The Shockingly Low Wages We Pay People Who Look After the Elderly
Curtis Smith couldn’t help grinning as he took another bite of chocolate-frosted cake. His favorite restaurant always gave patrons a birthday discount equal to their age, so on this day, the occasion of his 101st birthday, the dapper centenarian was not only going to get a free meal, they were going to pay him. “That’s what I call a deal!” he said, cheerfully pocketing the 20 cents.
Curtis was my great-grandfather, and he was a lucky guy in many ways. He drove his car and climbed ladders well into his 90s. At 101, he was still regaling us with funny stories that took place decades before. He ate fried eggs and bacon every day, to no apparent ill effect. But perhaps luckiest of all, he lived his entire life at home. When he died a few months short of his 102nd birthday, he’d spent less than six months total in a nursing home.
This is what most of us want for our parents, our grandparents, and eventually, ourselves—to stay independent as long as possible, live at home as long as possible, eat what we want, and definitely, stay out of the nursing home. The key in my great-grandfather’s case was having family members nearby who were willing to help out—manage medications, clean the house, and generally keep an eye on him.
But many Americans don’t live near their relatives anymore. And even if they do, their adult children work or have other responsibilities. That means that in order for America’s seniors to spend their twilight years as they wish, they need someone else.
Someone like Leslie.
Leslie Roberts has two teenage sons, an 11-year-old daughter, and a warm laugh that makes you feel like you’ve known her for ages. She’s 39, and she’s been a home health aide for 15 years.
Every morning, she gets up, takes her kids to school, and drives across town to the homes of two to six elderly clients. She cooks their meals, helps them eat, helps them shower, and ties their shoes. She lifts them in and out of wheelchairs, beds and bathtubs. She reminds them to take their medications. She listens to their stories about their childhoods, their children, or the things they’re afraid of. She shops for groceries and vacuums; she changes the sheets and tidies the house. And then she goes to the next house and does it all over again.
She loves it. She loves being the person who gets them up out of bed and into the sunshine, who brings the outside world in with tidbits of news, who brings some hustle and bustle to a house wrapped in stillness.
“I have one lady who is always really down when I get there, and I just go in and start throwing open all the windows, and teasing her about this and that,” Roberts says. “She’s always like, ‘Aw, Leslie, you get on my nerves,’ but by the time I leave, she’s up and around, smiling and talking, doing her thing. She’s like a whole different person.”
Roberts is often the only person her clients will see all day. “If I don’t show up, there’s nobody to fix them breakfast, nobody to get them out of bed,” she says. “They’ll sit alone in the house for 12 hours and won’t see a soul.”
She’s often the person with the closest relationship to the client, or at least the most honest. “I had this one lady who was mean to everybody but me, and everybody was like, why isn’t she mean to you? And I would just tell them, well, we spend a lotta time together." Roberts took the client out to eat and to the hairdresser, and found ways to encourage her to interact with her neighbors. She even got her up and walking on her own.
“She would sit all day in her chair, and I’d just be like, hey, come on. Let’s take a walk down this hall, and one day she did!” she says. When the therapist came by, the client would turn stiff and silent, but as soon as the therapist left, “that walker would be in the corner, and she’d be trotting all over that house,” says Roberts. “I loved helping her progress like that. It makes you feel good.”
Leslie Roberts is the answer to many Americans' prayers—the prayer of everyday citizens who hope they or their elders can grow old at home with dignity, and of policymakers eager to encourage “aging in place” for reasons of cost savings or health. She works at America’s fastest-growing occupation; in the next 10 years, there will be more new home healthcare jobs—more than a million—than any other kind of work.
So everybody wants her. Everybody needs her. And yet, for her work—work everyone values, this service almost all of us will one day need—Leslie Roberts and her peers around the country are paid wages they cannot live on, averaging about $9.75 an hour, with a median annual income of $20,000.
They almost never get health benefits, sick time or vacation; if they get sick, they just don’t get paid. Astonishingly, in many states they aren’t even guaranteed the minimum wage, thanks to a longstanding federal loophole allowing lower pay for workers providing “companionship.” This was nearly rectified when the Obama administration issued a new rule requiring minimum wage and overtime pay for home health workers, but at the last minute, a U.S. District Court judge struck it down; the Department of Labor is considering an appeal.
Roberts and other home healthcare workers are not paid for travel time and are rarely reimbursed for mileage, both of which are a pretty big deal when your entire day is a patchwork of client visits punctuated by driving. They don’t get paid if a client cancels for a doctor’s appointment or any other reason.
“You don’t work all day for the same client: You’ve got two hours here, an hour here, and three hours there, driving in between,” says Roberts. “It’s really hard to make that add up to eight [paid] hours a day.”
That means the $9.75 average is really more like $8.75, or even lower.
And the work is tough. As a home health aide, Roberts is more likely to be injured on the job than a miner or a steel mill worker. Clients have to be lifted or maneuvered from bed to chair, chair to tub, day after day. “I had one lady I had to literally pick up like a baby and carry her to the bathroom,” Roberts says. Even if the client has a mechanical lift to assist them, there’s still the challenge of maneuvering the machine. “In a nursing home, that’s a two-man lift,” she says, “but you’re out there by yourself. What else are you gonna do?”
Even the clients themselves can be dangerous at times. Home health aide Artheta Peters tells the story of a male Alzheimer’s client, six feet tall and still plenty strong, who suddenly exploded into a rage and backed her into a corner, screaming obscenities. Peters managed to defuse the situation, speaking softly and darting past him to grab her phone. But it was still terrifying; the petite 38-year-old is maybe five-foot-one on tiptoes, and there was no one else in the house. “Alzheimer’s is a huge issue, because you never know where they are inside their mind: Is it today, or is it 10 years ago? Do they remember who you are?” Peters says. “And it can change from one minute to the next.”
Some of the other hard parts of the job are drawn in subtler shades. How does it feel to find a client all dressed up to go buy a brand-new car and you have to tell her the dealership was torn down 20 years ago and she hasn’t driven in 10 years? How do you respond when one adult child demands one thing for mom’s care, and the other just as vehemently demands something else? And what do you say when a bedridden client takes your hand and whispers, “It’s time, honey. I really think it’s time”? (Roberts gently told the woman, “No, just a second, ma’am, it’s not time,” and the woman responded, “Honey, I’m 100 years old. Ain’t no more seconds.” The client passed away later that night.) How does it feel to grow to care for a person and have to watch them decline, day after day, up close, in person?
Say the words “low-wage work,” and most people picture a high school kid serving French fries, a teenager working summers until he gets a “real" job later on. But Roberts and Peters are not teenagers. This is not a temporary job. And while speeches about bootstraps or college may be well intentioned, the fact remains that people need the work Roberts and Peters do every day as home health aides.
“We’re fundamentally confused as a society about what to pay for this work. We pay lip service to loving and respecting our elders, but then we don’t want to pay the people who care for them,” says Claire Stacey, a professor of sociology at Kent State University and author of The Caring Self: The Work Experiences of Home Health Aides.
“It’s like daycare workers: We say our children are these precious treasures, and then we pay the people who take care of them seven dollars an hour.”
Home health agencies contend that raising aides’ wages will put them out of business because clients can’t afford to pay higher rates. At a cost of, say, $15 an hour, four hours of home care every weekday for a year would ring up at $15,600—more than tuition at some colleges, and certainly more than most families can afford, says Josh Wiener, senior researcher and distinguished fellow at RTI International, an independent research institute. Medicare doesn’t cover it, and few Americans have long-term care insurance. When Medicaid pays, agencies say the reimbursement rates are not high enough for them to pay their aides more. (While some aides are independent or employed by the state, the majority work for private agencies that are in turn reimbursed either by their clients or by Medicaid.)
But it’s like squeezing a balloon: Compress your costs on one side, and they inevitably bulge out somewhere else. Making the choice to pay meager wages or poor benefits is also a choice to shunt workers onto food stamps and Medicaid just to feed and care for their families. It’s asking the government—and by extension, taxpayers—to pay for things the home health agency chooses not to. And it’s making the choice to have increased turnover, and a stressed-out, financially fragile workforce living perpetually on the edge. As author Barbara Ehrenreich puts it, “If your business plan requires you to pay people starvation wages, that’s not much of a business plan, now, is it?”
The specific solutions for home health aides could include several things, say experts Wiener and Stacey, including unionization (already somewhat successful in several states), credentializing home care workers (in hopes they could then command better pay), or wage pass-throughs (boosting state Medicaid payments to home health agencies and asking them to “pass it through” to aides—a nice idea, but often hard to track). Though the political path would be rocky, a public long-term care insurance program, with higher aide wages required as a condition for contracts, could resolve much of the problem. A closer eye could also be turned on home health agencies’ profit margins. “One agency I worked for made a million dollars its first year, and my little paycheck never changed,” Roberts says wryly. “Kinda makes you wonder, doesn’t it?”
But we can’t keep kidding ourselves that all low-wage workers are temporary part-time teenage fast-food employees; just ask Roberts or Peters or their nearly two million colleagues around the country. And we can’t expect to recruit one million new home health aides—or workers in any service sector—for the mentally and physically demanding jobs they’re needed for, if we’re going to pay them peanuts and then deride them for needing food stamps to survive.
As the debate about the minimum wage heats up, we need to think hard about whether the people who will help us grow old with dignity should be paid a wage that lets them live with dignity, too.
“We love what we do,” Leslie Roberts says. “We just need enough money to take care of our families ... so we can take good care of yours.”
Postscript: Not long after our interview, and after 15 years doing work she loved, Leslie Roberts left her job as a home health aide, no longer able to cope with the financial strain. Her new job as a city bus driver has reliable hours, better pay and benefits.
Karen Weese is a freelance writer whose work has appeared in Salon, Dow Jones Investment Advisor, the Cincinnati Enquirer, Everyday Family, and other publications.