Photo courtesy Margaret Boyce

Elder care worker and union member Margaret Boyce speaks at a rally in Trenton, N.J. 

As elder care grows, so do labor battles

Monday, January 23rd, 2012 

Rolanda Wade works as a restorative aide and certified nursing assistant. To her patients, she is everything. 

“A lot of them can’t get dressed by themselves. They can’t wash themselves,” said Wade, who has been on the job 17 years. “Some of them can’t even feed themselves. We have to brush their teeth, do their hair, pick out their clothes for the day.”

The pay is low, and injuries are common, but nursing care is a rare bright spot in the gloomy economic landscape, adding jobs at a steady clip. As the field has grown, so, too, have efforts to unionize. 

Those unionization campaigns are being fought on a shifting battleground, from massive chains to private homes. With baby boomers moving into retirement and beyond, the tensions aren’t likely to abate any time soon. 

Workforce shifts, as does industry

An aging population is increasing its demand for home health and nursing care. Relatively low training requirements mean the job is accessible to a broad range of workers. And the industry is booming. The ranks of home health aides, who today number about 1 million, are projected to increase by more than 50 percent over the next seven years, according to the Bureau of Labor Statistics. By 2018, there will be more direct-care workers, as they are known in the industry, than teachers or public-safety workers, based on BLS data. But mean wages for these careers still hover near the poverty line, and incidences of injury among workers in this category are second only to police officers, according to the Occupational Safety and Health Administration. 

Bill Cruice, the executive director of the Pennsylvania Association of Staff Nurses and Allied Professionals, a labor union representing 6,000 nurses and health professionals, said he has seen many changes in the industry. Nursing homes have historically been owned and operated mostly by companies focused on health or elder care. But during the last 20 years, ownership has paralleled larger trends in the health industry, with big investors snapping up and consolidating homes. Private equity firms have gotten involved in the industry as well, with the Carlyle Group acquiring the nation’s largest nursing home chain, HCR ManorCare, in 2007. And the shift has raised some red flags. In 2007, both the House and Senate held hearings on how changes in the industry are affecting care and accountability.

Growth in home-health workers

By 2018, home health-care aides alone will have increased by 50 percent. A growing elderly population will make direct-care workers almost the largest occupational grouping, second only to retail sales persons.

Source: PHI National/Bureau of Labor Statistics
Graphic by Alissa Scheller, Investigative Reporting Workshop

The image of the small, family-owned nursing home is an antiquated one, Cruice says. Private investment firms purchased close to 1,900 homes from 1998 to 2008, according to a 2010 Government Accountability Office report. Just 10 private investment firms accounted for 89 percent of these acquisitions.

Labor costs are the single greatest expense for nursing home owners, said Cruice, which has made wages a frequent source of conflict. As changes in ownership structure have brought a greater focus on profits, he expects labor fights to pick up because of what he calls a “disconnect between decision makers and workers.”

Efforts to unionize health and elder care workers are under way across the country. But health-care workers are swimming against the de-unionization tide. The percentage of the overall labor force belonging to a union has been cut in half since 1979, from 24 percent to 12 percent, according to the BLS. Unionized health workers, in contrast, have increased their numbers in the past decade, now exceeding the percentage of workers belonging to unions across all industries. Health-care workers in unions earned 14 percent more than their non-union counterparts in 2009, according to the BLS.

Employees at the Broomall Presbyterian Village in Broomall, Pa., are hoping to join the ranks of union-represented health-care workers. They voted nearly two years ago to join Service Employees International Union (SEIU) Healthcare Pennsylvania. They are still working without a contract, after months of negotiations. Employees said the sticking issues hinge on the company’s demand that employees contribute more to pension and health care without guaranteed raises. 

Broomall is the only facility pursuing a union contract out of 28 facilities owned by Presby’s Inspired Life, according to Dan Magee, director of communications for Presby’s. 

“We remain committed to the bargaining-in-good-faith process toward fairness to our staff and, of course, most importantly, the sustained high quality of life to residents,” said Magee.  “Our goal is to pursue a fair and equitable contract,” he said, but declined to discuss details. 

Since the union vote, Regina Robinson, who has worked at the home more than 18 years, has not received a raise. She’s also seen her department, which helps residents maintain physical movement, whittled from four workers to one. 

Robinson is still in favor of the union, not just for better wages but also for a voice in patient care.

“We’ll have somebody in our corner,” she said.

Lack of insurance

Fewer than half of direct-care workers reported employer-sponsored health insurance plans overall compared with 68 percent of the general U.S. workforce.


Source: PHI National analysis of U.S. Census data
Graphic by Alissa Scheller, Investigative Reporting Workshop

Employee health care is a common bone of contention, as it is at Broomall. Nationwide, a quarter of direct-care workers lack insurance coverage. Robinson makes $14 an hour and is concerned about the proposed hike in the amount she would have to contribute to her coverage.

“Your co-pay is expensive; the specialist is expensive,” she said. “You’re paying a lot of money out of your pocket, plus what you pay here a month.”

Even for nurses with a contract, the grueling work doesn’t necessarily translate to high salaries. Wade and her co-workers at Delaire Nursing Home in Linden, N.J., are represented by 1199SEIU, the largest health-care union in the country.

Wade makes a little more than $16 an hour, she said, and supports herself and her college-aged daughter. But she is still living paycheck to paycheck, she said, and recent contract negotiations have been the most difficult she has seen. One proposal included an end to health benefits for Delaire workers. “If we don’t have health insurance, it’s going to come between me paying for health insurance or me feeding my family. That’s just the bottom line,” she said.

Home as a battleground

As the baby boomers age, the battleground in the elder-care fight is shifting from facilities to the home. About 89 percent of baby boomers would prefer to stay in their homes indefinitely, according to a recent study by the AARP.

Home health care workers often have lower wages and fewer protections than their institutional counterparts. They’re excluded from the Fair Labor Standards Act, which ensures minimum wage and pay for overtime. The Obama Administration recently proposed extending these protections to home care and domestic workers for the first time. 

In announcing the proposal, Labor Secretary Hilda Solis cited the staggering demand for home aides and said the field needs greater job security to attract qualified professionals. The Paraprofessional Health Institute (PHI National), an advocacy organization for direct-care workers, has endorsed the protections as a boon for both workers and seniors.

“The quality of care is directly connected to the quality of these direct-care jobs,” said Dorie Seavey, policy director at the institute.

While Seavey said collective bargaining provides the strongest path toward a boost in wages and benefits, PHI National endorses greater training as a means to improve workers’ lives as well. A 2008 Institute of Medicine study recommended a minimum of 120 hours of training to prepare workers for the increase in the aging population.

Federal training requirements for direct-care workers have not been updated in 20 years. While 31 states and the District of Columbia have adopted stronger standards for training, home-health training lags behind that of their institutional counterparts — although the two positions often involve the same work. 

“If you’re a nursing aide, you’re not going to quit a $14- or $15-an-hour job to go work for a home-care agency where you’re going to earn less than 10 bucks. It doesn’t make any sense,” said Seavey.

In fact, pay is so low that half of such workers receive some form of public assistance in addition to their pay, according to research conducted by PHI National.  A survey of direct-care workers conducted by the Department of Health and Human Services found nearly 40 percent of CNAs and 30 percent of home health aides reported forgoing employer-provided health insurance because they were unable to afford it. Many rely on Medicaid or other government programs for insurance..

Poor pay also contributes to a high turnover rate, which stood at 66 percent in nursing facilities, according to a 2008 American Health Care Association study. 

A little more than half of the direct-care workforce is full-time and is disproportionately made up of people of color. African-Americans and Latinos comprised 46 percent of the workforce in 2010, which also is overwhelmingly female — 89 percent. The low proportion of men in the fields has remained constant for the past two decades, said Ariane Hegewisch, study director at the Institute for Women’s Policy Research.

“Men don’t have that many incentives to go into those jobs because you can still earn more as a landscape worker or as a laborer,” said Hegewisch.

Hard work, with a purpose

Margaret Boyce has two full-time jobs. She works from 3 to 11 p.m. at one home in long-term care, dealing with permanent residents, and follows that with restorative care from 11 p.m. to 7 a.m. at another. She makes a little more than $12 an hour at each home. 

“You have to account for everything — every little scratch, every single thing that goes wrong with that patient… if they don’t eat, if you don’t record anything, your license is at stake,” said Boyce. “It’s like you have 16 kids.”

She begins her shifts by seeing how many patients she has to shower.  She gets residents ready for dinner and is responsible for getting them into bed. Most of her residents are also in adult diapers. In between, she offers companionship and comfort. 

“I hope the employers do know what this job is worth,” said Boyce. “This work is very, very, very hard. I can’t stress how hard it is.”

Boyce once dislocated her shoulder while lifting a patient and couldn’t work for a month. “Sometimes in this job you really want to turn around and go home,” she said. “But guess what? You have to live. You have to survive. You have to put your best foot forward, put a smile on your face and keep it moving.”

Despite frustration with pay and benefits, 80 percent of the workers in a government survey also reported job satisfaction, with most citing the good feeling they have from caring for others. Wade said she sees a higher calling in her job, a patriotic duty.

“The elderly took care of this country for years, and they’re so easily forgotten,” she said. “I feel honored that I can help someone who built a country for me to live in.”


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