In-home care is a growing necessity across the state. When will counties treat it that way?

By Mark Kreidler, Capital & Main

This story is produced by the award-winning journalism nonprofit Capital & Main and co-published here with permission.

Sydney O’Connor’s clients have disparate needs. One, a double transplant survivor who is almost blind, requires assistance for most of the critical transactions in his life, including paying bills and staying current with his finances. The other, a woman in the early stages of dementia, needs help with the basics: getting out of bed, making food, moving around her house, using the bathroom.

The first is O’Connor’s partner, the second her neighbor. As an In-Home Supportive Services (IHSS) provider, O’Connor is part of California’s answer to the number of its residents who need everyday assistance, lack financial resources and wish to age in place.

That number continues to grow. As of last December, more than 666,000 Californians were authorized recipients of IHSS care, according to the state Department of Social Services. In the coming decades, researchers say, that figure will skyrocket as the graying of California progresses.

But the state is already lagging in its ability to provide IHSS services, which it created nearly half a century ago. In 2020, the state auditor found that more than 32 million hours of assessed IHSS need were going unmet across California, a gap almost certain to widen.

One reason? Money.

O’Connor, 27, is paid just $15 per hour for her services. It’s a minimum-wage figure driven by an oddly constructed system in which each of the state’s 58 counties sets its own rate for IHSS work. Kern County, where O’Connor lives, has doggedly stuck to the lowest payment it can approve.

“It’s medical work a lot of the time, or at least paramedical,” O’Connor said. “I’ve operated dialysis machines, done IVs, adult diapers — I do a lot of the things that people in long-term care facilities do, and at a lot less cost to the county than someone being put in a hospital or a nursing home. But it’s not only minimum wage, it’s that it isn’t even full time.”

Instead, hours are assigned to each in-home patient by a county social services worker, who tries to learn about the patient’s needs and then estimate how many hours per month it would take to meet them. Since the pandemic began in 2020, O’Connor said, no social worker has made an in-person visit to either of the people in her care. She is authorized to provide 94 hours a month for her partner and 72 for her neighbor; in reality, she often works through the day and far into the evening to care for both, hours well beyond the county’s estimates.

The low pay and stressful job requirements discourage people from considering IHSS, and a growing number of workers, including O’Connor, have joined the labor organizations that bargain for better wages for them. But this is also part of a longstanding trend in the care industry, and researchers suggest that decades-old biases — against women and minorities, who make up most of the workforce — are still at play.

“My goodness, it lies at the heart of the issue,” said Marokey Sawo, a state economic analyst at the Economic Policy Institute. “What we see manifested here is part of a larger picture of systemic oppression, and it is tied to three things: who does the care work, what type of work it is, and who receives it.”

Last year, an EPI report co-authored by Sawo found that care work, including home care, was compensated nationally at a rate that’s about half the average wages for the workforce as a whole. Women make up 88.6% of the home health care workforce, with 54.6% of the workers women of color and more than a quarter immigrants. (Though the term “home health care” often refers to professional medical assistance, the EPI’s use of the term includes many home care job descriptions, Sawo said.)

“What would those wage levels look like if these factors — racism, sexism, xenophobia — were reduced in terms of the harm they cause? This is specialized labor, and it is tough to attract and maintain the necessary workforce,” Sawo said.

Created in 1974, the IHSS system was designed to provide in-home care to blind, elderly and disabled residents in California who meet income eligibility requirements. Essentially, those who qualify for Medi-Cal are also able to request IHSS. More than half of the estimated $18.5 billion cost to run the program in fiscal year 2022-23 will be borne by the federal government, with the state picking up most of the rest.

Counties are on the hook for only about 10% of the total cost, yet it is county supervisors who set the rates for IHSS workers in their areas. This has led to wide disparities in pay — as much as $3 per hour, depending upon geography. In general, the wages don’t reflect the importance of the work, especially considering that in-home care means other county and state health services are less strained.

“People truly need to be compensated and acknowledged for the care they’re providing,” said Anthony Wafer, who commutes about 60 miles daily from his home in Encino to Lancaster, where his sister deals with debilitating knee and back injuries. After caring for her most of the day, he drives another 65 miles to his night job doing housekeeping at the West Los Angeles Veterans Affairs Medical Center.

His hourly IHSS wage from Los Angeles County is $16. His sister is authorized to receive 109 hours of care per month. Wafer is logging something closer to 200.

“I was raised to take care of family, but we’re not just talking about a family member. We’re talking about a patient,” Wafer said. “These people need care. These are working jobs, period. It’s tough.”

For decades, the jobs have come with low pay and no benefits. While the EPI’s report highlights the gender and ethnicity of home care workers as one reason why, others note that family members are often the ones providing the necessary care, leading to a devaluing of the service.

“Some county boards of supervisors have expressed in the past that IHSS providers are lucky to get paid at all, as though caring for an elderly person or a person with disabilities full time isn’t work if you are related to them,” said Cherie Parker, public information officer for United Domestic Workers of America (UDW). “The low pay is leading to a long-term care crisis of alarming proportions.”

Although firm figures in California are hard to come by because people constantly move into and out of IHSS, officials estimate that 50% or more of such care is delivered by family members. (In another twist to the system, IHSS recipients select their own caregivers, while the county sets the rate and assigns the hours.) For many, choosing a family member is a matter of comfort and trust, caregivers say.

Tracy Mills Jones has extended such care to several members of her family, going back to the 1990s when her mother was diagnosed with Alzheimer’s. Jones provided in-home care for her mother and later for her cancer-stricken husband, and now cares for a brother who suffered a stroke and also requires transportation to a dialysis clinic.

“It was when the pandemic hit that I really noticed the pay issue more clearly,” said Jones, who lives in Palmdale in northern L.A. County. “I always knew I was underpaid, but I’d made up the difference with a bunch of odd jobs, cleaning places at night, things like that. During the pandemic, those jobs all went away and I could see that I simply could not make it on IHSS pay. That is a terrible feeling.”

What should her pay be? In a just released report, the EPI researched what home care wages would look like once factors like “wage penalties” associated with the nature of care work and the demographics of the workers themselves were removed. While the estimates are for all kinds of home care, including medical, the results are startling: California’s suggested hourly rate becomes more than $25, or roughly $10 above the current average.

Increasingly, home care providers in California have turned to labor organizations in an effort to move the wage question forward. The roughly 570,000 IHSS providers in the state are represented in contract negotiations either by SEIU 2015 or the UDW regardless of whether they choose to join the union. (Disclosure: Both organizations are financial supporters of Capital & Main.)

SEIU 2015 has launched an effort to set a wage floor of $20 per hour for home care workers. “That’s a great starting point,” Wafer said, “because then this can become a more competitive job field and we might have more caregivers open to doing IHSS work.” But that effort is ultimately local, since the unions must negotiate separately with each county.

Absent a state mandate to raise home care workers’ wages, this 58-piece puzzle will continue to exist. “It’s a necessary program that should be developed further,” O’Connor said. But with pay this low and work this undervalued, the massive gap in IHSS coverage in the state is certain to grow. It’s a care crisis waiting to happen.

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