The author (whose foreign name is due to Taiwanese ancestry, but this doesn’t particularly factor into her story) is billed as “Co-Director of Caring Across Generations and MacArthur “Genius” Fellow, and her background is not one of working with the elderly, but advocating for the home care workers (healthcare and, more typically personal care aides), alongside other “domestic employees,” and this book is not about the elderly per se, but those who work for them (with large portions of the text spent telling stories of individual workers), and her crusade for improved pay, working conditions, and respect.
She begins with her own personal story, and some general words about the increase in the number of elderly and the difficulties that it brings. For example: the lack of geriatricians, who aren’t just “nice to have” but important to healthcare for the elderly; someone without specialized training and experience will mistake a treatable condition for a normal consequence of aging. One difficultly: Medicare reimbursements presume a 15-minute appointment, but in reality, office visits for the elderly require much more time. Within families, daughters (because it’s generally daughters, not sons) caring for aging and severely impaired parents struggle mightily as the “sandwich generation,” feeling guilt for wishing the parent would die.
What about paid caregivers? Sometimes they’re hired via Craig’s List or other informal sources; other times from an agency. 2/3rds of domestic workers (that is, including nannies and housecleaners as well) are foreign-born; half are here illegally. They work far in excess of a 40-hour week, are paid less than minimum wage, are sometimes flat-out mistreated (even to the point of being subject to sexual demands) and, for those here illegally or otherwise working under the table, accept this for fear of being exposed or because they simply don’t want to lose the job and risk being unable to find a new employer.
She also cites a more general “unfairness” that all manner of “domestic work” is low paid, and attributes this to the fact that it’s viewed as “women’s work” and of little value accordingly. (Not for her questions of supply and demand.) And she describes the advocacy that produced the New York Domestic Workers Bill of Rights, and an update to Department of Labor regulations (effective 1/1/2015) that substantially narrowed the type of elder care that’s exempt from minimum wage and overtime; now, only work that is almost exclusively that of “fellowship”/”companionship” and “protection” (that is, making sure they don’t fall, etc.) is exempt, where previously, elder care was more generally exempt form minimum wage and overtime law. (Live-in workers are still exempt from overtime requirements, but are still covered by minimum wage law for all on-duty hours.)
What’s her agenda, ultimately?
First, a $15 an hour wage.
Training opportunities for elder care workers.
Legalization for all illegal home-care workers, and a new guest-worker program.
How to fund this? She’s not particularly interested in these details, but offers (1) tax hikes, (2) abandoning immigration enforcement and (3) Medicare and Medicaid “negotiation” of drug costs, and she cites long-term care benefits in Japan and Germany that are part of their social insurance programs, as well as proposals in various states. She doesn’t particularly make an effort to calculate the cost or outline the extent to which the government should pay. Does her preferred program include government coverage of 100% of care costs, and relieve family members who are currently caring for the elderly without pay?
What’s my take-away from this book?
She insists that institutional care is unaffordable because of its astronomical cost: she cites a cost of $84,000 per year for a nursing home stay, and says that home care is more economical, but if we take her proposed $15 an hour, and multiply by 24 hours a day, 7 days a week, 52 weeks a year, even excluding the additional costs for taxes, benefits, another other expenses, we’re at $131,000 per year, just for the care manpower.
She also focuses a great deal on the desire of the elderly to preserve their independence, even when, in reality, they are dependent on their caregivers.
But consider this: the only ones who hire workers to care for their children, directly in their own home, are the wealthy and upper middle class. Most families in need of child care services elect more cost-efficient daycare centers or home daycare providers. Surely in the same way, elder care is more efficiently provided, perhaps not in large nursing homes, but in small groups, either as a group home, similar to the disabled, or via adult daycare, when the elder spends nights at “home” (which may be a child’s home) — especially for those for whom the care needed is meal prep, toileting help, and general supervision. Or is the problem that the elderly want companionship, but don’t really want to be around, well, other old people?
Bottom line: she highlights a real problem, but is woefully short on real solutions.
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