s two thousand HHAs had been receiving some form of public assistance when they first enrolled: food stamps; Women, Infants, and Children (WIC) benefits; rent vouchers; or Temporary Assistance for Needy Families (TANF). Fifty-five percent of them had not held a job in the previous twelve months before signing up for the class.⁹ Yet the job they aspired to do was extremely stressful—physically, mentally, and emotionally. The training class’s curriculum was an intense education in how to take care of people who cannot take care of themselves.

The work schedule was one attractive feature of a job as an HHA, particularly for women who were also caring for their own children. At CHCA, the shifts could be eight, twelve, or twenty-four hours, so that a workweek might consist, for instance, of three days on at twelve hours a shift and four days off. Another advantage of the job was that employment opportunities—albeit at minimum wage—were numerous. A certified home care aide could almost always find a job. But to get that certificate from CHCA, Cherelle and her classmates had to arrange their lives—grocery shopping, cooking, child care, and all—so that they would be able to be in class all day, five days a week, for a month.

As if managing daily attendance were not hard enough, they had to spend their classroom hours learning how to sit our mothers and fathers on the toilet and clean them when they were done, bathe them, change their diapers, keep them free from infection, feed them, and monitor the slightest changes in their blood pressure, pulse rate, skin condition, or temperature. In short, they were learning how to keep our vulnerable loved ones safe while we were elsewhere, and they would get paid less for doing so than they would have made working as waitresses.

Anyone who has ever spent as little as a day caring for someone with Alzheimer’s disease, or assisting a parent confined to a bed or to a wheel-chair, knows that it is by no means an easy job. The work is not comparable to flipping hamburgers or mopping floors. It may include cooking and cleaning, but it is a harder job—much harder. Even though demand for their services outpaces supply, workers often have uncertain schedules, and many have no health benefits or paid vacation time. Because turnover is so high among home health aides, some agencies will hire just about any woman willing to work for the low wages they offer, sending her out to care for us with minimum training: two weeks is the federal Medicaid requirement. If it’s an agency that handles only private-pay cases, no formal training is required.

At CHCA, turnover was considerably below the industry average, and job satisfaction well above it. Nationwide in the spring of 2017, the estimates of annual turnover rates among aides ranged between 45 and 60 percent, while at CHCA it was 25 percent.¹⁰ The agency took great care in its recruitment practices, and some 70 percent of new trainees each year were referred by word of mouth, frequently by someone already employed at CHCA. In addition, it was CHCA policy to try to fill all in-office vacancies by bringing in an aide from the field. While some women did not want to trade their HHA jobs for working in the office, others were happy to do so.

Background checks were run on every applicant, in addition to one-onone interviews and written tests, to determine who would be accepted into the training classes. Only about one in every ten women who expressed an initial interest eventually enrolled.¹¹ From that 10 percent, the agency insisted on full commitment.

CHCA was certainly getting full commitment from the women in Cherelle’s class. They were scoring high on the daily quizzes; day after day, Maria Soto, the associate instructor who was herself a former aide, brought the previous day’s tests back to the class, saying, “Congratulations, everyone passed.” Then, the class’s nurse instructor, Bridget Winslow, led them in a round of self-congratulatory applause. These two women taught with sharply distinct styles, but they both kept the classes orderly and quiet while keeping the trainees engaged. They also shared an openness about the job they did, and both of them welcomed me, unreservedly, to attend the classes.

Bridget Winslow was a short auburn-haired woman who sang with the New York City Opera company for more than thirty years before pursuing her second career choice and becoming a registered nurse. Her discipline in the classroom was light but firm. “I give everybody respect,” she told me. “The most dangerous moment for many of them is just past halfway through the training. Students with low self-esteem get tired and they mess up, proving to themselves once again that they’re not worth anything. That’s when the respect I show is most important. A lot of these women have not had much respect in their lives, they’re not used to getting it, and they respond. When students start to fail tests, I ask what’s happening in their lives. You can’t imagine the things that I’ve heard.”¹²

Over 50 percent of CHCA’s one hundred employees working in the office started out working for the agency as aides, and Maria Soto was one of them. A solid middle-aged blonde with a strong Bronx accent, she had worked as an aide for eight years before coming into the classroom in 2005 as an assistant instructor. Both Bridget and Maria were light-skinned second-generation Puerto Rican New Yorkers who were perfectly fluent in both Spanish and English.

The agency offered the month-long training classes in both languages, and students in the Spanish-language classes were invariably well behaved, quiet, and attentive. For a woman living in the Bronx who spoke only limited English, working as a home care aide was likely to be one of the few jobs open to her. “These women are just desperate for work,” Bridget Winslow told me. “They are just glad for the chance to be here, and they behave accordingly.”

The English-language classes, by contrast, had a reputation among the nurses and instructors as more problematic and difficult to teach, the students less disciplined and respectful. “It can be like an entitlement for them,” Bridget said. “This was my first English class, and I was worried about teaching it, but it has been great. They’re terrific.”

The only problem that Cherelle’s class generated came during lunch hour or the twenty-minute morning and afternoon breaks. Some of the students had raucous laughs, and some were prone to talking at a volume that could be heard through the walls of the adjoining classrooms. The tendency of conversations to veer toward loud was not surprising, given the borough’s ambient noise levels. Anyone wishing to be heard in the South Bronx had better speak up. Noise was a constant in the streets. Mufflers were often altered or eliminated so that cars and motorcycles roared by at deafening volume. Traffic was heavy, streets were packed with trucks, cars, and buses all making their own racket, honking their horns, loud wails of sirens piercing the hubbub, big jets growling loudly as they came in low for a landing at LaGuardia Airport, and the level of bass issuing from the sound systems of passing cars—deep, throbbing notes—was loud enough to make panes of glass shiver in the windows of buildings as they drove by. Mister Softee trucks constantly cruised slowly through the streets, their loudspeakers blaring a piercing, inane, tinny jingle over and over again to call people out of their houses for soft ice cream.

Unlike their Latina counterparts, English speakers could choose from a number of minimum wage jobs, all of which were less taxing physically, mentally, and emotionally than being an aide. Most of the women in Cherelle’s class, however, had taken care of ill family members or neighbors at some time in their lives. In addition to needing a job, they were attracted to what they saw as a “helping” employment. Some viewed a home care aide’s certificate as the first step on the road to becoming a certified nursing assistant (CNA), which in New York State would require additional training and earn them a couple of dollars more an hour with a job in a nursing home.

When CHCA began, and for years afterward, about seven of every ten aides were African Americans. Over the decades that ratio changed, and by 2017 it had undergone a complete reversal. Latinas, mostly from the Dominican Republic and Puerto Rico, made up about 70 percent of the workforce, although some 55 percent of the clients CHCA served were English speakers.¹³ In fact, there were not enough English-speaking aides to meet demand, and one of the complaints most often heard from CHCA clients was that their aides knew so little English, it was hard to make themselves understood.

The home care industry in both urban and rural settings depends on immigrant labor. Without first-generation immigrant women to care for our parents, we would be in dire straits. The ratio in my class was an exact reflection of the nation’s 25 percent: two Jamaicans, one Senegalese, and one Thai out of sixteen trainees. Four others in the class, along with the two teachers, were second-generation daughters of migrants from Puerto Rico, born and raised in the Bronx, and the remaining eight women were African Americans.

Some of the nation’s native-born laboring poor have always blamed their penurious circumstances on newly arriving foreigners—an attitude often encouraged by demagogic public officials. The question of whether and how much to restrict immigration in order to protect the jobs of those already here is a recurring subject of heated public debate. If xenophobic rhetoric, border walls, and increasingly restrictive visa policies succeed in discouraging immigration, while at the same time the deportation of legal and illegal “unskilled” immigrants increases, a drastic reduction in the number of women available to work as home care aides is going to result.

A 2017 study from the Paraprofessional Healthcare Institute (PHI), a nonprofit organization affiliated with CHCA, concluded that of the nation’s 4.4 million people working as personal care aides, home care aides, or certified nursing assistants, approximately a million were immigrants.¹⁴ In New York State, over 40 percent of the people working in these professions were immigrants. Reports have estimated that one in five of them was undocumented.¹⁵ Many of these were in private duty, hired from the gray market, or working for agencies that needed aides more than they needed documents. This was not the case with CHCA, which carefully checked the enrollees in its classes to be sure they had their immigration documents in order and had nothing in the way of a criminal record that would disqualify them.

The countries contributing the most personnel to the direct care work-force in the United States are Mexico, the Philippines, and Jamaica, with the predominant number of workers from Central America, the Caribbean, and Southeast Asia.¹⁶ These women come from cultures where the role of caring for elders and the disabled is assumed by the females in the family. Many of them have seen ...

Table of contents

• Introduction
• 1. Not for the Fainthearted
• 2. Observe, Record, and Report
• 3. Home Care for Sale
• 4. Parasites of the Elderly
• 5. Graduation Day
• 6. Welcome to These Shores
• 7. “I Don’t Do It for the Money”
• Acknowledgments
• Notes
• Suggested Reading
• Index