Surveying the Home Care Workforce

Surveying the Home Care Workforce: Their Challenges & The Positive Impact of Unionization

In the closing months of 2016, we asked home care workers (i.e., caregivers who provide non-medical in-home assistance with daily living tasks such as mobility, eating, dressing, toileting, and bathing) to participate in an online survey about their jobs and their lives.^[i] More than 3,000 workers located in 47 states and the District of Columbia responded to a short survey; 2,600 of them went on to complete a second, more detailed section. These responses reveal an experienced and committed workforce that puts in long hours caring for consumers but receives unsustainably low pay and few benefits. A sizeable percentage of respondents are treated as independent contractors and may be misclassified. These workers are overwhelmingly women of color, many of whom are in their prime earning years. Despite the importance of the work they do, they frequently have to supplement their home care work with other jobs to make ends meet.

In addition to examining the experience of the workforce as a whole, we also compared the responses of unionized versus non-unionized home care workers. In doing so, we found several trends that speak to the difference that unionization makes—not only for home care workers but for the consumers they care for as well. To gain additional insight into the impact of home care unionization, we conducted phone interviews with four unionized home care workers whose stories are included in this report.

It’s a hard job. It’s not an easy job. It takes a toll on my life. But I really enjoy my clients because they appreciate my services to them.

As the U.S. population matures and more people seek to age in place in their homes, the Department of Labor predicts 26 percent growth in this occupation by 2024.^[ii] These survey responses and worker stories give a window into the nature of home care work and the struggles of those who do it.^[iii] In order to meet the demand for home care services in the future, it is important to attract and retain a qualified workforce. Low wages, few benefits, and a lack of training are just some of the features of this job that contribute to the high turnover rate. Allowing this otherwise decentralized workforce to come together and work with stakeholders, including consumers, state officials, and community advocates, to improve standards for this occupation can have a significant impact on the size and quality of this workforce in the future.

The Nature of Home Care Work

Short Schedules, Uncompensated Hours

Home care workers taking our survey were asked how many hours they had clocked the previous week (Figure 1), and they revealed that this is largely a part-time workforce. Sixty-one percent of respondents work less than full-time (less than 40 hours per week).^[iv] Most said they would work longer if they could: 81 percent said that they “sometimes” or “always” wanted to work more hours (Figure 2). Almost one-third work a second job other than home care, and 53 percent are currently seeking another job in addition to or other than being a home care worker.

This data gives us insight into our respondents’ last week, and indeed most said that the number of hours they reported was typical. We do not know how many work these hours only part of the year, however. Other surveys have shown that nearly 67 percent of home care workers work part time or get full time hours but for only part of the year.^[v] Three out of every 10 workers in these surveys report working in home care for only a portion of the year.^[vi]

A significant portion of this workforce provides care without getting paid by working “off the clock.”^[vii] A majority of respondents said that they “sometimes” or “always” work before or after their shifts without pay, meaning that some of these workers could be putting in more time than their official schedules call for and that they are doing it for free.

She was my last client of the day. I would work later in the night. And sometimes I needed to make the drive in the middle of the night. I would drive the 38 miles there and back to help her in the middle of the night. I was all she had.

Moreover, only 18 percent of those taking the second half of the survey said that their employer paid for on-the-job transportation costs such as reimbursement for public transportation, mileage, or gas. Fifty-two percent of workers reported having more than one consumer in their care. These responses indicate that some workers may be spending part of their day—and their own resources—getting from one consumer to the next.^[viii]

She says that whenever she’s feeling down, I help to lift up her spirits. Home care is not just about going by the care plan; it doesn’t say “comfort her” or “make her feel like she’s a part of society.”

Low Wages, Few Benefits

In addition to the struggle to receive enough hours, many workers and their families remain in poverty due to the low wages they are paid. Although home care industry revenues have rapidly grown, real wages for this workforce have actually declined since 2004.^[ix]

Our survey found that roughly one-third are earning less than $10.00 per hour (Figure 3).^[x] Less than two-thirds (58 percent) earned between $10.00 and $15.00 per hour. The weighted-average range among our respondents was $10.50 to $11.00 an hour. This is slightly higher than national findings of a median hourly wage of $10.09 but still falls within poverty wages for a family; it may be higher because our survey had more experienced workers and a higher percentage of unionized workers than represented nationally.^[xi] With the 2015 extension of federal minimum wage and overtime protections to this workforce, and state minimum wage increases, we hope to see workers bringing home larger paychecks. Without a robust wage increase, home care workers could leave for less demanding low-paying jobs, further harming the supply of workers.

Way back when I started, I was getting paid $3.90 an hour. That was before there was a union. At the time, I knew nothing about unions. I wasn’t a fighter then. When I stopped working, I was making $13.85 an hour. When we unionized, we fought for paid training, paid time off, benefits, health insurance, and life insurance.

Virtually all who took our survey said that they worry about their economic security (Figure 4), and nearly 75 percent of those putting in 40 or more hours a week as a home care worker said that they at least sometimes worry about paying the bills. Nationally, almost half of all home care workers must rely on a publicly funded program like Medicaid, Supplemental Nutrition programs, the Earned Income Tax Credit, or TANF to make ends meet.^[xii]

As we noted above, many workers expressed a desire for more hours, but extra time on the schedule may not translate to significantly higher wages. While overtime pay is a complicated issue in an industry where workers may have several distinct employers (e.g., they may work for multiple agencies or a mix of agencies and self-directing consumers), many of our respondents indicated that they do not get paid at time-and-a-half when they put in more than 40 hours a week (Figure 5). Of those who indicated that they at least occasionally work more than 40 hours in a week, only half said that they sometimes or always get overtime pay, and 40 percent said that they never receive time-and-a-half pay for their time over 40 hours.^[xiii]

I’m always feeling economically insecure. Living in a place like New York, with the cost of living, it’s hard. But at least I have the union. Before the union, I didn’t have any benefits. And if a client stopped getting services, you could be out of work for a month. With the union, we get reassigned fairly quickly.

Those who completed the second detailed half of the survey shared information about employer-provided benefits with us, and the results are not heartening. These workers, who care for older adults, people with disabilities, and those with illness, do so for the most part without employer-provided healthcare (61 percent did not report receiving health insurance) or paid sick days (only 19 percent get them). Less than half reported even getting employer-provided safety equipment, like gloves. Of respondents who were injured on the job, 57 percent indicated that their employer did not provide health insurance, and 78 percent indicated that they did not have a sick day benefit. If injured without access to insurance or time off, the financial and health consequences are clear for caregivers and consumers.

In a sad irony for a workforce tasked with helping our seniors live with dignity, of the 112 workers in this group aged 65 or older, 79.5 percent do not have employer-provided retirement benefits (Figure 6).

Value of Training

Unlike Medicare-funded home health aides[xiv], there are no federal training requirements for home care workers.^[xv] And at the state level, training requirements for home care workers are minimal or nonexistent in the vast majority of states.[xvi]

Many of our respondents want to continue developing skills in order to improve the care of their consumers. A full 82 percent indicated that they thought consumers would benefit if workers received ongoing training. Many indicated interests in specific skill sets (Figure 7); among the most popular topics were those that address preventative care, including nutrition and meal prep (30 percent interest) and monitoring consumers’ health and wellness (27 percent). But most popular was training in specialized care for specific diseases or disorders (43 percent), perhaps indicating the shifting nature of home care as baby boomers age and seek to remain at home with conditions that previously would have sent them to a nursing home.

Education is a big thing. When I first started, you only had to go to classes for 28 hours and it didn’t go into depth. A bunch of us SEIU members got together and said we wanted to change the curriculum and people voted for us to take over the training, which is now 78 hours of training, a state board test, and every year, you need to do 12 hours of continuing education. It has made a big difference in the quality of care our clients receive.

Independent Contractor Misclassification
Personal care and home care services are seldom performed by individuals running their own separate independent businesses, but home care agencies frequently mislabel their employees “independent contractors” and deny them basic workplace protections and benefits. Correct classification of workers as employees is key to securing their legal protections and ensuring fair competition by law-abiding businesses. Misclassification complicates workers’ relationship to their employers and comes with sometimes confusing implications for their income taxes, contributions to safety net programs, and workplace protections. To truly understand the extent of misclassification in this industry and its effect on workers and customers would require a more detailed set of questions and conversations with workers; however, a few questions in this broader survey do point to the need for such an investigation. While we did not ask about this legal status directly, answers to our survey questions about tax documents indicate that 23 percent of respondents may be misclassified as independent contractors. When comparing how wages were reported and whether workers were compelled to agree not to work for other companies in the industry, we discovered that 14 percent are likely misclassified, signaling that some employers may be shirking their responsibilities and putting consumers and workers at risk. These results, while not conclusive, suggest that the issue of independent contractor misclassification requires additional study.

The Impact of Home Care Unions

The high turnover rate among home care workers of 50 to 60 percent annually has been well documented.^[xvii] Turnover can impact the quality and continuity of care that a consumer receives. And, as this report has explored, home care workers face many challenges that contribute to the high turnover rate. In addition to the physically demanding nature of the job, the home care workforce often contends with low wages, few benefits, insufficient training opportunities, isolation, and, for some, uneven access to basic workforce protections such as health and safety provisions and workers’ compensation.

Few studies have analyzed the impact of unionization for home care workers. To do so, we asked survey respondents whether they were members of a union and compared the survey responses of unionized versus non-unionized workers. One-third of survey respondents indicated that they were members of a union. Workers from the Northeast, Midwest, and West were well represented in our unionized sample; the lack of unionized respondents from the Southeast and Southwest mirrors the overall lack of unionization among this workforce in those regions.

In comparing the responses of unionized versus non-unionized workers, we focused on the survey topics that are most influenced by home care unions. For example, unions have little to no means of influencing how many hours workers get, whether they have a consistent schedule, or how workers are classified for tax purposes. A breakdown of the differences in percentage points between the two samples across each pertinent topic can be found in Table 1 in Appendix C. In addition to comparing unionized versus non-unionized workers overall, we analyzed the percentage-point differences between the two samples within subgroups.^[xviii]

We don’t just fight for our wages; we fight for our clients. We so often put our clients’ needs in front of ours. It helps us in the long run. In the recession, hours were cut and it caused confusion and anxiety amongst our clients. Every time someone takes services away, it causes anxiety. A lot of our clients got all of the hours back that were cut from them.

As the data illustrates, allowing home care workers to form an organization that can advocate on their behalf has a number of measureable impacts. These factors can improve the working conditions and well-being of the workers, and because they support a more stable, better trained, and healthier home care workforce, they translate to higher quality care for consumers as well. The trends below were found within the entire unionized and non-unionized sample, and nearly every trend persisted within each subgroup as well.

Unionized workers were:

1. More likely to expect to still be a home care worker a year from now;
2. less likely to be looking for a job other than home care;
3. more likely to say they would benefit from training;
4. less likely to say they are never paid overtime when they work over 40 hours in a week;
5. more likely to receive an array of benefits; and
6. found to have higher wages on average—see distribution of wages in Figure 8, below.

Trends #1 and #2 suggest that turnover among unionized home care workers may be lower than among non-unionized home care workers. Turnover can impact the quality of care and affect health outcomes for consumers. The slightly more positive attitude towards receiving training expressed in trend #3 may be related to the success that unions have had in advocating for, and in some cases directly providing, training for workers they represent. Trend #4 likely reflects the role that unions can play in fighting against wage theft and advocating for more equitable policies. And trends #5 and #6 speak to the primary economic impact that unions have for home care workers, which has implications for recruitment, retention, and reliance on public assistance. The difference in weighted-average wages between unionized and non-unionized workers was $2 an hour more for unionized workers. The benefits home care workers gain can also impact consumers. Home care workers with health insurance (61 percent of unionized versus 28 percent of non-unionized respondents) and paid time off (55 percent of unionized versus 23 percent of non-unionized respondents said they receive either vacation or sick days) can better tend to their own health needs and take off time, while a respite or backup caregiver fills in for them, without going to work sick.

I like making people happy. A lot of my clients don’t have family. They shouldn’t feel alone when they are sick…I tend to go a little above and beyond and I treat them as my own. I become a member of the family.

Finally, for several of the survey topics, we found no significant difference between unionized and non-unionized workers. For example, the rates of workers reporting that they had to seek medical attention for an on-the-job injury, that they have a second job other than home care, and that they are concerned about their economic security were similar between the two samples. This reflects the fact that while unionized workers are better off overall, the work can be very physically demanding and the occupation continues to be a low-wage job.

As the demand for home care services grows in the coming years, so too will the need to recruit, train, and retain a dedicated workforce to meet that demand. Given the many challenges that home care workers face, stakeholders should note that unions have been critical in improving outcomes for these workers. Allowing this otherwise disaggregated workforce to come together and advocate for improvements that make this occupation more desirable can have significant impact on the size and quality of this workforce in the future.

The work is hard and physically and mentally straining but it’s rewarding. I like the people the most and I like feeling like I’m needed and appreciated…We are providing a vital service.

For the Appendix A, B, and C and to see report charts, download the full PDF below. 

[i] For more on how our survey was conducted and disseminated, see Appendix A on methodology and Appendix B on the survey sample.

[ii] Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2016-17 Edition, Personal Care Aides, on the Internet at https://www.bls.gov/ooh/personal-care-and-service/personal-care-aides.htm (visited March 22, 2017).

[iii] For a more in-depth description of the home care and home health workforce and the job duties and working conditions, see, National Employment Law Project, Upholding Labor Standards in Home Care, https://www.nelp.org/wp-content/uploads/Report-Upholding-Labor-Standards-Home-Care-Employer-Accountability.pdf

[iv] More than 2/5 of our respondents (44 percent) said that they had worked fewer than 30 hours, with almost another fifth (17 percent) saying that they had worked between 31 and 39 hours. Only 14 percent reported a 40-hour workweek.

[v] Paraprofessional Healthcare Institute (PHI), U.S. Home Care Workers: Key Facts, September 2016, https://phinational.org/sites/phinational.org/files/phi-home-care-workers-key-facts.pdf

[vi] Paraprofessional Healthcare Institute (PHI), Value the Care! Minimum wage and overtime for home care aides, November 2013, https://phinational.org/sites/phinational.org/files/phi-value-the-care-06.pdf

[vii] Annette Bernhardt, et al., Broken Laws, Unprotected Workers: Violations of Employment and Labor Laws in America’s Cities, September 2009, https://www.nelp.org/wp-content/uploads/2015/03/BrokenLawsReport2009.pdf

[viii] Federal labor protections mandate that, when working for one employer, workers get paid for time spent getting between consumers.

[ix] National Employment Law Project (NELP), Giving Caregivers a Raise: The Impact of a $15 Wage Floor in the Home Care Industry, February 2015, https://www.nelp.org/wp-content/uploads/2015/03/Giving-Caregivers-A-Raise.pdf

[x] Respondents had the option to list hourly wages for up to 10 consumers. While 66 percent reported caring for only one consumer, significant proportions said that they cared for far more, and this calculation uses all of the wages reported in the survey. See the appendix on methodology for more details.

[xi] Bureau of Labor Statistics, U.S. Department of Labor, note 2 supra.

[xii] National Employment Law Project (NELP), Giving Caregivers a Raise: The Impact of a $15 Wage Floor in the Home Care Industry, February 2015, citing University of California, Berkeley Labor Center calculations of federal data. https://www.nelp.org/wp-content/uploads/2015/03/Giving-Caregivers-A-Raise.pdf

[xiii] Legally, workers are entitled to a premium payment of one and a half of the regular rate of pay when they work overtime hours for the same employer. Home care structures can aid in people working more than 40 hours in a week without overtime pay.

[xiv] 42 CFR 484.36, https://www.law.cornell.edu/cfr/text/42/484.36

[xv] Paraprofessional Healthcare Institute (PHI), PHCAST: Final Evaluation Underscores Urgency of Building out Comprehensive, Competency-based Training for Direct Care Workers, July 2016, https://www.phinational.org/blogs/phcast-final-evaluation-underscores-urgency-building-out-comprehensive-competency-based

[xvi] Paraprofessional Healthcare Institute (PHI), Personal Care Aide Training Requirements, https://phinational.org/policy/issues/training-credentialing/training-requirements-state/personal-care-aide-training (visited July 5, 2017).

[xvii] Annual turnover rates range from an estimated 50 to 60 percent. Paraprofessional Healthcare Institute (PHI), SURVEY: Home Care Worker Turnover Topped 60 Percent in 2014, April 2015, available here: https://phinational.org/blogs/survey-home-care-worker-turnover-topped-60-percent-2014 and Paraprofessional Healthcare Institute (PHI), Paying the Price, February 2015, available here: https://phinational.org/sites/phinational.org/files/research-report/paying-the-price.pdf .

[xviii] The subgroups were “IP only” (short for “independent provider” where the worker is hired by their consumer rather than an agency), “agency only”, “publicly-funded only” (i.e. Medicaid or other publicly-funded options), and “privately-funded only”. To compare responses across delivery models a respondent was assigned to a subgroup if they reported exclusively providing care through only one delivery model (regardless of how the services were funded). For example, respondents who reported providing both agency and IP home care were excluded from the “agency only” and “IP only” subgroups so that the responses we were analyzing could be clearly associated with a single delivery model. Respondents who reported providing both agency and IP home care were, however, included in the overall category of “all”. Similarly, only respondents who reported exclusively providing either publicly-funded or privately-funded care (regardless of delivery model) were included in those subgroups.