Earlier this month, the Department of Health and Human Services finalized an obscure rule that could have huge implications for an estimated 800,000 independent home health providers paid directly by the state for Medicaid-funded services. Under the rule, these workers will no longer be able to assign deductions from their paychecks to cover things like insurance premiums, retirement contributions, and union dues. The rule singles out the most isolated home health workers who are not employed or paid via agencies; those who are can assign deductions at will.
Advocates argue the rule is designed to suppress unions by making it more difficult to collect dues. And there’s more than union dues at stake: Home care providers could, for example, experience lapses in health coverage by failing to keep up with premiums.
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Many home care workers are family members providing home and community-based care to loved ones. Their work can include assistance with activities of daily living like bathing, dressing, and toileting, along with light housekeeping, help with errands, and other services designed to help disabled people and older adults stay in their communities. Home care is one of the fastest growing professions in the United States, with a projected growth rate of 41 percent for those working at agencies.
The median wage for home care workers is $10.49; a 2017 National Employment Law Project survey found unionized employees made $2 more per hour when examining the difference between weighted average wages. The majority are women of color, reflecting the gendered and racialized history of the field, and 28 percent are themselves on Medicaid.
In some ways, Medicaid-funded home care can act as an anti-poverty program and compensate people for care work that is normally considered unworthy of pay. “When I found out about In-Home Support Services [the California implementation of the program],” said Andrea Dudley, who cares for her son, “it was like a godsend…it’s not a lot of money, but it’s helped me.”
Home health work, like other labor that takes place in the intimate setting of the home, has been historically undervalued. When the Fair Labor Standards Act (FLSA) passed in 1938, domestic workers were explicitly excluded from wage and hour protections, in part at the behest of Southern Democrats. In the years since, domestic workers, including those offering home health services, have fought to organize. In the 1970s, Congress amended the FLSA to cover some domestic workers, but home health aides were still left out by a provision excluding “babysitters” and “companionship services.” But recently, they’ve started making gains. They won wage and overtime protections under FLSA in 2015 and have grown home care worker union participation. In 2010 they pushed for the passage of a Domestic Worker Bill of Rights in New York, and a similar national bill to extend these protections nationwide has been introduced by Sen. Kamala Harris (D-CA) and Rep. Pramila Jayapal (D-WA).
Now anti-union proponents, pushed by groups such as the National Right to Work Committee, are on the offensive. In 2014, they won a significant victory with Harris v. Quinn, which ruled that home health care workers are not public sector employees. Therefore, those who choose not to join the union may not be required to pay service fees, enjoying the benefits of collective bargaining without the costs.
In this instance, the government argues Medicaid monies should only be paid out to providers, with exceptions for tax deductions but not for third-party payees. In response to concerned comments about the implications of this rule, the government insisted that “it in no way prevents” home health workers from paying union dues, insurance premiums, and other costs via other means. To prove their point, HHS staffers even calculated the cost of envelopes and stamps for mailing payments.
While HHS staffers dismissed concerns, worker advocates argue this rule change could make things extremely difficult for home health workers, and not just when it comes to sending in union dues. Some are unbanked, making it challenging to mail a check. Others deal with significant demands on their time and schedules that could make it hard to keep track of due dates and mail things on time. Issues like these could potentially lead to lapses in health coverage and other problems that could be easily resolved with automatic deductions. More to the point, home health workers themselves have repeatedly stated they want the option to make assignments.
The extremely targeted nature of this rule has big implications. Independent providers are difficult to organize because of their far-flung nature. They don’t have a shared office, meeting place, or workspace to network, because they labor entirely in private homes, out of the public eye. They are underpaid and vulnerable to exploitation. Union membership can change that. Dudley commented that the union helps her “stay informed” and connected with other workers.
The rule is “a blatant attack on us,” she added, asking what should make care workers in particular subject to a bar on withholdings. It’s a question shared by other worker-advocates and their allies. Unions such as the SEIU and AFSCME are organizing against it, and at least five states are suing.
“It’s our choice to take our deductions out of our checks,” said Dudley.