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The Caring Class: Home Health Aides in Crisis

The Caring Class: Home Health Aides in Crisis

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The Caring Class: Home Health Aides in Crisis

279 Seiten
4 Stunden
15. März 2021


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.

15. März 2021

Über den Autor

Richard Schweid was born in Nashville, Tennessee, and now lives in Barcelona, Spain, where he is a founder and senior editor of the city magazine Barcelona Metropolitan. His previous books include Consider the Eel and The Cockroach Papers: A Compendium of History and Lore. He served as production manager for the Oscar-nominated film Balseros, a documentary feature about Cuban refugees.

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The Caring Class - Richard Schweid


Home Health Aides in Crisis






Dedicated to all the home health aides who are doing a good job of making people’s lives easier on a daily basis

My present purpose is to write to you something about Old Age. For I desire that you and I may be lightened of this burden, which we have in common, of old age already pressing upon us or drawing close at hand.


I like to say that there are only four kinds of people in the world—those who have been caregivers, those who are currently caregivers, those who will be caregivers and those who will need caregivers.




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



Suggested Reading



To write a book is to undertake a journey, and when this one began, I had a mistaken notion about where it was headed. I thought I would be writing about cooperative farms and businesses around the world and their worker-owners: people like the 5.6 million ejido members who farm more than half of Mexico’s arable land, or the eighty thousand members of the Mondragon cooperatives in Spain’s Basque country who own the factories, banks, universities, and businesses where they work.

When I began to research cooperatives in the United States, I quickly learned that not many existed, and that the largest one was Cooperative Home Care Associates (CHCA), a home health care agency located in the South Bronx, which provided home health aides to elderly and disabled Medicaid recipients. I read that in 2014 the agency had more than two thousand employees, over a thousand of whom owned a share of the business.¹

One thing led to another, as it often does. In the spring of 2017, when I was visiting my son’s family in Princeton, New Jersey, I took the train into Manhattan one morning and made my way by subway from Pennsylvania Station in the heart of the city to CHCA’s offices in the South Bronx. It took an hour to get there from midtown. I was late to my meeting with Michael Elsas, who was stepping down as president of the cooperative after seventeen years. He was kind enough not to mind my tardiness. After we spoke for a while, he suggested I sit in on a training class for prospective home health aides (HHAs), as part of my introduction to the agency.

I expected to spend an hour or so listening to the details of something as boring as the instructions for any minimum wage job—how to mop floors or cook hamburgers—but that first class astonished me. The day’s lesson was infection control, and it became clear that the trainees were learning not how to clean floors or fry food but rather how to help our elders stay alive, a job they would be expected to do for minimum wage.

At the same time that about 2.3 million HHAs were paid to do this work every day in the United States,² more than 40 million Americans were providing unpaid care for elderly or disabled family members.³ All of these many millions of caregivers, both paid and unpaid, already knew what I began to learn that first day in class: caring for someone is a hard job. It can generate grave physical and emotional stress, as well as undermine a family’s economic well-being.⁴

As baby boomers age, about ten thousand Americans turn sixty-five every day.⁵ Sooner or later nearly half of them will need some kind of care to get safely through their daily lives, according to the federal government.⁶ Currently, much of that care comes from aides who are sent by franchised home care agencies, which generate millions of dollars for their owners, while the aides they employ are paid minimum wage. Ninety percent of the nation’s HHAs are women,⁷ and about a quarter of them are first-generation immigrants.⁸

Most Americans over sixty-five want to grow old at home, but the reality is that to do so, the majority of us will eventually need someone to help with what are called activities of daily living (ADLs), those things basic to maintaining life like eating, bathing, and using the toilet, and with the instrumental activities of daily living (IADLs), such as cooking and cleaning.⁹ Those millions of women employed as aides to help the elderly with these tasks in the United States are treated as menial laborers, paid minimum wage, often with no benefits, although the job they are doing is critically important to both our personal well-being and that of society as a whole. We need to think about how we can treat HHAs as an important part of a health care team rather than as domestic help.

Like other parts of our health care system, home care is tailored for private enterprise. As first hospitals, then nursing homes, lost their glow for investors, home health care has become ever more attractive to equity fund managers. Home care, as it is currently practiced in the United States, can deliver hefty profits, and it is one of the fastest-growing sectors of our economy. The largest home care franchises have annual revenues of more than a billion dollars.¹⁰

While many agency owners reap outsized profits, the women who work for them often have trouble just keeping their families fed. Given the low pay and stressful work, it is not surprising that HHAs have one of the highest turnover rates of any job. In fact, before COVID-19 erupted in 2020, agency owners were virtually unanimous in declaring that finding and retaining aides was their biggest problem, and that it was becoming more difficult every year.¹¹ At the same time that the number of elderly citizens needing help with their lives increased, the number of aides available to provide it was decreasing.

A benchmark survey of seven hundred agencies found that turnover rates in 2018 had risen an astonishing 15 percent over 2017, and a median of 82 percent of the home care workforce was not in the same job after a year. Of the agencies surveyed, 63 percent were franchises, and 28 percent were independent operators, with the rest affiliated with hospitals and other networks. A majority of the agencies surveyed reported that they had been forced to turn away business during the year because of staff shortages, according to an analysis of the data by Home Health Care News.¹²

When I was writing this book in 2019 the nation was enjoying a strong economy. In many states, the minimum wage was rising, and the problem of turnover in the home care industry was steadily worsening as it grew ever easier to leave one job and find another. This situation was upended by COVID-19, as were so many other aspects of life. With so many people suddenly unemployed and staying home—where they could act as caregivers—the demand for aides decreased temporarily. Depressions, recessions, and economic downturns do not last forever, however, and it is certain that as the unemployment figures improve, home health agencies will find themselves again with a shrinking labor pool and the same turnover problems. In addition, many older survivors of COVID-19 who were previously living independently may have lingering effects from the illness and may need help with their ADLs, adding to the demand for HHAs.

When I came to CHCA in 2017, unemployment was low. The pandemic was still three years in the future and even in the South Bronx, the poorest part of New York City, minimum wage work was not too hard to find. The women in that CHCA class could have chosen a much less stressful job, or no job at all; most of them had kids and were eligible for some kind of public assistance. Why, I wondered, would they want to spend their workdays bathing frail elderly people, taking them to the toilet, tolerating their bad moods, changing their diapers, or dealing with their dementias, all for minimum wage?

I was intrigued and signed on for CHCA’s next month-long training class, envisioning it as an experience that I would weave into a book about cooperatives around the world. Yet as I learned about the lives of my fellow trainees and the jobs they were learning to do, I came to realize that what I wanted to write about was home health care and the women who do it; to try and present my classmates, and the millions of others doing this hard work, to the wider world of readers.

This book follows the same trajectory that I did. As I got to know the trainees, and began to learn about the actual chores that their job would entail, I also began to see what was wrong with our current system of providing home care to the elderly and how those deficiencies might be remedied. Indeed, the problems are pressing: if we do not modify the current system soon, it is likely that more and more people will be increasingly priced out of home care, and they will suffer more and die earlier than is necessary.

For many of us, it is rewarding to care for those near and dear as they approach the end of their lives. After all, we make formal or informal commitments to our spouses and our families that we’ll be there for them when they need us. The time spent making a loved one’s life easier in the final years, being by his or her side, can bring a lot of satisfaction. But the double burden of that care’s financial strain and the time required to assist an individual who needs help performing ADLs and IADLs can rob us of that satisfaction. It can also poison our relationships with other family members and render our loved one’s final years tremendously stressful for all concerned. This is neither a good way to live nor a good way to die, and it doesn’t have to be this way.

The work of caring for those among us who cannot care for themselves is part and parcel of being human, regardless of race, ethnicity, or birthplace. Most of us will be called on at some point to both give and receive care. At the end of our lives we will need help, just as we needed it at the beginning. To learn about how that help is provided to our nation’s elderly—what it consists of and who is doing it—seemed like a journey well worth undertaking.



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

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