How a Next President Could Boost Home Care and Childcare Without Congress

Originally published in The American Prospect‘s fall 2019 magazine

A future president can leverage their executive authority to improve the working conditions of millions of home care and child care workers in the United States—low-paying, critical fields where more than 90 percent of workers are women. The easiest, and perhaps most straightforward, action the next president can take is restoring the union rights of over 800,000 home care workers. With a total of 14.7 million unionized workers in the U.S. in 2018, this single move is likely to generate a tangible increase in union density.

Home care workers provide support to elderly or ill patients in their own home. They include certified nursing assistants, personal health aides, and in some states family caregivers and companions. In addition to responsibilities like administering the proper dosage of medication, they assist with everyday tasks like bathing, meal preparation, and cleaning the home. Most of these workers are paid through their patients’ Medicaid coverage.

Home care is one of the fastest-growing jobs in the U.S. economy. The federal Bureau of Labor Statistics projects demand for home care workers will increase by 41 percent between 2016 and 2026 as more baby boomers head into retirement. And it’s also a notoriously low-paying profession, with median annual pay of just $24,000. Union protections can give these workers a voice on the job and bargaining leverage with states.

More than 500,000 home care workers are unionized through the Service Employees International Union. In 2014, the Obama administration facilitated this with the “Provider Payment Reassignment” rule, authorizing unions to automatically deduct dues from their Medicaid-funded wages. Automatic dues deduction—also known as dues checkoff—makes it easier for workers to be union members, as they can permit their dues to be taken out of their wages directly, rather than deal with the hassle and chaos of sending their union individual checks each month.

Republicans correctly recognize that if they can make it harder to pay union dues, fewer workers will. Indeed, they have waged a long war on this checkoff provision, first at the state and more recently at the federal level. Conservative activists have sought to nationalize what Republicans achieved in Michigan in 2013, by barring dues checkoff for home care workers in the state. Over the last six years, this has led to an 84 percent drop in SEIU Healthcare Michigan membership and a 74 percent drop in union revenue.

This attack on home care workers came on top of Michigan’s passage of right-to-work, which the U.S. Supreme Court effectively expanded for all public-sector workers in 2018 in the Janus ruling. Michigan activists, led by the right-wing Mackinac Center for Public Policy, have argued disingenuously that automatic union payments for home care workers amounts to exploitation and so-called “dues skimming.”

After successfully making home care dues checkoff illegal in Michigan, Republicans soon realized that getting other union-dense states to follow suit would be politically difficult, with their more labor-friendly lawmakers. So conservatives turned their attention to the federal government to hasten their anti-union agenda. The Koch-funded State Policy Network said their goal would be to get an administrative rule passed at Health and Human Services under Trump, and bragged on a private donor call that they were “the only group that’s driving this effort at a national level.”

In May 2019, conservatives reached their goal, as the Trump administration’s Centers for Medicare and Medicaid Services (CMS) announced a new final rule barring home health care workers from automatically deducting union dues. The rule is currently being challenged in court, led by five state attorneys general and eight unionized home care workers. The plaintiffs argue that the Trump administration has illegally reinterpreted federal law “in service of anti-union objectives.” While it remains to be seen if the courts will block the rule, a next president can restore workers’ union rights.

A future president could commit to immediately reversing this highly damaging decision, by scrapping the CMS rule. Doing so is within a president’s executive power, and does not require congressional approval.

While this would not overturn Michigan’s prohibition, which would still need its own state-level fix, the stakes remain high, not only for the current home care workforce but also for the workforce of the near future. Potentially millions of home care staff would have an easier path to union membership if the Trump administration rule were eliminated, enabling workers to band together for higher pay, retirement benefits, and better working conditions.

An organized home care sector can also spur action on the looming long-term care crisis. In April, Washington state passed the nation’s first publicly funded long-term care benefit, a hard-fought victory by advocates including SEIU 775, which represents 45,000 home care workers in Washington and Montana. The law is poised to become a model for other states, but without strong labor backing, its prospects are dim.

The fight for a living wage goes right through the home care industry, and raising wages for the female-dominated profession would go a long way toward boosting pay equity nationwide. It also would be the most direct way to improve the fortunes of the labor movement, whose decline has accompanied setbacks for workers across the economy. In this sense, restoring dues checkoff for home care workers could positively impact even non-union worker wages.

A next president can also demonstrate their commitment to home care workers by using discretionary dollars from the federal Center for Medicare and Medicaid Innovation to fund demonstration programs assessing the impact of home care aides as key members of a patient’s health care team. Robyn Stone, the senior vice president of research at LeadingAge, a membership group of 6,000 nonprofits focused on elder care services, says that despite a recognition that home care aides deliver between 60 and 80 percent of all long-term care services, evidence of their actual impact on health care outcomes is overwhelmingly scant, which then makes it easier to devalue them as professionals delivering critical care.

The lack of research evidence is largely a reflection of society’s disregard for these workers more generally. A next president could begin rectifying this wrong by funding research to build the evidence base showing the importance of high-quality home care aides for the elderly, which could help estimate home care workers’ compensation value.

Child care workers perform the critical work of caring for infants and toddlers. Many people across the country are still not well versed in the research evidence that shows the bulk of brain development happens in a child’s earliest years, and greater investments in our youngest learners can help close the achievement gap, and help more students graduate from high school and avoid the criminal justice system. A next president can use the power of the White House to elevate the issue of properly investing in young children.

In 2018, local elected officials in Washington, D.C., passed the most progressive legislation in the nation on this front. A key piece of the comprehensive bill is to raise the wages of early-childhood workers, a largely female and immigrant workforce. While a president would need Congress to pass similar legislation on the federal level, they could begin elevating the importance of the issue by championing the District’s Birth-to-Three for All DC Act.

“State leaders must embrace their youngest constituents and share in the investment if we are to address this national need,” says Patricia Cole, senior director of federal policy at ZERO TO THREE. “But federal leadership is also essential. I would call on the president to convene a summit with the nation’s governors to underscore the high stakes for our future in solving the child care conundrum.”

Lastly, a next president must commit to prioritizing the scarcity of child care in the U.S. by ensuring that all candidates and administrators for the Departments of Education and Health and Human Services are committed to expanding access to early-childhood learning, and by extension direct some existing federal funding streams—such as through Head Start and the Every Student Succeeds Act—to professional development for early-childhood workers. Without a strong push from the federal level, the dearth of available child care opportunities will likely grow more severe.


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