GOP-Led Efforts to Crush Unions Have a New Target: Home Health Care Workers

Originally published in The Intercept on May 16, 2019.
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Five states are pushing back against the latest Republican-led assault to weaken unions across the country, which targets in-home caregivers who work with Medicaid beneficiaries.

On Monday, attorneys general representing California, Connecticut, Oregon, Massachusetts, and Washington filed a lawsuit against the Trump administration challenging a new rule, announced earlier this month, that impedes home care workers from paying union dues through their Medicaid-funded paychecks. The rule, which goes into effect in July, will impact more than half a million workers in California alone, and several hundred thousand more in 10 other states.

The case was brought against the Department of Health and Human Services and its secretary, Alex Azar, and filed in San Francisco federal court. The plaintiffs argue that the defendants have illegally reinterpreted federal law “in service of anti-union objectives.” The new rule, they say, disrupts long-settled arrangements that allow seniors and individuals with disabilities — who work with state governments to set wages, benefits, and terms of service for their providers — to direct their own health care. More than 700,000 individuals across the five plaintiff states currently use consumer-directed Medicaid programs.

The lawsuit against the Trump administration rule, which was finalized by the Centers for Medicare and Medicaid Services, or CMS, comes the same week as two major developments for home care workers in the United States. In Washington state, Democratic Gov. Jay Inslee signed into law 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. National advocates say they will use Washington’s policy as a model to push for in other states.

Also this week, the U.S. Supreme Court denied a petition to review a case led by a group of Minnesota home care workers who argued that a state law that made Service Employees International Union, or SEIU, their bargaining agent violated their First Amendment rights. The plaintiffs pointed to Janus v. American Federation of State, County, and Municipal Employees; the 2018 case struck down public sector unions charging fees to non-dues paying workers. The same conservative legal groups that supported Janus also helped the Minnesota home care providers, though this time their efforts failed.

While the high court’s ruling marks a setback to conservatives seeking to leverage free speech laws against union power, there are still dozensof other Janus-inspired lawsuits winding their way through federal courts, with two more lawsuits filedin the last month. This week’s lawsuit against HHS is the opposite of that — a proactive effort to get the courts to defend the rights of unionized workers.

The plaintiffs argue that HHS and Azar have violated the Administrative Procedures Act, the law governing how federal agencies can propose and implement regulation. Their complaint says the new rule “abruptly and without any sound rationale or conversations with affected states” overturns an Obama-era rule that confirmed the practice of taking direct deductions from home care workers’ paychecks. The Trump administration has been repeatedly accused of violating the APA, issuing new rules and mandates, and repealing old ones, often outside the bounds of established protocol.

“With this rule, the Trump administration is not only harming Medicaid skilled home care workers who have joined unions, but the millions of seniors and people with disabilities who depend on these indispensable workers,” said California Attorney General Xavier Becerra in a statement.

SEIU, which represents most home care workers, released a statement calling the rule “racist” — noting that 90 percent of home care workers are women, more than half are women of color, and a quarter are immigrants. “The administration’s attempt to silence home care workers reflects a long history in the United States of double-standard policies that deny working people of color like home care workers and domestic workers basic legal protections and rights, including protections for minimum wage and overtime pay, and the right to organize and form strong unions,” the union said. Without a union, SEIU added, independent home care workers earn a median wage of just $10.49 an hour, with no paid sick time or health care benefits.

The federal Bureau for Labor Statistics projects that demand for home care workers will increase by 41 percent between 2016 and 2026, as the baby-boom generation continues to get older. Union membership gives home care workers an incentive to stay on the job, according to a 2017 survey by the National Employment Law Project of more than 3,000 home care workers, of which one-third were union members. The researchers found that unionized respondents were more likely to expect to be a home care worker a year from now, less likely to be looking for other jobs outside of home care, more likely to receive benefits, and had higher wages on average.

The Trump administration announced last August that it was considering scrapping the Obama-era rule that affirmed home care workers could deduct union dues from their Medicaid-funded paychecks. This practice has been criticized by conservatives who argue that in-home caregivers shouldn’t be able to “skim” government funds away to union coffers and that doing so “damages the integrity” of the Medicaid program.

Mark Mix, the president of the National Right to Work Legal Defense Foundation, which files lawsuits in favor of banning unionized workplaces from requiring dues for bargaining representation, praised the Trump administration’s new rule in a statement, calling it a “long-overdue rule [that] closes the illegal loophole created by the Obama Administration that has provided union officials with legal cover to siphon hundreds of millions of dollars in Medicaid funds into union political and lobbying activities.”

In 2014, thanks to a lawsuit backed by Mix’s group, the U.S Supreme Court ruled in Harris v. Quinn that Illinois home care workers could not be required to pay union agency fees. Mix said the Trump administration’s new rule represents “another important step forward in protecting the rights of home care worker from rapacious union officials” and pointed to the 2014 Supreme Court decision, describing it as a situation where “[National Right to Work] Foundation attorneys freed homecare workers” from making payments.

CMS Administrator Seema Verma has denied their new rule is about making it harder for workers to be in unions; she said it’s simply to ensure that any diversion of Medicaid payments is truly lawful.

Last April, the Senate Committee on Homeland Security and Government Affairs — which is tasked with investigating “the efficiency, economy, and effectiveness” of all government agencies — wrote to Verma requesting that she look into this alleged “dues skimming” and cited rising Medicaid costs. The letter, authored by committee chairman Sen. Ron Johnson, R-Wisc., said allowing unions to take dues from home health care providers saps $200 million annually from Medicaid recipient care. Johnson asked CMS to review the practice “and determine whether changes to law or regulation are necessary to ensure Medicaid funds are provided to the program’s intended beneficiaries.”

“The effect of this final rule is the elimination of one method of getting payment from A to B,” the final rule states. “It in no way prevents healthcare workers from purchasing health insurance, enrolling in trainings, or paying dues to a union or other association.”

Critics say the Trump administration’s rationale makes no sense, pointing out that eliminating the ability to directly deduct union dues does nothing to curb Medicaid spending.

Caitlin Connolly, the director of social insurance at the National Employment Law Project, a union-backed legal advocacy group, told The Intercept the argument put forward by the Trump administration and its Republican allies is misleading because the money spent on dues is taken from workers’ wages, who get to decide how to spend the money that they earn.

“When I look at my paycheck, I get my wages and I decide, thanks to the convenience of my right as an employee, to allocate some of that money to a retirement account, some to a health savings account, and some to my union dues,” she said. ‘It’s my money, and I get to choose how to spend it. Just because the source of these workers’ wages is Medicaid dollars doesn’t mean they don’t have the right to choose how to spend it.”

And since workers are still able to take their wages and spend it on union dues, just without the convenience of direct paycheck deduction, Connolly said this shows the point is to create more hurdles for workers to jump through to exercise their union rights.

“I think there are locals working with members to see how they can handle dues payments in a way that would reduce the burden if direct deposit were restricted, and I think workers are sharing with them ideas on what would be helpful, but there’s nothing easier than saying, ‘I don’t have to think about this, I agree to this, and please take care of it,’” Connolly said.

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Washington Becomes First State To Approve Publicly-Funded Long-Term Care

Originally published in The Intercept on April 26, 2019.
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Washington state lawmakers on Tuesday passed the nation’s first long-term care benefit program, which would provide residents with up to $36,500 to pay for costs like caregiving, wheelchair ramps, meal deliveries, and nursing home fees. Jay Inslee, Democratic governor and 2020 presidential candidate, has said he intends to sign the Long-Term Care Trust Act into law.

The measure is hailed as a monumental achievement not only for Washingtonians, but also for advocates working nationally to tackle the rising and formidable costs of care work and old age, something that’s become only more pressing as the baby boomer generation heads into retirement. The Long-Term Care Trust Act comes on the heels of a novel cash benefit program Hawaii launched in 2017 that distributes $70 a day for up to 365 days to family caregivers. A growing number of states have passed paid sick leave policies over the last five years, and more presidential candidates are elevating the issue of child care and how to afford it. Washington Rep. Pramila Jayapal’s new Medicare for All bill even includes coverage of long-term care, something not currently provided by the federal insurance program.

The ultimate goal, advocates say, is some kind of universal family care, a comprehensive social infrastructure to support all the varied costs of care work from birth to death. “That’s our North Star,” said Sarita Gupta, co-director of Caring Across Generations, a national campaign that launched in 2011. “We have really been trying to help people go from seeing care work as an individual burden to a shared responsibility that we’re all going to face.”

With the Long-Term Care Trust Act, taxpayers expect to save $3.9 billion in state Medicaid costs by 2052. The bill had bipartisan support early on, including three Republican co-sponsors, but it was approved largely along party lines in the Democratic-controlled legislature. Advocates for the bill said that Republicans voted against it for political reasons amid heated budget negotiations, and not because they disagreed with it in substance. Republican Reps. Drew MacEwen and Paul Harris, both original co-sponsors, did not return request for comment.

In some ways, it makes sense that the groundbreaking long-term care legislation would originate in Washington, which has been leading the country in progressive policies. In 2013, the small town of SeaTac, which surrounds the Seattle-Tacoma International Airport, voted to increase its minimum wage to $15 an hour. This marked the first real policy win for the nascent Fight for $15 movement. Seattle would becomethe first major U.S. city to approve a $15 minimum wage a year later. In 2016, voters approved a state ballot measure to raise Washington’s minimum wage and establish a paid sick leave program. The same year, SEIU 775, which represents 45,000 long-term care workers in Washington and Montana, negotiated a home care worker retirement benefit, the first of its kind in the nation.

“We first started talking about long-term care about 10 years ago, because the funding system is really broken and because we’re focused on lifting caregivers out of poverty,” said Sterling Harders, president of SEIU 775, which helped push for the bill. Harders said the union’s work began with commissioning studies, followed by many years of slow coalition-building. “I think it’s easy to forget on days like this when I’m jumping up and down celebrating our victory that we’ve essentially been working on this for the past decade, and intensely for the past three years,” she said. “This is really the end of a long road.”

The bill works like this: Beginning in 2022, workers will pay a modest monthly payroll tax, 58 cents for every $100 they earn in income. The per capita average income in Washington is about $37,000, meaning that the average monthly contribution would be about $18. Those who pay into the program for three years, or for a total of 10 years including five consecutive years, will be able to access the benefit, which, at present, maxes out at $36,500. In 30 years, as it’s indexed for inflation, the benefit will be more than $88,000.

The $36,500 could pay for respite care, in-home caregiving, time in a nursing home or assisted living facility, home modifications like constructing a wheelchair ramp, and other elderly care expenses.

The legislation was first considered by lawmakers in 2018, but at the last minute, the state’s chapter of the American Association of Retired Persons, or AARP, withdrew its support, citing disputes over details like eligibility for qualifying as a caregiver. Members of civil rights, disability, senior, and health care groups who organized under the banner of Washingtonians for a Responsible Future reconvened this year to hash out compromises.

“I think what changed this year is that coalition members just met more and worked more closely to hear each other’s concerns,” said Janet Kim, a spokesperson for Caring Across Generations. “The resulting policy is more comprehensive and flexible than what was considered in 2018.”

Legislators worked on the bill with a few key facts in mind: Caregiving is an increasingly stressful burden for not only seniors, but also for their family members. Nationally, relatives spend an average of 20 percent of their own money on caregiving costs, according to the AARP, and often have to leave their jobs, sacrificing hundreds of thousands of dollars in income and benefits. A 2018 Associated Press-NORC Center for Public Affairs Research poll found that approximately two-thirds of adults support a long-term care program like Medicare, including 76 percent of Democrats and 56 percent of Republicans.

In addition, legislators grappled with the mounting strain on the state’s budget. Seventy percent of Americans end up needing long-term care after turning 65, and more than 90 percent of people do not have private long-term care insurance. While Medicare does not cover the cost of most long-term care services, many individuals don’t realize this until it’s too late. Medicaid, however, does cover long-term care services, but to access it, individuals have to deplete their assets until they have less than $2,000 in savings, a system that literally incentivizes going into poverty. As Washington’s population gets older, actuaries have projected that the state’s Medicaid-funded long-term care program would almost double to $4.01 billion annually by 2030.

Ruth Egger, A 65-year-old retiree in Seattle and a part-time caregiver for her parents, has advocated for the bill since it was first introduced. Though she and her parents, who are in their 90s, are unlikely to directly benefit from the Long-Term Care Trust Act, she said her personal experience as a caregiver and her professional experience as a social worker motivated her to fight for the legislation. She personally testified in support of the bill last year and this year before the Washington State Legislature.

Egger’s father fell and broke his hip a few years ago, which brought on debilitating depression. “My father temporarily lost the ability to dress himself, and if he had had access to this benefit, he would have been able to pay for an aide to come help him,” she said. “It was exhausting watching him trying to figure out how to get his clothes on, and at that point, it would have been really beneficial if he had access to this extra money.”

Egger also stresses that so-called orphan elders — single seniors, or seniors who never had children or have children who live across the country or abroad — are also in particular need for long-term care assistance. “They get old and they have no support to help them, and they may need someone to come in twice a week and help them bathe or set up their medication,” she explained.

Washington’s benefit could also prove beneficial to the long-term care insurance industry. “Those companies didn’t expect people to live so long and to pay out so much, so fewer companies are writing those [long-term care] plans,” said Egger. Some experts think that the Long-Term Care Trust Act will make the economics of supplemental long-term care insurance plans more feasible, similar to the supplemental private Medicare insurance that 13 million Americans currently pay for. A recent article in Forbes reported that insurance industry officials expressed interest “in developing products” to supplement what Washington state is proposing.

Ultimately, Harders sees the Long-Term Care Trust Act as not just providing a needed economic benefit, but also as one more step toward elevating the field of caregiving, which is largely dominated by unpaid or low-wage women and people of color.

“Caregivers are really members of a larger health care team; they spend hours and hours with the person they’re taking care of, they know when that person has changes in their health condition, when someone is losing weight, when someone gets dizzy, but it’s really a struggle for caregivers to be taken seriously as health care professionals,” Harders said. “That’s part of why this bill is so important for our union because we feel this is a step down the path of making sure caregivers are given the respect they deserve.”

Draft Legislation Suggests Trump Administration Weighing Work Requirements And Rent Increases for Subsidized Housing

Originally published in The Intercept on February 1, co-authored with Zaid Jilani.
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Draft legislation obtained by The Intercept suggests the Department of Housing and Urban Development is eyeing a proposal to overhaul the federal government’s administration of subsidized housing, through measures such as rent hikes and conditioning aid on employment.

This change would significantly impact those who rely on public housing and housing choice vouchers, often referred to as Section 8 in reference to Section 8 of the Housing Act. The news comes just weeks after the Trump administration announced that states could start imposing work requirements as a condition of Medicaid eligibility.

When asked about the document, Department of Housing and Urban Development spokesperson Brian Sullivan would not confirm its existence, but he suggested more would become clear when the Trump administration announces its budget later in February. “I think what you’re talking about is going to be expressed publicly in the budget coming up, so prior to that we would have nothing to say,” Sullivan said. He did not return multiple requests for further comment.

Document metadata reveals the name of the author of the document; she is listed as an HUD employee on a number of department web pages between 2013 and 2017.

It is unclear at this time whether the draft legislative language, dated January 17, will be proposed as a standalone bill or included within existing legislation. There are many parts of the 28-page document that are vague and even contradictory. However its text strongly suggests the administration is considering rent reform.

Under current regulations, most households that receive federal housing subsidies pay 30 percent of their adjusted income as rent. Adjusted income is a household’s gross income minus money taken out for four mandatory deductions: dependent deductions ($40 per month per dependent), elderly and disabled deductions ($400 per year), a child care deduction, and medical and disability expense deduction. This 30 percent threshold, which has been the standard for most rental programs since 1981, is based on a rule-of-thumb measure that estimates a household can devote 30 percent of its income to housing costs before it becomes “burdened.”

The draft legislation eliminates all four deductions, effectively making the changes most burdensome on households with children, the elderly, or people with medical problems.

If the draft’s proposals are enacted, those families would have to pay the higher of two figures: Either 35 percent of their household’s gross income, or 35 percent of what they earn from working 15 hours a week for four weeks at the federal minimum wage. A comment in the margins of the document notes that the latter would equal $152.25, something housing advocates say is effectively a new minimum rent floor.

Additionally, the draft legislation would allow public housing authorities to impose work requirements of up to 32 hours a week “per adult in the household who is not elderly or a person with disabilities.” According to the Center on Budget and Policy Priorities, more than half of all recipients who lived in subsidized housing in 2015 were elderly or disabled, and more than a quarter of all households had a working adult.

Diane Yentel, the president and CEO of the National Low Income Housing Coalition, expressed alarm at the possible changes.

“HUD’s proposals could raise rents on millions of low-income households that receive federal rental assistance, with some of the largest rent increases for families and individuals that have the greatest difficulties affording housing,” Yentel said. “By raising rents on some of the lowest income and most vulnerable families in HUD subsidized housing, HUD would jeopardize family stability by increasing the financial burdens they face through higher rents.”

With New Protections Tied Up in the Courts, Home Health Care Workers Aren’t Waiting Around

Originally published in The American Prospect on April 3rd, 2015.
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Almost two years after the Obama administration extended historic labor protections to the nation’s 1.79 million home healthcare workers, those new rights remain in limbo. In September 2013, the Department of Labor (DOL) announced plans to amend a longstanding regulation that has excluded them from earning the federal minimum wage, overtime pay, and compensation for travel on the job. For home healthcare workers in the United States—a group that is nearly 90 percent female—this move marked a significant step towards setting a floor of decent labor standards.

But the rule-change, which was set to go into effect on January 1st, now faces a challenge in federal court, and critics say state legislators are using the ongoing litigation as an excuse to avoid implementing the new protections. At the same time, given that most home healthcare workers are paid through Medicaid and Medicare—two underfunded public programs—many also worry that states will respond to the rule-change by curtailing consumers’ access to quality care. Activists across the country are working to pressure their lawmakers to reckon with these new standards and avoid potential calamity.

Four decades ago, Congress decided that home healthcare workers should be classified more like babysitters who provide “companionship,” rather than as workers entitled to basic protections. Nursing home employees, by contrast, are fully covered under the Fair Labor Standards Act (FLSA), despite performing many of the same tasks. As home healthcare has ballooned in recent years, these occupational distinctions have become harder to justify.

According to the Bureau of Labor Statistics, the U.S. will need one million new home healthcare workers by 2022. But the work is draining, the pay is paltry, and turnover is high. When adjusted for inflation, home healthcare workers’ average hourly wages have declined by nearly 6 percent since 2004. In 2013, the average earnings of home healthcare workers totaled just $18,598. 2013 was also the year that the Obama administration decided it was well past time to update FLSA’s policy. Because the DOL has the authority to amend federal regulations, it was able to enact this change without seeking Congress’s approval.

Though the new DOL rule-change would most directly benefit home healthcare workers, it carries implications for all domestic workers, including nannies and housekeepers. “By improving the conditions and protections in one area, you’re broadly boosting the sense that this is dignified work,” says Elly Kugler, an attorney with the National Domestic Workers Alliance, (NDWA) a group representing domestic workers in the United States.

Whether that change will actually be implemented is another question. Last year three industry groups filed a lawsuit against the DOL rule-change, insisting that it would have a “destabilizing impact” on home healthcare and hurt millions of elderly individuals. On December 22, 2014, a D.C. district judge vacated the rule for third-party employers, arguing that the executive branch cannot make such a regulatory change. A few weeks later, the same judge also vacated FLSA’s revised definition of “companionship services.” The DOL filed a challenge in appeals court, and arguments will be heard later this spring. Some suspect this may ultimately make its way to the Supreme Court.

Then, on March 20th, Labor Secretary Tom Perez sent a letter out to all 50 governors, urging them to focus on budgeting the minimum wage and overtime protections now, “to ensure that [they] will prepared if the Department prevails” in appeals court. Across the country, activists are also pressuring their representatives to focus on these issues. Yet many lawmakers are using the litigation as an excuse to avoid reckoning with the thorny budgetary questions. This means workers may not see minimum wage, overtime, and travel pay increases anytime soon.

“In Georgia, we’re seeing that our lawmakers are not talking about these issues,” says Tamieka Atkins, who leads Atlanta’s chapter of NDWA. “They have the attitude that we’re not going to move on this until the lawsuit comes down.” In response, Atkins’ group launched a campaign to lobby lawmakers and health agency commissioners in advance of their next legislative session. They also started a petition—“Governor Deal: All Eyes Are On Georgia”—asking for gubernatorial support towards minimum wage and overtime.

Activists in Texas are also applying pressure to their leaders. In January, domestic workers launched a home healthcare campaign, bringing together consumer groups, disability rights organizations, and labor unions. The following month—for the first time ever—domestic workers traveled to Austin to share their personal stories and lobby state legislators. “It was a really great opportunity because we agitated on different levels,” says Mitzi Ordonez, a domestic worker organizer at the Fe Y Justicia Worker Center in Houston.What we found is that many of the lawmakers just didn’t know about these [DOL] changes.”

Compared to Texas and Georgia, some states have made greater progress towards implementing the new labor protections. California, which already pays its home healthcare workers minimum wage, allocated new funds for overtime pay in its 2014-2015 budget, and was prepared to pay workers more at the start of 2015. But after learning about the federal lawsuit, California Governor Jerry Brown decided to postpone the overtime pay, even though there is nothing legally obligating him to do so. Frustrated activists have launched a campaign in protest; they organized meetings with state legislators, held rallies and candle light vigils, and even set up a“Justice for Homecare Tribunal”—a mock trial against the state. “The best thing for us to do is to not rest on our laurels,” says Doug Moore, the executive director of the United Domestic Workers of America. “The governor wants this to go through the courts, but we will use pressure to change his position.” Moore says that if the DOL rule-change is upheld in appeals court, they will then move to demand retroactive overtime pay back to January 1st.

Yet for some states that have reckoned with the rule-change, the results haven’t always been encouraging. “What we have been seeing, unfortunately, is that you can equally comply with FLSA by paying overtime and travel time, or by setting caps on the number of working hours,” says Alison Barkoff, the Director of Advocacy at the Bazelon Center for Mental Health Law. This scenario is playing out in states like Arkansas, which is looking to cap homecare workers to just 40 hours per week, and to limit each worker to just one customer per day. In effect, this would enable states to avoid paying workers overtime and travel costs. But such measures will hurt employees who make their living by piecing together multiple part-time jobs. It may also impact consumers who need more than 40 hours of care, or who may have a harder time finding someone willing to work for just a few hours per day.

Some hope that the Americans With Disabilities Act (ADA) and the Olmstead v. L.C. Supreme Court case, both of which protect disabled individuals from discrimination and unjustified segregation, will help consumers fight back against cuts to healthcare services. “The ADA and Olmstead provide important protections to consumers, but they won’t completely prevent a state from implementing restrictive policies,” Barkoff explains. “The laws do not prohibit a state from capping worker hours, so long as the state has a process for exempting individual consumers who will be seriously harmed. Most consumers will have to shift the way their care is provided.”

Meanwhile, labor activists maintain that their interests are not at odds with those of healthcare consumers, because quality care depends on creating sustainable working conditions. Many in the disability community have also signed amicus briefs in support of extending minimum wage, travel time, and overtime protections to home healthcare workers. “I think it’s important to know that there isn’t just one disability rights community,” says Sarah Leberstein, an attorney with the National Employment Law Project. “Many groups are very supportive, but they’re also really concerned about states taking it seriously and implementing the rules in a thoughtful way that doesn’t result in cuts to services.”

Even if upheld, the DOL rule-change may be hard to enforce. In New York City—a place that has instituted a progressive domestic workers’ bill of rights and a paid sick leave policy—activists have learned first-hand how enforcing these types of laws can be quite challenging.

“It’s really hard to be reliant on a complaint-driven process where workers have to come forth, but still fear retaliation,” says Irene Jor, a New York organizer with NDWA. Many domestic workers are also isolated in private homes, without much regular interaction with other workers who might provide them with moral support to raise grievances. Even once complaints are filed, not all are likely to be dealt with. “The Department of Labor, both on the federal and state level, is incredibly underfunded and does not have enough investigators,” says Leberstein. “So often they can’t simply respond quick enough, and they can’t do targeted enforcement.”

Nevertheless, if the DOL rule-change were upheld, it would be an important achievement. Some businesses would certainly have to adjust their operations to accommodate the new labor protections, but supporters of the rule-change insist that the industry’s opposition is overblown. According to national surveys, less than 10 percent of home healthcare workers even report working more than 40 hours a week. “We’ve also got many examples of big home care agencies that have figured out ways to pay workers properly, and still provide good care,” says Leberstein, who points out that many organizations already operate in states that require minimum wage and overtime protections. “So they’ve either figured out a way to do it and still earn profits, or they’re admitting to violating the laws in their state.”

Asking the public to pick between providing quality care and treating workers fairly is ultimately a false choice wrought through a political culture of austerity. States could avoid this by increasing funds towards Medicare and Medicaid, which would help ensure that the disabled and elderly can access the high-quality and flexible care without compromising national labor standards and worker dignity.

Though the future of the law is still unknown, one thing is clear. This is an issue that cannot be put on hold—thousands of health homecare workers live in poverty and 10,000 more baby boomers turn 65 every single day.

‘Housing First’ Policy for Addressing Homelessness Hamstrung By Funding Issues

Originally published in The American Prospect on January 27, 2015.
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In an era of shrinking financial resources, policymakers, providers, and activists who work on homelessness prevention and care in the United States have been forced to develop new strategies. There was a time when officials at the Department of Housing and Urban Development (HUD) saw it as their responsibility to provide both housing and supportive services for homeless individuals, but now HUD now is refocusing its budget predominately on rent and housing—with the hope that other local, state, and federal agencies will play a greater role in providing supportive care. However, whether other organizations will actually be able to pick up those costs and responsibilities remains unclear.

The first major federal legislative response to homelessness was the McKinney-Vento Act of 1987, which passed both the House and Senate with large bipartisan majorities. The McKinney Act—which Bill Clinton later renamed the McKinney-Vento Homeless Assistance Act—provided funds not only for emergency shelter, transitional housing, and permanent housing, but also for job training, primary health care, mental health care, drug and alcohol treatment, education programs, and other supportive services. The consensus was that homelessness is a complex problem whose solution requires more than simply a roof and a bed.

The statutory goal of the McKinney Act was to gradually move homeless people toward stable housing and independence—a model that came to be known as “Housing Readiness.” Though this sprung from well-meaning intentions, it eventually became clear that this “gradual” approach frequently led to unwise and unfair ways of distributing welfare.

“We had this system that said homeless people essentially have to earn their way to permanent housing,” explained Ed Stellon, the senior director of the Midwest Harm Reduction Institute, and someone who has worked within the substance use and mental health treatment systems for more than 20 years. “Homeless people had to earn their way into transitional housing, make progress on certain goals, and finally when they were deemed well enough, they would earn their spot in permanent housing.”

A different model, known as “Housing First”, has been gaining steam over the past decade. What at first sounded revolutionary now feels fairly obvious: The Housing First approach posits that the only requirement for housing should be homelessness—that shelter is a right, not a privilege. “Plus, if you have conditions like out-of-control diabetes, congestive heart failure, or schizophrenia, housing is actually part of the solution,” adds Stellon. “It’s hard to make any meaningful progress on these chronic conditions without stable housing.”

Though exact estimates are hard to come by, HUD recently reported that as of January 2014, the chronically homeless numbered some 84,291, with 63 percent of those individuals living on the streets. HUD says this number has declined by 21 percent, or 22,937 persons, since 2010—in large part because of the embrace of Housing First. (Some, however, have accused the federal government of using data gimmicks to paint a more cheery picture of progress than has actually been made.)

Nevertheless, the reality is that at the same time policymakers are embracing the idea of Housing First, fewer affordable housing units exist than ever before. According to the National Low Income Housing Coalition, federal support for low-income housing has fallen 49 percent between 1980 and 2003, and the Joint Center for Housing Studies found about 200,000 rental units are destroyed annually. Research also suggests that a supply of 8.2 million more units would be needed to house extremely low-income households, up from a gap of 5.2 million a decade earlier. Though Congress recently authorized funding for the National Housing Trust Fund—an entity that was created in 2008 to fund affordable housing proects—its budget is nowhere near large enough to meet the demand.

“We’re not doing enough to expand housing availability, and HUD can’t expand its services unless Congress allocates it more funding,” says Barbara DiPietro, the director of policy for the National Health Care for the Homeless Council.

Given the fiscal climate, HUD is looking for new ways to spend its increasingly limited budget. Consequently, the agency is moving away from the supportive services that, through the McKinney-Vento Act, once accounted for most of its spending. In 1998, for instance, 55 percent of HUD’s budget was spent on supportive services, and 45 percent was awarded for housing. By 2013, just 26 percent of HUD’s competitive homeless assistance funds went to supportive services, and 66 percent was spent on housing. According to Ann Oliva, director of HUD’s Office of Special Needs Assistance Programs, the department’s goal now is to help local communities become more strategic with existing resources and available opportunities.

To do this, HUD has been working closely with other federal agencies, especially the Department of Health and Human Services (HHS), the Department of Veterans Affairs (VA), and the U.S. Interagency Council on Homelessness. In 2008, a joint program known as HUD-Veterans Affairs Supportive Housing (HUD-VASH) launched, combining housing vouchers for homeless veterans provided by HUD, with case management and clinical services provided by the V.A. Experts agree that HUD-VASH has been quite successful in helping both vets and their families, and it’s typically held up as the poster child for future interagency collaborative efforts. However, the program came with additional appropriated dollars, and it is typically easier to convince Congress to fund programs for impoverished military veterans compared to other downtrodden groups.

One of the most significant recent changes to homelessness policy has come through the expansion of Medicaid—a key feature of the Affordable Care Act. Now that nearly all individuals with incomes up to 138 percent of the federal poverty level are eligible for health insurance in states that opt for the expansion, agencies are scrambling to enroll thousands of homeless people so that they may benefit from new streams of mandatory government spending.

But Medicaid is, at its heart, a program controlled by the states. And with some states still vigorously opposed to expanding Medicaid—despite the ACA’s mandate for the federal government to pick up nearly all of the tab for the expansion—let alone some of the flexible legislative adaptations that HHS is encouraging, consistent and widespread changes to supportive services seem unlikely in the near future.

Though Medicaid expansion presents great opportunities for providing services to the homeless, some are concerned that the more flexible federal dollars currently set aside to work with homeless people will eventually just be funneled into the larger health insurance pool, with little, if any, allocated to doing what it takes to bring those with no homes into the government support system, which is needed in order to provide preventive care.

“Going out four or five times to visit with a woman living alone under a bridge, just trying to form a relationship and build trust with her so she will feel comfortable coming in to get more help—those types of health encounters are not typically billable through health insurance,” adds Stellon, who says outreach can be one of the hardest things for him to fund. “In our current system, it’s easier to pay for someone’s amputated fingers than to build a human relationship.”

Ultimately, there is only so much the government can do to advance the goal of Housing First with a depleting stock of housing units and a shrinking budget for supportive services.

“It’s a big mistake to come up with a good solution like Housing First and then to hamstring it because we don’t actually have the money for it,” says Todd Stull, the clinical director at a JOURNEYS | The Road Home, an organization that provides services and shelter to families and individuals in Illinois’s North and Northwest suburban Cook County. “One of the worst things you can do is get someone into housing for a short period of time and then they lose it. Then they lose trust in the providers.”

“We have not done well as a nation taking on poverty and implementing policies needed to address homelessness,” says Dr. Sam Tsemberis, the founder and CEO of Pathways to Housing, a national organization that first pioneered the Housing First model in 1992. “So we end up taking care of homelessness out of desperation, but we’ll be taking care of homelessness forever if we don’t take care of poverty.”

“We need more money,” adds DiPietro. “Until then, we’re just rearranging the priority list.”