The push to improve working conditions for U.S. caregivers

CHICAGO (Reuters) – Ai-jen Poo wants to transform caregiving into real work.

By “real,” she does not mean more difficult. Rather, the activist and author is seeking recognition of the value of domestic work, and to raise its status and pay accordingly. “It’s the work that makes all other work possible,” said Poo, executive director of the National Domestic Workers Alliance (NDWA) and author of the  best-selling book “The Age of Dignity: Preparing for the Elder Boom in a Changing America.”

“Caregiving is the work that allows the rest of us to go out and do our work in the world, but it has been made invisible and taken for granted,” she said. “It’s not called real work – it’s unskilled, ‘help’ paying poverty wages.”

Poo has been active since the mid-1990s in the movement to organize caregivers, nannies and other domestic workers to fight for equal rights and better wages. Along with leading the New York City-based NDWA, she co-directs Caring Across Generations, which focuses mainly on policy at the state and local level. Poo’s work was recognized by the John D. and Catherine T. MacArthur Foundation, which awarded her one of its “genius grants” in 2014.

NDWA has 63 local affiliates and chapters around the country, and organizes nearly 200,000 workers. In 2013, the organization played a key role in getting the U.S. Department of Labor to rewrite rules to include domestic workers in the federal government’s minimum wage and hours protections. The organization also has helped win passage of legislation in eight states that extends basic protections such as overtime rules, paid sick days and the right to unionize to domestic workers.

In 2019, NDWA will be pushing legislation at the federal and state levels aimed at lifting up this crucial work.

U.S. lawmakers will introduce legislation in Congress next year that would close legal loopholes excluding domestic workers from some federal labor and civil rights laws, create new benefits and protections for them, and encourage innovations to address the unique challenges of domestic work. The legislation, called the Domestic Workers Bill of Rights, is sponsored by U.S. Senator Kamala Harris and Representative Pramila Jayapal, both Democrats.

The legislative push has important implications not only for the well-being of caregivers, but for the labor market and economy as the country ages.

By the year 2030 there will be a severe national shortage of caregivers, according to recent research by human resources expert Paul Osterman. We will be short 151,000 paid direct-care workers, and 3.8 million unpaid family caregivers. Osterman, a professor of human resources and management at the Massachusetts Institute of Technology Sloan School of Management, projects that by 2040 the shortfall will rise to 355,000 paid workers and a shocking 11 million “family and friends” or unpaid family caregivers. (


Lifting up domestic work, including caregiving, can make this work more desirable, Poo thinks, and attract many new workers to the field.

Currently, most domestic workers still earn only $11 an hour or less, according to Bureau of Labor Statistics data, and most do not receive healthcare or retirement benefits. “With the need for family care growing – both child care and elder care, but especially elder care – we will need a strong, professional workforce to meet the need,” Poo said.

But she also argues that caregiving can provide quality jobs at a time when automation and artificial intelligence threaten to displace people in many occupations. “We know for sure care jobs will not be automated in the near term, nor can they be outsourced,” she said.

The normal economic laws of supply and demand should boost wages naturally – if the market for caregiving labor was a normal market. But it is not.

Two-thirds of long-term care in the United States is funded by the federal Medicaid program, with the remainder paid through private commercial insurance or out-of-pocket. Medicaid payment policies vary widely among the states, but cash-strapped Medicaid programs have limited ability to boost wages, and Medicaid determines reimbursement rates for the payrolls of health providers, limiting the impact of labor market demand. Outside of Medicaid, the insurance market for long-term care is dysfunctional, with only a very small fraction of older households having purchased commercial policies.

NDWA is part of a coalition working to advance an innovative approach to funding care through social insurance programs in the states. Proposals to create publicly funded long-term care benefits have been advanced in seven states: California, Illinois, Iowa, Maine, Michigan, New York and Washington. In most cases, the programs would be financed through an additional tax on payroll or income.

It has been clear for some time that social insurance can provide part of the answer to the nation’s long-term care funding dilemma. In 2016, three reports developed by a nonpartisan consortium of researchers, representing an ideological middle ground, called for streamlining private long-term care insurance to make it work better, but also covering the most extreme risk through publicly financed insurance ( This approach makes eminent sense, and states could provide the catalyst to get the country moving.

As Poo points out, a win-win is available: meeting the surging demand for caregiving while creating quality jobs for millions of Americans. “These jobs will be a large share of the jobs of the future,” she said. “Just like we turned manufacturing jobs from poverty wage, dangerous jobs into jobs with real economic mobility, we can and should do the same for care jobs.”

(The opinions expressed here are those of the author, a columnist for Reuters)

Reporting and writing by Mark Miller in Chicago; Editing by Matthew Lewis

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