Caring for America: Home Health Workers in the Shadow of the Welfare State, By Eileen Boris and Jennifer Klein (2012, paperback 2015) Oxford University Press, 320 pages. ISBN: 978-0-19-937858-6 (paperback)

This book is on the US home care system and its evolution beginning with the 1930s. It critically analyzes the treatment of home health care workers by the welfare state and the unionization of home health care aides under Service Employees International Union (SEIU), with gains achieved by the unionization and still goals to accomplish. The book shows how home care system developed in the US, and how the society arrived to the point that the labour of home health care aides became invisible, under-compensated and not falling under labour laws in the US. There are a variety of terminologies used for home health care workers, in the US, Canada and elsewhere, and here, following the authors’ most commonly used terminology, I use home health care aides in referring to US workers. A more or less similar counterpart of these workers in Canada would be personal support workers in the community and home care.

The book is for those interested in home care system and workers in the US. While there are similarities with the Canadian system and personal support workers experience in Canada in terms of overall working conditions and their position in the health care hierarchy, there are a number of differences in specifics of working conditions between the two countries. Most importantly, the legal protection of personal support workers and the percentage unionized in Canada are far better than the US. I recommend reading the book for an understanding of the history and current working conditions of this large and growing segment of the workers. However, readers from Canada and other countries might want to seek publications that are specifically on their country’s system and workers in this sector.

The book discusses both services funded through various public programs and the private market where families with financial means can purchase care for the recipients. The work is long hours with no overtime pay, low pay, and no health insurance. The US Supreme court in 2007 sustained the exclusion of home health care aides from the US Fair Labor Standards Act, even when employed by a for-profit agency, essentially excluding these workers from the minimum wage and hours of work legislation. The book explains how the work done by these workers is invisible because it is done in private, in the home of the care recipient. It also shows that, as elsewhere in many other countries, the workers are disproportionately women—poor white women, women of colour, and immigrant women. In the US, in the 1970s and1980s, home health care aides organized into unions for respect, dignity and recognition, and had some modest gains in employment conditions.

The book gives a history of home care in the US, explaining how the government had a central role in creating labour markets in human and social services fostering the development of new occupations such as home health care aides, and actively channelling poor and minority women into these jobs, perpetuating gender and racial inequality.

The book is divided into seven chapters, in addition to the introduction and epilogue and afterward sections. Chapter 1 provides the history of the beginnings of the sector with the New Deal and the Welfare State in 1930s. It explains how the need for caring for chronically ill and elderly, and to assist individuals in their own homes rather than the more expensive institutional care started the need for an occupation to aid nurses, though these individuals were neither nurses nor maids—but somewhere in between. They were a part of the rehabilitation and care at home team but not considered as health care workers.

In Chapters 2 through 4, the book discusses how the system developed with the state support as a hybrid public-private entity. Then, starting in the 1970s, the government with Medicare rules, state subsidies, federal social services grants, job training funds and service contracts, boasted a for-profit industry in home care. The authors ably discuss how the cost shifting and privatization tactics of home care from all levels of governments, and the public ambivalence over paying for social services that should be provided freely by wives, mothers, and daughters, led to the emergence of home care sector with low-wage labour market and casualized employment.

Chapters 4 and 5 show how states used the politics of budgetary crises of 1970s and 1980s, and restructured the labour market for care and the nature of the home health care aide job. The home health care aides were excluded from legislative coverage. The sector increasingly used workers in independent contractor designation and created more and more casualized employment. The authors argue that this had broader implications with the practice spreading throughout the American economy, affecting workers in many other sectors. These chapters show many similarities with the developments in Canada and other industrialized countries. I would argue that there are similar developments currently in the newly industrialized countries with the aging population and cost containment goals in health care. These chapters can be a particularly interesting read for the readers globally.

In Chapters 6 and 7, the authors turn their interest to the unionization activities of these invisible workers. These chapters critically examine how the political environment of 1960s and 1970s in the US lead to a collective action of workers, care recipients, and voters demanding better wages and better care, and a new type of unionism for home health care aides with workers organizing under SEIU. The authors discuss how the unionism of home health care aides originated in the domestic workers activism in New York and San Diego, farm worker unionism in California, public sector militancy, and community organizing of groups such as migrants. The workers, under SEIU, created a ‘care worker unionism’ with a combination of : political unionism aimed to influence the state for visibility, dignity and better working conditions; social movement unionism mobilizing care recipients and communities; and service sector unionism creating a new epicentre of organized labour. The aim, according to authors, was to move the labour of care from its marginalized status to recognize its centrality to the contemporary political economy.

This book is an interesting read for those interested in the US system of home and community care sector development and unionization. For those who are familiar with their country’s home care system, this is also a valuable read, particularly for comparison with their country’s system. However, for those less familiar with the home and community care sector in their country, I recommend first reading about their country’s system, followed by this book to enrich the understanding of their system. I recommend this book to those interested in gender and work issues, industrial and employment relations, political economy, and sociology of work and organizations. The book shows how home care system is built on the labour of marginalized women—predominantly poor white women, women of colour, and immigrant women—, and how the casualized employment conditions are dictated by the system on these workers if they want to or have to be employed in the sector.