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Debate Persists Over Pay For Disability Caregivers


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As a home health aide, Nicole Fletcher, 40, provides personal assistance to the elderly, people with disabilities and those living with chronic conditions in their own homes. She assists them with activities of daily living — including bathing, dressing and eating — and, on occasion, she often stays to help them overnight.

“Sometimes there will be 24-hour cases because the client needs care and cannot be left alone depending on their condition,” she said.

Working for a District of Columbia-based company, she earns more than the minimum wage and is paid time-and-a-half for every hour she works beyond her usual 40 per week. But unlike Fletcher, close to 2 million in-home care workers and personal care aides in the United States don’t always get paid for overtime work or receive minimum wage, according to the U.S. Department of Labor. They are explicitly excluded from a key federal wage law that carved out exceptions for causal babysitters and companions for people who are sick or have disabilities.

The average yearly salary for home health aides in 2012 was $21,830, according to the Labor Department.

Only 21 states and the District of Columbia extend minimum wage guarantees to at least some in-home care workers. Among them, 12 states have a minimum wage that is higher than the federal standard — $7.25 an hour.

The administration wants to change that, however. In December, 2011, President Barack Obama proposed a revision to the Fair Labor Standards Act that would extend both overtime and minimum wage protections to home-care workers employed by third parties, such as home care agencies. “They work hard and play by the rules and they should see that work and responsibility rewarded,” Obama said.

The proposal has been under protracted review by regulators and is now being analyzed by officials at the Office of Management and Budget. Thousands of comments have been filed with the government on the plan.

When a 90-day review window came and went on April 15, key supporters of the proposal organized a conference call urging the Obama administration to expedite the change.

Bruce Vladeck, who ran Medicare and Medicaid under President Bill Clinton and is now a senior adviser at the consulting firm Nexera, pointed in that call with reporters to the political power of the home care industry, which is opposing the proposal. In a subsequent interview, he said, “Based on my understanding, the OMB folks have met with industry representatives who have raised concerns publicly about the impact on them with the proposal.” He added, “It will take until somebody at the political level decides to either issue a regular order or bury it. There’s absolutely no telling.”

The plan has been criticized by some Republican lawmakers and Medicaid directors. In addition, some disability advocacy groups have complained that it will increase the health care costs for people who want to remain in their homes and avoid moving to institutional care.

If finalized, the proposal would redefine “domestic service employment” to include home health aides and personal care aides as domestic workers. It would also narrow the definition of “companionship services” and clearly outline what duties would qualify for overtime pay. For example, medically related tasks that generally require prerequisite training, such as wound care and blood pressure testing, would become eligible.

“The (current) rules don’t really reflect the job being done by home health aides and home care aides,” said Steven Edelstein, the national policy director of PHI National, a nonprofit group that aims to improve working conditions for direct-care workers. “When the (companion services) exception was first created, they were looking to provide an exception to friends and neighbors who would be helping out, not a situation where people are making their livelihood by providing long term services and support.”

The key stakeholders in the home care industry, however, have been less optimistic about the proposed revision, raising concerns that include higher labor costs and reduced affordability for consumers.

“Pretty much no one is not getting paid minimum wage unless it’s somebody working under the table,” said William Dombi, the vice president of the National Association for Home Care & Hospice. According to Dombi, Medicare and Medicaid pay for most of the services but they would not reimburse the businesses for overtime pay. Businesses may respond by restricting the work hours of home health aides so they would stay under the overtime threshold, potentially lowering their gross income and raising the potential for higher turnover among workers.

Peter Ross, the CEO and co-founder of Senior Helpers, an in-home senior care staffing agency based in Maryland, says paying his workers minimum wage isn’t the issue. He is more worried about the potential impact on consumers who, as a result of businesses not wanting to pay overtime, may end up having multiple caregivers.

“You want to keep consistency and continuity of care with the client because they’re most comfortable with that caregiver,” he said. “The challenge the government has to understand is if the families can no longer pay, because the government has basically put in a rule that is going to drive the costs up, then they’re going to have no choice but to go into a facility.”

The demand for home health aides is expected to increase by 69 percent between 2010 and 2020, PHI estimates, and is potentially fueled by ongoing efforts to keep seniors and those with disabilities out of nursing homes.

In an April 8 letter to the OMB, leaders from the National Association of Medicaid Directors said the proposal may “jeopardize” existing Medicaid delivery system models that give consumers options when hiring potential caregivers. They urged OMB to “examine the unintended consequences, cost-effectiveness, and alternatives to this complicated and burdensome rule.” According to NAMD, Medicaid was the single largest payer of spending on long-term care services and supports for home-based care in 2009 — paying more than $126 billion that year.

Edelstein and his colleagues at PHI, however, disagree. “The truth is that these protections have been provided to workers in some states already under state law,” said Edelstein, “There isn’t an issue in terms of the affordability of these services. It’s not causing more people with long-term care needs to have to get their care in nursing homes rather than at home.” According to a PHI report, rates of institutionalization are not higher in states that currently extend minimum wage and overtime protections to home care workers.

Marla Lahat is the executive director at Home Care Partners, the agency that employs Fletcher. Lahat says that employers arguing against minimum wage and overtime protections are missing the bigger picture and said her agency’s home health aides are paid for overtime work even though the District of Columbia only extends minimum wage provisions and not overtime to in-home care workers.

“This is a job that requires training, it requires skills, it requires compassion, it requires the ability to work independently,” she said. “It’s a very challenging, demanding, yet gratifying job but at a minimum should be getting minimum wage and overtime protection.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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Comments (10 Responses)

  1. Karen Driver says:

    People hired directly by the family should remain excluded as there are several other “benefits” that take place of the overtime . . . VERY flexible hours, free room and board, ability to care for their own family members at the same time (grandchildren, etc.), etc. But, those hired by 3rd party agencies should definitely receive overtime pay! NEVER should “employees” be overworked without compensation . . . this practice encourages burnout of the good workers in this field and leads to only the “desperate” employees remaining . . . those who are stressed and frustrated and taking it out on the very people they are to be providing QUALITY care for! When direct care workers are paid FAIR wages and the focus becomes QUALITY care, having numerous QUALITY caregivers for the same person will be a welcome change . . . vs the current occasional “good worker” due to underpay resulting in less than quality care.

  2. Whitney says:

    I am going say family does not equate to caregivers. Giving room and board does not equate future income security when children reaches the age where they need caregivers. Unless parents provide for the child’s who happens to be caregivers golden years. Because being parent caregiver is thankless and another form of slavery in my opinion because I will not have the same retirement benefits as my parents. So sacrificing the child’s retirement income so the parent of the child can live the quality of life they enjoy. Yeah my parents who quadripleagic and one is senile dementia ask me give up my future so they can save a few bucks.

  3. Janine Hunt-Jackson says:

    I am confused; I do not see anywhere on the ADAPT site to which the link in your article leads, a complaint that minimum wage and overtime pay will lead to increased costs for people who want to stay out of nursing homes. ADAPT is invested in insisting that quality home care is provided to people who want to live in their communities. Part of that quality home care is a living wage for home care aides.

  4. Katherine Carol says:

    In Colorado, we can set wages for caregivers via our consumer directed program. For the most part, people are paid well above minimum wages. What is needed is health insurance, sick time and paid vacation. It is intense work and often, caregivers will burnout and quit when all they needed was a vacation.

  5. Elizabeth says:

    California’s IHSS workers, under the proposed overtime regulations, willlikely be limited to working a 40 hour week. The state will dig its heels in and not pay overtime. For those of us who provide care for disabled family members this is a potential disaster…instead of being paid for 70 hours a week, there will
    only be 40 hour paycheck. This impacts rent and mortgage dollars. We will end up
    in a studio instead of the one bedroom house. The section 8 (for subsidized housing) has an
    eight year wait for help. This is one instance when good intentions are a disaster.

  6. Philip Bennett says:

    To Janine Hunt-Jackson and everyone else: I have worked in home care for over 36 years. I occasionally work an 84 hour week (even more during Hurricane Sandy). I would love to receive that extra 50 cents-on-the-dollar this proposal seems to promise. But I’m grounded in reality. It’s just too easy for the home care agencies to avoid paying it, as the article explains. Instead I will be losing money. I also don’t want to force the people I assist to shell out a much higher co-pay which will force them into nursing homes (institutions which PHI also support). Please Google IHS Global Insight Companion Care Report for the results of a nation-wide survey of what the agencies and people receiving care will do if this proposal goes into effect.
    Yes the job can be hard, particularly when dealing with an emotionally difficult person. But usually it’s a dream-job where I interact and provide life-support for people who’ve lived remarkable lives and have greatly enriched my own. Please don’t take this away. If PHI and other ivory tower dwellers want to help us, then push for a higher hourly wage. Drop this pie-in-the-sky shell game and leave well-enough alone.

  7. Lori Owen says:

    I am a disabled person currently living in a nursing home. I have had home health aides, many of them underpaid. I did not and do not have the additional funds to pay the difference between minimum wage and a good living pay. If I did, I would. I am also a new member of ADAPT. We do support increased pay for our aides so that people who want to be as independant as possible can stay that way. I also did not see ADAPT mentioned in this article.

    Personal Care Attendants/Home Health attendants need to make a good living for what they are doing. They do not need financial stress on an already stressful job. They don’t need to have to chose between putting gas in their car to get to work, groceries, paying other bills versus not coming into work because they can’t afford to.


    We need to Close all institutions and Mandate that all direct support workers be paid a livable wage for providing community based services for people with developmental disabilities!!! NO MORE SEGREGATION! END THE INSTITUTIONAL BIAS NOW!! NURSING HOMES AND institutions are Unsustainable housing models!

  9. nancy becker kennedy says:

    on behalf of Michael Condon


    My name is Michael Condon I’m a disabled Veteran, paralyzed from the neck down for the last 40 years. I live in San Diego, CA, in a home I rent,and I am assisted by a caregiver paid for by In-Home Supported Services (IHSS). IHSS employs nearly 400,000 caregivers across the State. Almost 50% of these caregivers currently work more than 40 hrs/week. In addition, 70% of the IHSS caregivers in this program care for family members, many of whom require protective supervision (24 /7 care).

    The State has neither the funds nor the inclination to pay overtime. This will put me, and hundreds of thousands like me, at risk of institutionalization. Because our caregivers will be limited to a 40 work week, I will be forced to have multiple caregivers while there are already not enough to meet the current need. Please do not institute the DOL regs. requiring overtime. The disabled, elderly and blind on …this program would love to have their caregivers receive time and a half, but that will not happen. What will happen (unintended consequences) instead, the caregivers hours will be cut driving many deeper into poverty. The caregiver loses, the senior/disabled loses and the Unions almost double their membership dues.


    Michael Condon

    This is why a 40 hour work week mandate is bad. It will be financially devastating to 46% of IHSS IP’s (190,000 workers)in CA alone.

  10. Abby Doodle says:

    I wish the family members that give their life as a caregiver could be reimbursed someway….my husband has done much more than the professionals for me and the household when I have had severe seizures, in a coma, and been unable to take care of myself as my genetic disorder has fun playing with my memory, executive skills, behaviorial skills, —because of metabolic deficiencies I cannot take care of the house cleaning, washing, and cooking. He is 74 and doing all he can to keep us afloat. Yet when I revert to one of my critical stages he is there 24/7—missing out on jobs and not getting paid by his customers nor getting paid to take care of me. And having a 3rd party is a cost we cannot endure.

    It is sad that Whitney is so cold about his/hers parents. Even though I am disabled, my mom has a home with me anytime it is needed. My my brother and sister would be expected to help from time to time. That is what family is for. Only when she no longer has the mental or physical faculties to take care of her self would we consider third parties. Even for myself this will be all written out. I just wish if family does the jobs (including injections, breathing treatments, food preparation and feeding, wound care, etc—it could be paid medicare. In many cases family does a better job than a 3rd party. Hubby has kept me out of hospital with agreement of doctor because he said he could be there 24/7 sleeping in the room and nurses had to be split between patients. Plus he did not want me exposed to MRSA and other infections that now haunt hospitals. We have all the equipment needed when I need that level of nursing care and he does it even though I am 56 and he is 74. He does it out of love and respect and he says he knows me better than strangers. The dogs inform him when my body is thinking about a seizure so he has help.

    The best third parties I have ever seen are hospic —everyone I have met seems to love the giving from their heart and has an intense desire to insure the patient is as comfortable as possible in times of stress and pain. They have such a gift and help families so much.

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