Last Updated on June 26, 2024 by BVN
Mariah Brown
In San Bernardino County, Lesia Louro begins her day at 5 a.m., ready to visit her first client, an elderly woman who relies on Louro to be her eyes and ears. Her elderly patient’s eyesight and hearing have begun to deteriorate in her old age. This is one of two clients Louro cares for within a three-mile radius of her home. Louro is among approximately 470,000 professional in-home health care providers in California, all represented by the Service Employees International Union Local 2015 (SEIU 2015), the state’s largest union for long-term care workers.
Louro represents professionals who navigate the complexities of rising demand for in-home care, diverse employment structures and varying training requirements. As families manage the logistics of in-home care, caregivers advocate for improvements to ensure sustainable and quality support for California’s elderly population while addressing their own financial struggles.
“The work we do is imperative,” Louro said. “The financial compensation we receive is nothing. We want better wages and benefits.”
The state is experiencing a surge in the demand for home care services, driven by an aging population referred to as Baby Boomers, people born between
1946 and 1964, and an increasing preference for home-based care. Caregivers offer a range of services, from medical care like wound dressing and medication management to personal care activities such as bathing and meal preparation. Specialized services, such as dementia care and palliative care, require additional training and expertise.
The U.S. Census Bureau forecasts that the number of individuals over 65 will increase from 43 million in 2012 to 84 million by 2050, with their share of the population rising from 14%to 21%. As people age, they require more extensive and complex healthcare services, which in turn heightens the demand for healthcare workers, including those working in-home.
Employment Structure and Training
Nealy all in-home caregivers in California work as individual providers. Those involved in programs like In-Home Supportive Services (IHSS) are unionized. In IHSS, caregivers who are Medicaid care workers are represented by unions: SEIU Local 2015 represents workers in 37 of California’s 58 counties, while the United Domestic Workers (UDW) represents those in 21 of the state’s remaining counties.
Agencies often handle administrative tasks such as background checks and payroll, while independent contractors may have more flexibility, but must manage these aspects themselves. Unions like the SEIU 2015, which advocates for better wages and working conditions for long term care workers, ensures caregivers undergo specific training programs that cover basic health care skills, emergency procedures, and specialized care techniques. However, the requirements for caregivers can differ.
IHSS providers must pass a background check, complete necessary forms through the Department of Social Services, attend a local orientation and fill out enrollment paperwork. Training and certification requirements vary by county, but no formal certification or bonding is required.
About 70% of IHSS providers are family members of the care recipients. The remaining 30% are friends or community organization members chosen by the care recipients. Those without a personal IHSS provider turn to the county public authority for help finding an eligible provider. Most of them work independently, although some work through private agencies like Homebridge in San Francisco, which contracts with the city and county to serve high-need clients. These agency workers, about an estimated 300 in the city, are also unionized under SEIU Local 2015.
Work Conditions and Compensation
On average, caregivers in California work around 30 to 40 hours per week, and can work up to a maximum of 66 hours per week. Though many work beyond those hours to meet the demands of their clients. The work can be physically and emotionally demanding, often requiring long hours and the ability to handle stressful situations. Caregivers are usually assigned to clients based on compatibility and the client’s specific needs. Compensation varies, with hourly rates ranging from $15 to $25, depending on experience and location.
One of Louro’s clients was approved by Medicaid insurance for up to 50 hours a month. However, Louro spends significantly more time with her client due to her extensive needs. She also observes that her client is isolated and lacks family or friends to provide care. Louro not only fulfills her client’s basic care requirements, but also addresses her need for companionship, which she considers crucial.
“It’s really the love we’re providing them, because love is what we all need to survive,” Louro said.
Despite their vital role, the average wage for an IHSS provider in California is around $17.50, which is not a living wage anywhere in the state, according to Brandi Wolf, policy and research director for SEIU Local 2015. According to Massachusetts Institute of Technology’s (MIT) Living Wage Calculator, the average hourly wage for a single adult in California should be $27.32. The state’s hourly minimum wage is currently $16.
The IHSS program, grounded in a social rather than a medical model, emphasizes providing social support to its consumers. Consequently, many caregivers have to take on additional clients or work extra jobs, such as in nursing homes or fast food restaurants, to make a livable wage. To address these challenges, the union is advocating for a living wage and aims to move collective bargaining from the county level to a statewide master contract.
Many caregivers strive to meet the demand for services and are often compelled to take on multiple clients to make ends meet.
Louro, who makes $18.10 an hour, explained, “We can barely afford to pay our bills.”Funding should be allocated in the budget for workers like us. We are essential to the lives of those we care for, who cannot otherwise care for themselves.”
Financial Assistance and Support Options
Medicaid, also known as Medi-Cal in California, funds family caregivers for eligible individuals. For those with Medi-Cal, in-home care can be a lifesaver. It covers many aspects of in-home care, including paying family members or qualified caregivers to provide tailored care.
However, for those without Medi-Cal, paying for care out-of-pocket can be prohibitive. Options for these individuals include sliding scale services, subsidies and assistance from non-profit organizations. Families who exceed the income threshold for Medi-Cal but still need care have options such as long-term care insurance, state programs and financial planning services. For those who do not qualify for Medi-Cal and cannot afford private care, community programs and volunteer organizations offer vital support.
If a person who needs care does not qualify for Medi-Cal and cannot afford private services, they may need to deplete their savings and live at the poverty line to become eligible for IHSS, according to Wolf. Alternatively, they might rely on unpaid care from family. Those who struggle because they don’t qualify for Medi-Cal often face significant barriers to accessing the caregiving support they desperately need, exacerbating challenges within the system.
As a full-time caregiver for her husband, 81-year-old Cheryl Brown, California State Commissioner on Aging and former California State Representative finds it disheartening that he doesn’t qualify for assistance.
“It’s a complex process to determine eligibility and the number of hours of support provided,” she explained. “But any help would be welcomed, as I still need to pay for additional caregiving support.”
Challenging Misconceptions and Accessible Care
The COVID-19 pandemic highlighted the critical importance of IHSS providers, demonstrating their value as frontline caregivers who enable aging adults to stay in their homes and communities rather than moving to more expensive institutional care facilities.
“There is still a narrative in California that 70% of IHSS providers are family members and that people shouldn’t get paid to care for their relatives,” Wolf explained.
According to Wolf, this perspective fails to acknowledge the professional care delivered by these workers, regardless of familial connections, and emphasizes the need for public education about the impact of caregiving. Additionally, with long-term care insurance and privately paid home care being unaffordable for many Californians, IHSS is indispensable for those unable to pay out-of-pocket.
“If IHSS providers weren’t able to earn an income, many consumers would end up in institutions, which would be far more costly to Medicaid,” Wolf said.
With the aging Baby Boomer population driving up the demand for IHSS providers, there is an urgent need to attract more workers to this field. While counties are tasked with maintaining registries of available providers, “even when the registry is up and running, it can be difficult for consumers to find a provider,” Wolf said, emphasizing the need for a more user-friendly statewide system.
Professional caregivers face numerous challenges, including low pay, frequent emotional and physical stress and limited opportunities for career advancement. Workforce shortages further strain the system, impacting the quality of care provided to clients. Caregivers and industry experts alike advocate for several changes, such as better wages, more comprehensive training programs and greater recognition of the critical role caregivers play.
“I don’t see it as just providing a service, I see it as ensuring she can live in her own home with dignity and pride,” Louro said.
On June 22, Ca Governor Gavin Newsom, and leaders of both branches of the legislature announced an agreement on the 2024 state budget. The agreement includes pushing back the highly anticipated health care wage hikes until October or possibly until 2025. Although there was heavy opposition from labor unions, state officials claim the action could save the state hundreds of millions of dollars.
This article is part of the 2024 Black Voice News reporting series on Caregiving in the IE supported in part by the United Domestic Workers of America representing home care and family child care providers across the state of California.