The Politics of Care Work
04.29.22
Shantonia Jackson, a certified nursing assistant (CNA) in Chicago, Illinois, isn’t shy about her pro-union stance. “I’ve told my director of nursing quite a few times, ‘You ain’t gonna scare me. I am a CNA. I’m certified to clean ass all over Illinois.’ It’s like the only job up in here… They could close the building down and those employees could just walk into another job.”
Jackson believes her employer’s union shop status — a rarity in the healthcare world, present in just 16.8% of nursing homes nationwide — affords her greater job security and the ability to speak out against workplace abuses. “One of my friends said, ‘I was never too keen about the union.’ And when she got fired for no reason, the union got her job back. After that she called me all the time saying, ‘Let me know when there’s another union meeting. Because, you know, having a union is like having your own personal lawyer.’ I told her, ‘Bing bong baby, yes, you’re right. That’s your own personal lawyer. That’s right.’”
While Jackson’s union status is unusual, her chosen occupation is not: she is part of a much larger, tectonic shift in working class employment — from one based around traditional industry to one based around institutionalized healthcare. In particular, the lowest strata of the healthcare market — nursing assistants, technicians, housekeepers, etc. — faces an onslaught of new demand. “The need is so great for this grunt work that virtually anyone who can pass a good urine sample can probably get a job somewhere as an aide,” admits one former nursing home aide.
“Care workers’ numbers today have grown to the extent that their census designated sector of the labor market — ‘health care and social assistance’ — is the country’s largest, claiming about one in seven jobs nationwide,” writes political scientist Gabriel Winant in his new release, The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America. “In the bottom quintile of the American wage structure, the care economy accounted for 56% percent of all job growth in the 1980s, 63% in the 1990s, and 74% in the 2000s.”
Despite the ballooning care economy, nursing homes lost more than 240,000 employees during the pandemic, a reality few institutions have come to grips with. “Our whole upstairs is empty,” said one director of nursing. “I could fill this building with residents tomorrow. It’s the staff I don’t have.” Many healthcare institutions suddenly find themselves competing head-to-head with Amazon and McDonald’s in a desperate bid to attract more labor. “If you look at CNA wages and compare it to McDonald’s hiring for $15–17 an hour? I can go flip burgers for almost the same pay but with less stress,” said one CNA. “And it’s not like CNA work, where anything you do wrong can impact a patient forever.”
This week, in the wake of the Biden administration’s call for a federal minimum staffing requirement (a move much maligned by the nursing home industry; it “would close every building in the country,” said Mark Parkinson, president of the American Health Care Association), we discuss the increasingly central role of care work in the larger economy. Why has demand for care work dramatically outpaced supply, and how will we care for the tidal wave of baby boomers just entering their golden years?
A Brief History of Care Work
Contrary to popular belief, the United States did not shift from a nation of idyllic families caring for their honored elders to a nation of cold-hearted institutionalists dumping grandma into the nursing home. Yet that is often the narrative presented within both scholarship and popular media.
One such scholar, Deborah Stone, attributes our current care crisis to the “wrenching” of care out of families and into the labor market: “Caring comes from the private world of love, intimacy, families, and friendship, but much of it is now done in the public world of work, organizations, markets, and governments. Just as farm and craft labor were once wrenched out of the family and brought into a system of work controlled from outside, caring work is increasingly separated from the personal relationships in which it naturally arises and is performed instead in a system of managed and waged labor.”
While the presence of an immense hospital and long-term care system is certainly unique to the last century, private care work has always been supplemented by external labor, whether in the form of immigrants, slaves, child labor, “hired girls,” or domestic servants. Huge waves of Irish immigrants supplied the bulk of domestic workers in 19th century northern cities: nearly half the domestic servants in 1900 were pulled from immigrant families. Those unfortunates outside the purview of paying families — orphans, older adults, and the disabled — were left to the devices of poorhouses, institutions “known for nonexistent safety and sanitation standards and poor-quality care that was not customized to an individual’s needs.”
It also helped that, as late as 1900, the average life expectancy at birth in the United States was only forty-seven years old (in 1950, it reached sixty-eight years, and in 2004, seventy-eight years, a number that still applied in 2021). “Caring for a ninety-year-old parent who needs help toileting and walking is profoundly different from having a grandmother in her sixties living in a spare room with the extended family,” writes sociologist Mignon Duffy in her historical study of paid care work. “The notion of long-term care is relatively new, meaningful only because large numbers of people are now surviving for longer periods with more complex medical conditions. The needs of an older population with more chronic illnesses and long-term disabilities are more intense and more complicated than those of a hundred or even fifty years ago.”
At the same time, supply of care workers dwindled thanks to child labor laws, “draconian immigration restrictions in the 1920s,” and better employment opportunities for women. But Mignon doesn’t buy the idea that the resulting emergence of institutionalized care work and medical experts is, by nature, less caring.
“We invest more time and money and energy into keeping people alive than we ever have before. We believe it critically important to spend time with children, both actively engaged with them as well as supervising them closely. And we consider those with even severe mental illness as deserving of treatment,” writes Mignon. “This is not to minimize the real and urgent problems in the care sector today, but to point out that nostalgia for the past is misplaced and leads to misguided policy prescriptions to address today’s problems.”
The Slow March to Organize
Care workers have waged a long battle against discrimination and exploitation thanks to their strong association with family, intimacy, and women’s “natural tendencies” rather than skillset. Historically, care workers found it difficult to even classify themselves as “workers,” with many industries trying to relegate them to volunteers, servants, or glorified babysitters. “They tell us that as hospital workers we should think of dedication,” said one early x-ray tech striker in 1967. “Well, you can’t pay bills with dedication. When we go into a supermarket, we pay the same prices as bankers.”
In 1940, when Pittsburgh hospital workers attempted to unionize in response to twelve-hour days and starvation wages, twenty-six hospitals sought an injunction against the union. “Hospitals are not employers, nor are persons connected with them employees,” argued the petitioners. Instead, they were a form of “semipublic service” rather than an industry (in 1944, federal courts overturned this argument, affirming that, yes, hospital work did impact interstate commerce).
Congress, at the behest of the American Hospital Association, quickly followed suit with an amendment attached to the Taft-Hartley Act exempting hospital work from the Fair Labor Standard Act’s and NLRB’s regulations. “At the cultural level, state regulation now positioned health care as an intimate sphere, more akin to the family than the factory,” observes Winant. “Health care was outside the circulatory system of commerce.”
But today, the tide is changing. In 2011, large groups of CNAs were finally allowed to organize following a decision by the National Labor Relations Board. Since then, health care has accounted for more strike activity than any other industry and 2018 saw the highest level of strike participation since the mid-1980s. And while care workers are still shamed or chastised for striking today (in 2020, nursing assistants who threatened to strike over safety concerns were disparaged by the Chicago Tribune as “selfish” and “reckless”), at least they have the mobilization to try.
Some, such as Winant, hope to see a wholesale revitalization of the working class centered around care work. “Caregiving generates a potent political capacity,” says Winant. “The key question is their ability to mobilize broader political support, since even the private-sector health care industry is in so many respects a delegated arm of state power, implicating the broader public in manifold ways.”
Where is the Labor Force?
Researcher: “Do you feel that Pepper [humanoid robot] is alive?”
Eriko: “I know Pepper is not alive, but he seems more than if he was only a doll. [Prolonged silence] In some way, Pepper feels alive.”
Researcher: “How so?”
Eriko: “It’s hard to explain. I’ve never really thought about it … Pepper keeps engaging me in conversation, answering my questions, looking into my eyes. He feels alive.”
Researcher: “How does Pepper make you feel?”
Eriko: “I really like Pepper, and I hope he likes me back! I can also hold hands with him. Over time, I’ve grown quite fond of him and would miss him if he were to break down or was removed from this nursing home.”
The most commonly touted solutions for decreasing the labor force shortage of care workers include 1) increasing immigration, 2) increasing wages (and deficits), 3) lower life spans, and 4) turning to robots.
Immigration reform and higher wages are largely dependent on policymakers since most nursing homes rely on Medicare and Medicaid for funding. “We just don’t have it in our piggy bank to increase wages,” said one nonprofit director. And unless state and federal governments raise reimbursement rates, she anticipates more of an exodus. “They’re tired. They’re burned out. They’re physically exhausted, and even committed people in this industry will turn around and say, ‘I don’t know how much longer I can do this.”
Others posit a return to shorter lifespans, facilitated by a return to more in-home care. “Underdeveloped countries appear to deal better with old age, perhaps because economically they have no choice,” writes Gass. “Their practice is to allow death rather than to fight it off at astronomical costs.” Some even regard it as a mercy: “Back in the day when you stopped eating, you just died,” says Jackson. “Now you’ve suddenly got all these people in comas and feeding tubes and they can’t even speak. They can’t tell you, ‘Turn me.’ But [nursing homes] want to keep them alive for the money… Every day [they] get paid for this person staying alive. But why make them suffer?”
Japan, which only recently amended its immigration laws in an attempt to stave off the elderly care crisis, provides an interesting case study for the final option, robots. The Japanese government, well aware of its hyper-aging society, began actively investing in “kaigo” robots to offset labor shortages and high turnover rates among long-term care workers. Today, over 30,000 service and social robots are in use — approximately one device per 50 elderly residents. Many elderly care centers report that service robots reduce staff burden, decrease physical accidents, and prevent client hip problems. “It’s a force multiplier for care staff,” said one robotics engineer. “It’s not to replace people, but it’s to augment how people care for people.”
And, better yet, people seem to like them. Even Qoobo — a social robot marketed as “a tailed cushion that heals your heart” — has proven wildly popular, despite not having a head. Simply petting the pillow and watching the movement of its tail calmed users and gave them some small simulation of a pet. As Eriko, an elderly woman attended by the companion robot Pepper says, “You know, Pepper, today I feel content because I’m here with you. You make me happy.”
