INVISIBLE SWEATSHOP

THE PLIGHT OF HOME CARE WORKERS

IN NEW YORK CITY

A Report byMark Green

Public Advocate for theCity of New York

June 2001

INVISIBLE SWEATSHOP

THE PLIGHT OF HOME CARE WORKERS

IN NEW YORK CITY

A Report byMark Green

Public Advocate for theCity of New York

Tom HilliardSenior Analyst for Health Policy

June 2001

INVISIBLE SWEATSHOP: THE PLIGHT OF HOME

CARE WORKERS IN NEW YORK CITY

TABLE OF CONTENTS

Executive Summary.............................................................................................................i

I. Introduction....................................................................................................

1

II.History of the Home Attendant System: Cycles of Reform and Neglect...............

2

III. Overview of the Home Attendant System

5

A. Home Care and Institutional Care

5

B. The Provider Agencies and the Government

7

C. Profile of the Client in the Home Attendant Program

10

D. Profile of the Home Attendant

11

IV. Findings on Wages and Benefits........

13

A. Wages and Benefits in the Non-profit Sector

14

1. Low Hourly Wage: Full-time home attendants remain in poverty

14

2. Not Enough Hours of Work: Many home attendants cannot

obtain stable, full-time work

15

3. No overtime pay: Home attendants work long hours while

excluded from earning overtime pay

16

4. Unpaid labor: “Sleep-in shifts” force home attendants to

work up to ten hours without compensation

17

5. Health Benefit Package: Non-profit home attendants have

achieved comprehensive health insurance coverage

18

6. Health Benefit Eligibility: Many home attendants lose

health coverage when their hours fall short.

19

7. Fringe Benefits: Home attendants have access

to pension benefit, education and training, and

compensation for annual, holiday and sick leave

20

8. Education and Training: Home attendants can obtain

education and training but lack career opportunities afterward

21

B. Wages and Benefits in the For-profit Sector

22

1. For-profit agencies pay lower wages, even to workers

coping with the hardest cases in the home care system

22

2. For-profit agencies provide weaker health benefits

23

3. For-profit agencies provide weak leave benefits to home

attendants – and superior benefits to office staff

24

4. For-profit agencies spend less in wages and benefits

and more in administrative salaries

25

Recommendations

................................................................................................................................................

27

INVISIBLE SWEATSHOP: THE PLIGHT OF HOME

CARE WORKERS IN NEW YORK CITY

EXECUTIVE SUMMARY

The City of New York employs about 200,000 people to provide various services

to the public: fighting fires, protecting public safety, keeping our streets clean, and so on.

The City takes responsibility for its employees, paying their salaries, covering their health

care expenses, and giving them paid time off for vacation, illness and continuing

education.

The City of New York also oversees some 48,000 other workers to provide long-

term home care for elderly and/or disabled citizens. Home care is an extraordinarily

important and often physically and emotionally trying job. These home attendants, as

they are called, care for our loved ones as well as those without families – keeping them

safe in their own homes so they can avoid unnecessary hospitalization and nursing home

care.

Unlike City employees, however, home attendants are on their own. If a home

attendant cannot pay the rent, obtain health care or afford to take the day off when

seriously ill, it’s her problem. That’s because home attendants are not public employees.

Instead, they work on an hourly basis for independent vendor agencies that contract with

the City under strict funding guidelines established by the State. As employees of

contractors, their welfare is nobody’s business – not the State government, which

allocates the budget; not the City government, which manages the program; and not the

vendor agencies, which directly employ the home care workers. Yet these 48,000 low-

wage, low-income workers provide essential publicly-funded services that save the City,

the State and the federal government untold millions of dollars in costly nursing home

reimbursements.

The Office of Public Advocate decided to document the current status of home

attendants. The good news is that, thanks largely to the sustained efforts of labor unions,

the workers in non-profit agencies have some of the highest wages, health benefits and

i

fringe benefits of any home care workers in the country. The bad news is how little that

statement means. The average home attendant earns less than eight dollars per hour, with

an annual salary considerably lower than the poverty level for a family of four. Their

hours are unsteady and their health benefit funds are seriously underfunded, leaving

many workers unable to obtain or keep full-time work and health insurance.

We also found that employees at their for-profit counterparts fare even worse.

For-profit agencies spend much less on wages and health benefits and almost nothing on

vacation or sick leave benefits. Yet those same agencies spend substantially more on

administrative salaries, suggesting that money which could be going to impoverished

home attendants is instead diverted to managers and other administrative staff.

In sum, we found a home care system dependent on the exploitation of its

employees. The City cannot fix such a system alone, since the State tightly controls

funding for the home attendant program. But no reform will be possible until the City

accepts responsibility for the welfare of its home care workers and pledges to take action.

FINDINGS

1. Home attendants perform difficult work for low pay. Home attendants

assisting the most vulnerable elderly and disabled earn poverty wages. Their

financial situation actually deteriorated during the 1990s, a time of budgetary

prosperity for the State, which – along with the City – finances and controls the

Medicaid-funded home care program.

The starting wage for the best-paid home care workers,

home attendants employed by non-profit agencies, is $7.14 per hour,

which earns a full-time worker less than $15,000 per year – almost

$3,000 below the poverty line for a family of four.

From 1988 to 1991, the starting wage jumped 49%, from

$4.15/hr. to $6.10/hr., as a result of reforms instituted by Mayor Ed

ii

Koch and Governor Mario Cuomo in 1988. But wages stagnated over

the next decade. By 2000, the starting wage had risen only 15% to

$7.14/hr – compared to a 23% increase for City employees.

2. Many home attendants cannot obtain stable, full-time work. About one-

quarter of home attendants (26%) work 30 hours or less each week. As hourly

employees paid only when working, home attendants depend on the structure and

stability of their work. But home care assignments are often parceled out in

blocks of two, three or four hours per day – thus making it impossible for a home

attendant to work a full-time shift. In addition, home attendants find themselves

stranded without work if their client passes away, enters a hospital or nursing

home or asks for another worker.

3. Home attendants are excluded from earning overtime pay. The Fair Labor

Standards Act of 1938, which requires overtime pay for more than 40 work hours

per week, exempts several occupations from its scope of coverage, including “any

employees employed in domestic service employment to provide companionship

services for individuals who (because of age or infirmity) are unable to care for

themselves….” The Department of Labor allows states to designate home care

workers as companions, thereby arbitrarily denying them the benefits of overtime

pay. For home attendants, the exclusion is a costly one. Approximately one-third

(32%) of home attendants work between 51 and 84 hours each week, putting in

between 11 to 34 hours of overtime work without overtime pay. In contrast, City

staff who oversee the home attendant program earn overtime, as do administrative

and nursing staff at the vendor agencies.

4. Home attendants work sleep-in shifts potentially requiring several hours

of unpaid time. One of the most notorious practices in the New York City home

care program is the “sleep-in” shift, in which the worker works for 12 hours and

then remains available in the client’s home for another 12 hours – but is deemed

“off-duty.” The worker receives a per diem payment of $102.63, which equals

their pay for twelve hours plus an additional $16.95. But home care clients –

iii

especially clients who are ill or mentally impaired – frequently awaken during the

night and ask for assistance eating or toileting. As a result, the home attendant

may find herself working most of the night without pay and then beginning a new

work shift.

5. Home attendants lose health coverage if their hours fall short. Home

attendants in the non-profit sector can obtain comprehensive health coverage, but

the City and State provide insufficient funds to cover the costs. So eligibility

standards are strict. The home attendant must work more than 80 hours per

month for three months and then work at least 80 hours every other month to

maintain eligibility. About 19% of all non-profit home attendants, or 8,000

employees, fall short of the 80-hour threshold in any given month, including 3%

who are losing their existing health coverage.

6. For-profit agencies pay lower wages and benefits. The for-profit agencies

whose employees are not union-represented provide substantially lower wages

and benefits.

According to financial statements, for-profit agencies

paid a median hourly wage of $7.08 in 1998-99, while non-profit

agencies paid a median hourly wage of $7.74 – a difference of $1,373

for a full-time worker over the course of a year. Low wages are the rule

even for home attendants assigned the most difficult cases in the home

care system. These so-called “difficult-to-serve” clients may get

abusive, resist care or present a difficult challenge to the home attendant

for some other reason. Yet the two agencies specifically designated to

serve these clients pay home attendants wages much lower than the

average non-profit wage.

The median expenditure for health benefits by for-profit

agencies in 1998-99 was 52 cents per hour, less than half the $1.09 paid

by non-profit agencies. One agency achieved impressive savings by

paying only four cents per hour for health benefits. For-profit agencies

iv

reportedly achieve these savings by setting unusually stringent eligibility

standards.

For-profit agencies paid about one-third as much for

annual leave, sick leave and holiday pay as did non-profit agencies.

What’s more, some of these same agencies provide superior leave

benefits to their administrative staff.

For-profit agencies paid 51% more in administrative

salaries than non-profit agencies and 20% less in wages and benefits to

home attendants.

Recommendations

1. Provide home attendants and housekeepers with a living wage and reliable

benefits. The City employs thousands of home care workers to provide life-enriching

services to the elderly and disabled. The fact that we have chosen to provide these

services through a system of independent contractors does not relieve the City of its

responsibility. The City and State should take action to raise home attendant and

housekeeper wages sufficiently to lift them out of poverty. The City and State should

also fund health benefits adequately to provide home care workers access to

comprehensive health benefits that are reliable from one month to the next.

2. Shift toward full-time salaried employment. The hand-to-mouth existence of home

care workers results not only from meager wages, but also from meager and irregular

hours. While some home attendants work more than 80 hours a week, far more work

30 hours or less. Even those hours are threatened when a client passes away or goes

into the hospital. The City should restructure home attendant agencies to create a

core workforce of full-time salaried positions which could be supplemented, when

necessary, by part-time workers.

v

3. Allow home attendants to earn overtime pay. Federal law allows the State to

exclude home care agencies from paying overtime – an exploitative gimmick for

cutting corners on wages. The State should require home care agencies to pay time-

and-a-half overtime and fully fund the additional expense through Medicaid.

4. Abolish sleep-in shifts. It is not fair or appropriate for the City to require home

attendants to work twelve hours and then remain available for the other twelve hours

without pay. These “sleep-in shifts” should be abolished except in limited cases, and

those should pay full hourly wages.

5. Lift wages and benefits at for-profit agencies. For-profit home attendant agencies

have been allowed to provide low wages and limited benefits. All home attendant

agencies should meet a fair minimum standard for both wages and benefits. The

Human Resources Agency (HRA), which oversees the home attendant program,

claims that new contracts scheduled to take effect July 1, 2001 will establish such a

minimum standard. Yet the terms for these contracts allow HRA significant latitude

in defining ambiguous phrases like “comparable wages and benefits.” All agencies

should be held to a wage and benefit structure at least as good as the average non-

profit agency.

6. Level the playing field between non-profit and for-profit agencies. For-profit

agencies have been allowed more operating discretion with less oversight than their

non-profit counterparts. Not surprisingly, their administrative costs are substantially

higher than most non-profit agencies. While HRA should not single out for-profit

agencies for scrutiny, it should conduct program and field audits of all agencies with

high administrative expenses. In addition, HRA makes distinctions between for-

profit and non-profit agencies for purposes of fiscal oversight. HRA officials cannot

account for these apparently arbitrary distinctions, and other government agencies –

such as the City Department For the Aging – successfully manage home care

programs without such distinctions. They should be abolished.

7. Transform the crazy-quilt of long-term care programs into a seamless system.

Today, no fewer than five separate government-funded home care programs operate

vi

in New York City, not to mention institutional care provided in nursing homes and

adult care facilities. Such a fragmented system is wastefully expensive,

incomprehensible to senior citizens and their families, and potentially dangerous to

seniors in fragile medical conditions who need to make the right choice rapidly. The

City and State should work together to harmonize these programs – and ensure that

all of them meet minimum standards for wages, benefits and working conditions.

vii

INVISIBLE SWEATSHOP:

THE PLIGHT OF HOME CARE WORKERS

IN NEW YORK CITY

I. INTRODUCTION

Consider the plight of two women. One is elderly, frail, mentally or

physically impaired, impoverished – and desperate to stay out of a nursing home.

She doesn’t really need institutional care, either, just assistance in cooking meals,

shopping or other personal chores that she can no longer perform. For this

woman and more than 54,000 other home attendant clients, the City operates an

extensive and sophisticated system to provide the care needed to stay in a familiar

place.

The other woman is in her thirties or forties, impoverished and raising two

or more children on her own. She emigrated to the United States ten years ago or

so, and took a home care job to escape welfare dependency. For this woman and

approximately 48,000 other home care workers, the City operates a sweatshop.

Home care workers cope with low pay, unpaid overtime work and unreliable

hours. They work alone with clients who, due to depression, dementia or

frustration at their lost privacy and independence, may lash out in irrational and

unpleasant ways.1

Unlike conventional sweatshops, home care does not fit our image of an

exploitative workplace. There is no assembly line of oppressed-looking workers,

no pile of discarded fabric scraps, nowhere to picket. Unlike conventional

1 The pronouns “she” and “her” are used throughout this report when referring to the home care worker because the vast majority of home care workers are women. However, it is understood that there are also male home care workers.

1

sweatshops, the home care sweatshop is invisible to the naked eye, hidden behind

the closed doors of thousands of households scattered throughout New York City.

These two women, similar in many ways, have a single story to tell – a

tale of caring and neglect.

II. HISTORY OF THE HOME ATTENDANT

SYSTEM: CYCLES OF REFORM AND

NEGLECT

In 1973, the City of New York established one of the nation’s first

Medicaid-funded home care programs. It was a small (about 12,000 clients) and

informal program. Clients hired their own home attendants, supervised them and

billed the City for payment. As independent contractors, home attendants did not

qualify for unemployment insurance, received no training and no oversight, and

often found themselves at the mercy of mentally-impaired clients or abusive

families.

By 1980, after several waves of ugly nursing home scandals, City officials

began to see home care as the keystone of a non-institutional strategy for long-

term care. They reformed the home attendant program, contracting with nonprofit

agencies to administer and supervise it. The agencies could now hire, pay, train

and provide fringe benefits to their workers.2

The home attendant care program exploded in size and popularity. “We

don’t try to sell it as something that will save the city money,” said Robert Trobe,

then-head of the home attendant program. “We think it’s a wonderful program, a

very decent program. It makes us feel good to provide this kind of care.”3

2 Michael Sparer, Medicaid and the Limits of State Health Reform, Temple University Press, 1996, p. 110.3 Robin Herman, “Demand for Home-Care Workers is Rising in City,” The New York Times, October 2, 1981.

2

But home care did save money. The City and State avoided having to

build expensive new nursing homes, and saved additional money by keeping

family members (when available) involved in the care of their loved one. By

earning minimum wage with only a limited health benefit, home attendants also

subsidized home care’s massive cost advantage over nursing homes.

“We must recognize that home care will always be less costly than

institutional care because it does not have tremendous physical plant and

equipment costs,” said Rick Surpin, President of the Community Service Society

and founder of an innovative home care agency. “However, it is far less costly

today because the paraprofessional jobs are devalued and have below poverty-

level wages, with few benefits and no opportunities for advancement.”4

In 1987, pressure for new reforms began to mount. Dennis Rivera, then-

Vice-President of 1199 National Health & Human Service Union (“1199”), had

begun to organize the home attendants but found the public funding constraints a

major obstacle to improving their conditions.5 Together with Manhattan Borough

President David Dinkins, Rivera launched a campaign to persuade the City and

State to boost home care funding. Rivera organized a press conference that

attracted Cardinal John O’Connor and then-Presidential candidate Jesse Jackson.

Dinkins sponsored a hearing on the plight of home attendants, focusing

concentrated public attention for the first time on the terrible exploitation of the

City’s home attendants.

The report from that hearing provides chilling reading today. One home

attendant recounted having to give quarters to drug addicts to keep them from

harassing her, another of being physically attacked by one of her clients. Workers

spoke out about their working conditions: “if you don’t work the weekend, you

are suspended or you are fired,” noted Gladys Ford. “We do not make enough to

4 Office of the Manhattan Borough President, Plight of the Home Care Worker: Report of the Manhattan Borough President’s Hearing on April 29, 1987, January 1988, hereafter cited as “Dinkins Hearing.” Testimony of Rick Surpin, President, Community Service Society and President, Cooperative Home Care Associates, Inc., p. 83. Emphasis in original. 5 1199, New York City’s largest health care union, is now affiliated with the Service Employees International Union. Rivera became President of 1199 in 1989.

3

maintain a family, adequate housing, food, etc.,” declared Vivian Jones. “…Also

we need [a pension plan] to help us look forward to having something else besides

social security.”6

The following year, Mayor Ed Koch and Governor Mario Cuomo agreed

to a historic deal for home attendants: wages jumped from $4.15 to $5.90 over

three years, and agencies received additional funding to establish comprehensive

health coverage. In 1992, Mayor Dinkins pushed through additional pay raises

and a modest pension.

Public concern then drifted away to new crises. But while the public and

most elected officials may believe that the plight of the home care worker was

solved in 1988 and succeeding years, that view is not shared by home care

workers themselves, or by their unions, their employers and independent experts

on home care.

In fact, the perception that home attendant wage and benefit issues had

been resolved cleared the way for both Governor Cuomo and his successor,

Governor George Pataki, to attack what they viewed as excessive growth in the

home attendant budget. In the process, they undermined the gains of past years.

In particular, Governor Pataki’s focus on cutting home care costs blocked any

home attendant pay increase for four of the past seven years – despite strenuous

efforts by 1199 and other supporters of the home attendant program.

This study investigates the conditions of home attendants and documents

that the malign neglect of the 1980s continues today.

6 Dinkins Hearing, pp. 31-35.

4

III. OVERVIEW OF THE HOME ATTENDANT

PROGRAM

A. Home care and institutional care

A half-century ago, New York State’s network of nursing homes and

home care agencies did not exist. The elderly and disabled received care from

family members. But as the economy and society changed, the need for

structured settings for long-term care became widespread.

Another demographic change is on the way. As the baby boomer

generation ages, the number of senior citizens needing assistance with their daily

activities will grow dramatically. In 2000, there were 35 million seniors above

the age of 65. By 2020, the senior population will swell by more than 50% to 53

million.7 The choices we make today will have dramatic consequences for the

next generation of seniors.

In most states, a frail elderly person would have two long-term care

choices: to pay for a home-care aide out of his or her own pocket, or to enter an

institutional facility. Experts have long praised home and community-based care

as a more humane and less costly alternative, and the Federal government allows

states to receive Medicaid matching funds for home care programs, thereby

cutting the cost in half. Nonetheless, few states have taken advantage of their

opportunities.

New York State has gone further than any other state in shifting care away

from nursing homes and toward the home, aggressively leveraging Federal funds

wherever possible – notably Medicaid, Medicare and the Older Americans Act.

Medicaid is unquestionably the major funding source for home care. Out of a $27

billion Medicaid budget, the State spends about $12 billion annually on long-term

care. A third of that budget, $4 billion, goes toward home and community-based

7 A Profile of Older Americans: 1999, American Association of Retired Persons and U.S. Administration on Aging, 2000.

5

care – a far larger proportion than any other state.8 The Federal government pays

50% of Medicaid costs, the State pays 40% and the City covers the remaining

10%.

The unfortunate byproduct of New York City’s years of innovation is a

confusing jumble of programs – fractured, complex, impossible for non-

professionals to keep straight. The programs include:

Home Attendant program: Also known as personal care. A City-

administered program serving elderly and disabled people who need

non-skilled assistance in performing ordinary activities of daily living.

Caseload of about 46,000.

Long-term home health care: Also known as the “Nursing Home

Without Walls” or the Lombardi Program.9 A City-administered and

Medicaid-funded program serving elderly and disabled people who are

ill enough to qualify for nursing home care. Applicants must show that

the cost of care will not exceed 75% of nursing home care.

Managed long-term care: Pilot program that assigns a caseworker to

highly impaired elderly and disabled clients. Agency is assigned a

lump sum for each case, thereby creating incentive for caseworkers to

find most cost-effective care setting for client.

Homemaker program: Administered by the New York City

Department For The Aging, this program provides assistance to senior

citizens with activities of daily living. Also known as “EISEP”. The

homemaker program, funded by the Federal Older Americans Act,

provides up to 20 hours per week for about 3,000 seniors.

8 Susan Raetzman and Susan Joseph, Long-Term Care in New York: Innovation in Care for Elderly and Disabled People, The Commonwealth Fund, September 1999. The average state spends less than 20% of long-term care funds on home and community-based care. 9 Cite to Lombardi program.

6

Home Health Care: This Medicare-financed program provides home-

based medical services for elderly and disabled people after leaving

the hospital. Home health care covers physical and occupational

therapy, visits by Registered Nurses and use of medical technologies

such as infusion and ventilation. However, coverage is limited to 60

days.

The home attendant program serves approximately 54,000 seniors and

disabled people. The Home Care Services Program of the New York City Human

Resources Administration (HRA), which administers the program, oversees a

network of 86 home care agencies, each of which has won a contract to manage a

share of the overall caseload.

A senior or disabled person enters the Home Attendant program through

the recommendation of a physician. The physician fills out a form recommending

home attendant care, which is then forwarded to one of HRA’s CASAs.10 The

CASA sends a nurse and a social worker to the home of the prospective client for

a full evaluation. They determine what tasks the home attendant will have to

carry out for the client and how much time will be needed for each one, and

assign a certain number of hours per week. The CASA then assigns the client to

an agency – generally an agency that serves that community.

B. The Provider Agencies and the

Government

The City contracts with 86 home attendant and housekeeping agencies

throughout the five boroughs. These agencies employ approximately 48,000

home attendants and housekeepers to serve a caseload of 54,000 elderly and

disabled people.11

10 “CASA” is an acronym for Community Alternative Systems Agency.11 Sandata, Home Care Council.

7

The agency hires and trains the home attendant, dispatches her (or, very

rarely, him) to assignments for the designated number of hours per day and per

week, and oversees job performance. Beginning in the mid-1980s, the City began

contracting with for-profit agencies despite the narrow margins available for

profit. No for-profit agency has yet signed a union contract, although one is

reportedly in contract negotiations now. For-profit providers (which serve about

15% of the caseload) provide their own health benefits. Most non-profit agencies,

as unionized organizations, participate in the 1199 Home Care Fund or the

AFSCME Discrict Council 1707 Home Care Fund.

Provider agencies might seem to rank among the City’s largest low-

income employers. But financially, vendor agencies – at least non-profit agencies

– serve as little more than field offices of HRA, which regulates virtually every

agency expenditure. HRA officials monitor each line item on an agency budget,

disallowing any administrative expense they believe to be unjustified. Should an

agency retain any of the past year’s revenues, whether approved or not, HRA

takes the surplus back. Agencies that wish to purchase new computer systems or

award merit pay to managers must request funding from HRA, which has broad

discretion to grant or refuse the request.12

HRA maintains tight control of caseloads through its role in client

assessment, but little control over other aspects of agency behavior. HRA does

not monitor the quality of care provided to clients. Nor does HRA monitor

agency treatment of home attendants. HRA staff we interviewed could not say,

for example, what health benefits proprietary agencies offer their employees. The

City’s attorneys have warned HRA not to police agency treatment of workers or

even to collect the most basic information, arguing that HRA could expose itself

to legal liability.13

12 Personal Interview, Charles Healey, Director of Home Care Contract Services, New York City Human Resources Administration, April 23, 2001.13 HRA does maintain a Hotline for complaints from clients or workers, but they are few in number. A complaint hotline receives roughly 750 calls annually, and an unknown number of clients and workers send complaint letters.

8

The State controls the City’s overall home care budget, exercising fiscal

authority through two key mechanisms. First, the State sets the hourly fee paid to

each vendor agency for its services.14 Each year, New York State sets a “Vendor

Rate” for each county. In 2000, the vendor rate for New York City was $12.42

per hour. 15 That means the City can pay each home attendant agency $12.42 per

hour of home care provided to its clients. The State raises the vendor rate each

year by the rate of inflation as expressed in the Consumer Price Index – except for

years in which the State chooses not to. In several years, the State provided no

increase whatsoever.

Second, since 1996 the State has set an annual cap on the State

reimbursement for home care. If the City home care budget rises above that

target (which might happen if demand for home care rises in a given year), the

locality must pay the difference. In practice it is the home care clients and

workers who “pay” – through reduced and inadequate hours of care for the clients

and stagnant wages and part-time work for their caregivers.

Non-profit agencies are generally unionized and more likely to provide

home attendant services as their primary social service. Financial statements from

1998 and 1999 reveal substantial similarities in financial performance of non-

profit agencies. HRA tightly controls the budgets of non-profit agencies, to the

extent of capping executive salaries and taking back money that has not been

spent by year-end. In addition, wages and benefits are generally set through

union contract negotiations. See Chart 1 for revenue breakdown.

In 1988, Governor Mario Cuomo and Mayor Ed Koch agreed to

substantially raise the vendor rate for home attendant agencies. Non-profit

agencies then passed along the entire increase to their employees in the form of

higher salaries and comprehensive health coverage. The Koch/Cuomo reform

established an unusual collective-bargaining dynamic. The unions (primarily

14 In most counties, the State sets the rate for each vendor agency. In New York City, HRA assumes that role. 15 While some vendors may receive a little more and some a little less, the overall fee must not rise above $12.42 if the City is to remain compliant.

9

1199 and AFSCME DC 1707) sit down at negotiating tables with their ostensible

employers, the home care agencies, and each agency agrees to similar terms. But

the real negotiations take place in Albany and Gracie Mansion, where the unions

bargain for higher vendor rates which the agencies then pass along.

For-profit home attendant agencies operate very differently. Since none

are unionized (as of this date), they are under no obligation to pass along vendor

rate increases in the form of higher wages or better benefits. Thus for-profit

agencies pay substantially lower wages and provide weaker benefits than their

non-profit counterparts.

C. Profile of Clients in Home Attendant

program

The average home attendant client is frail, elderly and poor. A large

proportion would have to enter a nursing home if not for their home attendant.

According to a United Hospital Fund study, most clients are 60 years or older.

About half live with cognitive impairments such as Alzheimer’s syndrome, more

than two-thirds suffer from three or more chronic physical conditions, such as

diabetes, arthritis or hypertension. Almost three-quarters need help in at least

three basic functions, such as bathing, toileting, mobility, and eating.16

Home attendant care clients are poor and often lonely. Four out of five

live in low-income neighborhoods. Two out of five live alone, and three out of

five receive no help from family members with personal care.17

16 Alene Hokenstad et al., Medicaid Home Care Services in New York City: Demographics, Health Conditions and Impairment Levels of New York City’s Medicaid Home Care Population, United Hospital Fund, March 1997. 17 Alene Hokenstad et al., Medicaid Home Care Services in New York City: Service Utilization and Family Involvement, United Hospital Fund, May 1998.

10

Home attendants help these clients with the “activities of daily living” that

they can no longer perform: bathing and toileting, cooking, going to doctors’

appointments, and so forth.18

D. Profile of The Home Attendants

Social scientists and family members have long understood the difficulty

of providing home care. Two professionals in the field who employed a home

care aide for several years later wrote poignantly of their own experience:

“By relying on Jasmine, we avoided the most intimate forms of personal care such as bathing and dressing our father, which as his daughters we considered taboo. We also were insulated from witnessing the deterioration that might have disrupted both our image of him and his sense of himself as our father. What we tended to ignore was how difficult it was for Jasmine to provide the types of care we shunned…. [T]he job had several undesirable features, such as monotony, isolation and the constant need to confront aging and deterioration.”19

There is no “average” home attendant. But studies by the Hunter School

of Social Work and Brooklyn College, conducted a decade apart, have identified

very common traits among the home attendant workforce.20 Studied together,

they also demonstrate important areas of demographic change.

The majority of home care workers are older women. Almost all

home care workers (94%) are women, and their median age is 49. One

in four is younger than 30, and one is six is older than 60.

18 The term “home attendant” should be understood to include housekeepers as well, a separate job classification for workers who perform a similar although slightly narrower range of tasks.19 Emily Abel and Margaret Nelson, “Intimate Care for Hire,” The American Prospect, May 21, 2001.20 Dinkins Hearing, pp. 97-118, Appendix authored by Rebecca Donovan, Hunter School of Social Work, January 1988,. Data was collected from August to October, 1985. Immanuel Ness, “Organizing Home Health-Care Workers: A New York City Case Study,” WorkingUSA, November-December 1999, pp. 85-88.

11

The home care workforce is largely – and increasingly –

immigrant. In 1986, 55% of home care workers were native-born

Americans; in 1996, only 27% were. According to the 1996 Brooklyn

College analysis, 46% of home care workers are black, 42% Latino

and 8% Asian.

Most home care workers have children, for whom they are often

the primary provider. While 85% of home care workers surveyed in

the Hunter College study had children – between three and four

children, on average – only 36% were married. This corresponded to

testimony from our own interview subjects, several of whom were

single mothers raising several children.

Home care is a long-term career for many workers. Turnover is

low in the home attendant field, reportedly as low as 10 percent

annually. About half of all non-profit home attendants have been

working for five years or more, and 15% have worked as home

attendants for 13 years or more.21

21 Sandata, April 20, 2001. Sample of non-profit home care agencies representing approximately 85% of total caseload.

12

IV. Findings on Wages and Benefits

This section assesses wages and benefits in the home attendant workforce,

also known as the personal care sector. We reviewed financial statements for all

available vendor agencies, examined data on salary, hours and other aspects of

employee work life, interviewed agency directors, present and former government

officials, and outside experts on home care. We also interviewed many home

attendants about their working lives.

Home care unions have unquestionably improved home attendants’ wages

and benefits through organizing and political pressure. Generally speaking, home

attendants in non-profit agencies (virtually of which are unionized) earn the

highest wages and the broadest benefits of any home care workers anywhere in

the United States. It is therefore all the more alarming to discover how low the

“gold standard” has been set. Home attendants, even at the most generous non-

profit agencies, continue to live in poverty, vulnerable to sudden shifts that could

cost them health insurance coverage when they need it most.

For-profit agencies have wage-and-benefit systems that differ dramatically

from those of not-for-profit agencies. Whereas non-profit agencies spend similar

amounts on wages and benefits, each for-profit agency is a world unto itself.

HRA first allowed for-profit or “proprietary” companies to enter the system in the

mid-1980s, and they have greatly expanded their market share since then. Today,

HRA contracts with seven for-profit agencies, two of which operate multiple

divisions.

Unlike non-profit vendor agencies, for-profit agencies are supposed to be

“at risk”. HRA – at least in theory – does not cover the costs of for-profit

agencies that lose money, while profitable agencies earn up to a 3% profit margin.

But there is less “risk” than meets the eye. HRA reimburses the “direct” expenses

of home attendant wage and benefits (about 75% of a for-profit agency’s costs),

just as it would for a non-profit agency. As a result, a for-profit agency’s

financial exposure is limited to administrative expenses (about 25% of all

13

expenses), while its profit margin is based on total costs.22 If for-profit agencies

were evaluated on an even footing with non-profit agencies, they might not be

cost-competitive, given their substantially higher administrative costs.

For-profit agencies provide an interesting opportunity to revisit the legacy

of the Koch/Cuomo reforms. Those reforms reshaped the funding and structure

of the home attendant system – but only for non-profit agencies. We found that

for-profit agencies operate much as they would have if no such reforms had ever

taken place. While for-profit agencies have benefited from the increases in hourly

vendor rates achieved by union lobbying and organizing, they have opted not to

pass along these increases to employees.

For-profit agencies’ wage-and-benefit structure may change dramatically

on July 1, 2001. On that date, the City will institute new contracts for all home

care agencies.23 The new contracts call for “comparable wages and benefits” to

be provided to all home attendants. In theory, for-profit wages and benefits will

then be expected to rise to the level of their non-profit siblings. However, HRA

can interpret the word “comparable” either in a strict or loose fashion. If HRA

chooses the latter course, for-profit agencies will continue to differ greatly from

non-profit agencies.

A. Wages and Benefits in the Non-profit

Sector

1. Low Hourly Wage: Full-time home attendants

remain in poverty.

A full-time home attendant at the starting rate of $7.14/hr. earns an annual

salary of $14,851 – almost three thousand dollars below the poverty line for a

22 Charles Healey, Director of Home Care Contract Services, New York City Human Resources Administration, personal interview, April 23, 2001.23 Except in the Bronx, where contracts have already been renewed.

14

family of four.24 Counting supplements to the hourly wage available after

working 2100 hours or working hard-to-fill time slots, home attendants’ typical

hourly wage goes up to $7.75 per hour – still more than a thousand dollars below

the poverty line for a family of four.25

Yet the condition of home attendants was not always so bad. From 1987

to 1991, the starting home attendant wage rose 49%, from $4.15/hr to $6.10/hr.,

less than $1,000 short of the poverty line for a family of four. Over the next ten

years, however, the starting wage rose only 15% to its present level. These

stagnant wage trends primarily reflect

the Pataki Administration’s relentless

pressure to cut costs in the home

attendant program.

2. Not Enough Hours Of Work: Many home

attendants cannot obtain stable, full-time

work.

As hourly employees, paid only when working, home care workers depend

on the structure and stability of their work. But home care assignments are often

parceled out in blocks of two, three or four hours per day – thus making it

impossible for a home attendant to work a full-time shift.26 To earn anywhere

near an above-poverty wage of $31,000 per year, an attendant must work 70-84

hours each week. In addition, home attendants find themselves stranded without

work if their client passes away, enters a hospital or nursing home or asks for

another worker.

24 The Federal Poverty Level for a family of four in 2001 is $17,604. 25 These supplemental wage increases, referred to as “differentials,” include the following: $0.30 per hour for completing the first 2100 hours – the equivalent of a year of full-time work; $1.10 per hour for working a weekend shift; and $0.50 per hour for providing care to an eligible couple. 26 The lack of full-time employment is a long-term failure of the home attendant system. See Dinkins Hearing, Testimony of Rick Surpin, President, Cooperative Home Care Associates, Inc., p. 82.

15

“I just eat what I have to eat. Lucky I’m diabetic, so I just eat vegetables.”

About one-quarter of non-profit home attendants (26%) work 30 hours or

less each week.27

Table OneWeekly Hours Worked by Non-profit Home Attendants, April 2001Hours Employe

esShare Annual

Salary*Up to 20 4,748 11% $ 7,426 21 to 30 7,442 17% $ 11,138 31 to 40 8,221 19% $ 14,851 41 to 50 8,713 20% $ 18,564 51 to 60 7,884 18% $ 22,277 61 to 70 2,289 5% $ 25,990 71 to 84 3,855 9% $ 31,188 Total 43,152 100%Source: Sandata* At highest end of bracket, given starting salary of $7.14/hr.

3. No overtime pay: Home attendants work long

hours while excluded from earning overtime

pay.

The Fair Labor Standards Act of 1938 established the concept of overtime

pay in Federal Law – a historic breakthrough in worker rights. However, FLSA

exempts several occupations from its scope of coverage, including “any

employees employed in domestic service employment to provide companionship

services for individuals who (because of age or infirmity) are unable to care for

themselves….”28 The Department of Labor allows states to designate home care

workers as companions, thereby arbitrarily denying them the benefits of overtime

pay. 29

27 Sandata, April 20, 2001. Sample of non-profit home care agencies representing approximately 85% of total caseload. 28 29 U.S.C. 201 §13(a)(15). 29 CFR Title 29, § 552.6. The Federal Medicaid program, which defines “companionship” narrowly, prohibits Federal reimbursement for companionship services. Thus home attendants are denied overtime pay because they perform a service – “companionship” – which they are prohibited from performing.

16

Exclusion from overtime pay costs home attendants dearly.

Approximately one-third (32%) of home attendants work between 51 and 84

hours each week, putting in between 11 to 34 hours of overtime work.30 A home

attendant who works 60 hours a week at a wage of $7.74 per hour loses $4,025 in

overtime pay over the course of a year.

HRA staff who oversee home attendants earn overtime, as do clerical and

nursing staff at home care agencies.

4. Unpaid labor: “Sleep-in shifts” force home

attendants to work up to ten hours without

compensation.

One of the most notorious HRA practices is the “sleep-in” shift, in which

the worker works for 12 hours and then remains available on the premises for

another 12 hours. The worker receives a daily payment of $102.63, equivalent to

twelve hours of pay plus a small

lump-sum payment of $16.95.

But home care clients – especially

clients who are ill or mentally

impaired – frequently awaken

during the night and ask for

assistance eating or toileting. As

a result, the home attendant may

work most of the night without

pay and then, exhausted from lack

of sleep, begin a new work shift.

The City is now phasing out the more humane “split shift,” in which two

home care workers share a 24-hour case, with each home attendant working 12-

30 Sandata, April 20, 2001. Sample of unionized home care agencies representing approximately 85% of total caseload.

17

“I did a sleep-in once for this lady in a one-bedroom apartment. I was supposed to sleep in a sofabed, but it was really a chair. But it didn’t matter. She had Alzheimers, so I couldn’t leave her for a minute. I had to put the chair against the door to keep her from walking out. I was drained after a day or two because I had no time to sleep. I stayed on that case for about two months and then asked to be transferred.”

hour shifts. The City maintains a steady caseload for the sleep-in shifts, which are

far less expensive. Since 1994, the number of split shifts has dropped by 50%

while the number of sleep-in shifts has risen by 2%.31

5. Health Benefit Package: Non-profit home

attendants have achieved comprehensive

health insurance coverage.

In 1980, the City established one of the first health insurance plans for

home care workers anywhere in the country. But the plan left much to be desired.

It provided only 21 days of hospitalization coverage, no prescription drug

coverage, dental care or vision care. Said one home attendant about their health

plan: “the only time you can use it

is if you drop down outside and the

ambulance takes you to the

Emergency Room.”

Today, home attendants at

non-profit agencies have access to

comprehensive health benefits – the most important and life-changing legacy of

the 1988 reforms sparked by union activism. Home attendants receive

comprehensive benefits, including prescription drug, vision, dental and full

hospitalization coverage.

6. Health Benefit Eligibility: Many home

attendants lose health coverage when their

hours fall short.

To become eligible for health insurance, the home attendant must work

more than 80 hours per month for three months. To maintain eligibility, the home

31 Home Care Council.

18

“When I started working we didn’t have the benefits. Now we do. Health, pension, dental. It makes a lot of difference. There’s no money coming out of our pockets.”

attendant must 80 hours per month. A worker who falls short will drop out of the

system until she can bring her hours up again enough to requalify.

Unfortunately, many home attendants have trouble getting enough hours

to obtain or maintain their eligibility. About 19% of non-profit home attendants

fall short of the 80 hour threshold in an given month, including 3% who are losing

their existing health coverage.32

Any unforeseen event affecting either client or worker could suddenly

strip a home attendant and her family of health coverage. Such interruptions are

not uncommon in a profession based on care for fragile people. A client might

pass away, enter the hospital or move to another state. The home attendant might

need to cover for an unreliable day care provider or take care of a sick relative.

The home attendant could also lose coverage by falling sick, ironically losing

health coverage by using it.

Home care fund administrators report that their funds are severely

underfunded. The City budgets only $1.12. per hour of work to the 1199 Home

Care Fund, far less than would be

needed to cover all employees.33 Even

though part-time employees subsidize

union home care plans (since they pay

into the plans but do not work enough

hours to qualify for eligibility), the

plans have difficulty maintaining

solvency. But fully financing the

fund would require substantially more money, which would have to come out of

already-low wages, or by canceling a smaller fringe benefit, such as the pension

fund or some other small fringe benefit.

32 Sandata and 1199 Home Care Fund.33 One estimate is that full financing would require $1.57/hr. Ninfa Vassallo, Director, AFSCME DC 1707 Home Care Division, personal interview, May 13, 2001.

19

“I work four hours a day, five days a week. I would like to work more hours, but they don’t have any more. If I take a sick day, I’ll have to make it up to keep my health insurance.”

The State has financed a three-year demonstration program that bolsters

coverage, but that program lapses in 2002 and will require either reauthorization

or a more permanent source of funding.

7. Fringe Benefits: Home attendants have access

to pension benefit, education and training, and

compensation for annual, holiday and sick

leave.

Non-profit home attendant agencies provide seven paid holidays, two

weeks of vacation leave and two weeks of sick leave. They also provide modest

pensions which vest after ten years. The total cost of all these benefits is about 88

cents per hour of work.

8. Education and Training: Home attendants can

obtain education and training but lack career

opportunities afterward.

The 1199 contract calls for a small investment in an education fund, which

conducts English as a Second Language (ESL) and GED classes, along with

training for various health care certifications.34

Yet the difference between the 1199 Home Care Fund and training

programs operated by 1199 for nursing home and hospital employees is stark.

1199 and its nursing home and hospital employers have collaborated in building

“career ladders,” tiered job titles requiring additional training, education and

experience and providing additional compensation in return. Career ladders

motivate workers to improve their skills, provide greater job satisfaction, and give

managers a valuable tool for improving service to their client population.

34 DC 1707 sends its members to the Consortium for Worker Education for similar purposes.

20

There is no career ladder in home care, although there could be. A decade

ago, innovative HRA officials received grant funding for several demonstration

projects to test career ladders. “By linking additional training to more challenging

assignments,” said Deputy Commissioner Carol Raphael, “we may be able to

create the beginnings of a career ladder for home care workers.”35 HRA also

viewed the establishment of higher pay grades as a management tool to care for

clients suffering from multiple or severe impairments.

The promise to tie education and training to actual career opportunities

went unfulfilled. The responsible HRA officials moved on, the demonstration

programs lapsed, and no City official has stepped forward to take leadership.

Mutual finger-pointing is now the rule. Agency directors blame HRA for

cutting back on modest programs such as Field Support Liaison and “cluster

care.” HRA officials respond that their encouragement of additional training has

drawn little interest from the management of home care agencies. Union leaders

assert that they are forbidden even to speak with HRA managers, making

cooperative projects impossible. Finally, the City Corporation Counsel has

apparently warned HRA officials that assistance in worker training could expose

HRA to legal liability.

35 Dinkins Hearing, Testimony of Carol Raphael, Deputy Commissioner, New York City Human Resources Administration, p. 64.

21

B. Wages and Benefits in the For-Profit

Sector

1. For-profit agencies pay lower wages, even to

workers coping with the hardest cases in the

home care system.

According to agency financial statements, for-profit agencies paid a

median wage of $7.08 per hour in 1998-99. A full-time worker at a non-profit

agency in the same time period would make $7.74 per hour, a difference of

$1,373 for a full-time worker over the course of a year.

Surprisingly, the same wage gap applies to the two for-profit agencies that

serve “difficult-to-serve” clients who have been rejected by other home attendant

agencies. Most of these clients present behavioral problems, which often result

from mental illness, Alzheimer’s Syndrome or senile dementia. According to

professionals in the field, difficult-to-serve clients may be abusive, either verbally

or, in some cases, physically; resistant to dealing with the home attendant; or

unreasonably demanding of the home attendant. In addition, a client may be

considered difficult to serve because of family members who interfere with

service delivery or refuse to assist the client when the home attendant is away.36

Some agencies report that they also refuse clients with multiple impairments who

have been assigned too few hours by HRA to guarantee a safe level of care.

Not every home attendant can deal effectively with a difficult-to-serve

client. “Being responsible for the difficult-to-serve patient or family is an

emotionally demanding task,” notes leading homecare expert Margaret Walsh.

“The caregiver must understand and be able to deal not only with varied medical

problems, but also with increasingly complex psychosocial and environmental

problems.”37

36 Margaret Walsh, Resolving the Dilemmas of the Difficult-To-Serve, National Association for Home Care, 2nd Edition 1998.37 Ibid.

22

Clearly, home attendants at the two agencies assigned difficult-to-serve

clients face the toughest challenge of any home care workers in the City. Yet

these home attendants earned respectively $7.05 and $7.27 from their employers,

considerably less than home attendants with regular clients earn at non-profit

home attendant agencies. Employees of one large agency, Metrocare, complain

of not having received a wage increase in ten years – even though their employer

would be fully reimbursed by HRA for the cost of the wage increase.

Table TwoComparison of median hourly non-profit and for-profit wages and benefitsCategory Non-profit For-profit Difference Wages $7.74 $7.08 $0.66 Leave benefits 0.67 0.23 0.44 Medical benefits 1.09 0.52 0.57 Training 0.03 0 0.03 Pension fund 0.18 0.08 0.10 Other direct expenses 0.91 0.91 0.00Total direct expenses 10.62 8.82 1.80 Administrative salaries 0.59 0.89 -0.40 Other indirect expenses 0.49 0.71 -0.22Total indirect expenses 1.08 1.60 -0.52Total expenses 11.70 10.42 1.28Source: Home attendant agency financial statements, FY 1998 and FY 1999

2. For-profit agencies provide weaker health

benefits.

According to agency financial statements, for-profit agencies made a

median payment of 52 cents per hour for home attendants’ health benefits, less

than half the $1.09 paid by non-profit agencies. One agency achieved impressive

savings by paying only four cents per hour for health benefits.

In most cases, no information was available on the actual benefit package.

However, we obtained the employee handbook for one large agency, Metrocare,

which explains its health benefits policy: “An employee must work full-time (160

hours per month), continuously for six months, beginning at the date of hire, in

order to be eligible for health insurance coverage…An employee must work at

23

least 160 hours per month in order to maintain health insurance coverage

eligibility.”38

Metrocare’s standard is extremely stringent – as many as half of all home

attendants cannot obtain full-time work and would not qualify for Metrocare’s

health coverage.

3. For-profit agencies provide weak leave benefits

to home attendants – and superior benefits to

clerical staff.

Leave benefits include annual leave, sick leave and holiday leave.

Financial statements suggest that the for-profit agencies do not provide holiday

leave at all. Use of sick leave varies. Some agencies provide no sick leave, some

provide a token benefit, such as two days sick leave per year, while others have a

competitive sick leave policy, e.g., 10 days of paid sick leave per year. Yet only

two of the 11 agencies list any sick-leave expenses whatsoever.39

For-profit agencies do provide annual leave, although apparently less

generous than their non-profit counterparts. For-profit agencies paid 17 cents per

hour for annual leave benefits in 1998-99, while non-profit agencies paid 27 cents

per hour, or about one-third more. The median expense for all leave benefits,

including annual, sick and holiday leave, was 67 cents per hour for non-profit

agencies and 21 cents per hour for for-profit agencies.

Agency financial statements provide some information on for-profit

annual and sick leave policies. Not only do these policies appear to be less than

generous, some agencies clearly favor clerical and administrative staff over home

attendant staff:38 Home Health Aide/Personal Care Aide Manual: A Supplement to the Employee Manual, Metrocare Home Services, undated, p. 7. 39 Some for-profit agencies may be counting their sick leave expenses as wages rather than itemizing them separately. This practice would have the effect of understating sick leave expenses and overstating wages by as much as twenty to twenty-five cents per hour.

24

One agency provides no sick leave for home attendants, but 10 sick

days each year for administrative staff.

Another agency provides no annual leave for home attendants in the

first year and one week in the second year, but two weeks of annual

leave for administrative staff in the first year, followed by three weeks

in the second year. The same agency allows two sick days annually

for home attendants (after the first year), but six days for

administrative staff.

4. For-profit agencies spend less in wages and

benefits and more in administrative salaries.

Overall, we found that for-profit agencies paid $8.82 per hour in “direct”

expenses, primarily wages and benefits, while non-profit agencies paid $10.62 per

hour, or 20% more.

Administrative expenses are a very different story. For-profit agencies

paid $1.60 per hour in “indirect” administrative expenses, while non-profit

agencies paid $1.08 per hour, or 33% less. Most of the difference was in salaries:

for-profit agencies paid out 51% more in salaries to administrative staff. The high

expense resulted from large numbers of administrative staff, rather than high

salaries. One agency charged HRA for the time of more than 200 administrative

staff, more than double the number employed by the average non-profit agency.

These figures cast serious doubt on the competitive structure of for-profit

contracts, suggesting that a large proportion of the money saved from holding

down home attendant wage and benefit costs is being diverted to administrative

salaries.

25

We were disturbed to discover that the HRA Home Care Services Bureau

has no field audit unit.40 HRA staff review financial audits in great detail, but

they do not visit home attendant agencies to spot-check the veracity of

submissions by home attendant agencies. While all home care agencies must be

considered suspect, proprietary home attendant agencies are more likely to be

divisions of larger companies where expenses must be allocated across different

divisions and payers. False expense allocation is a key opportunity for fraud.41

40 Personal interviews, Bridget Simone and Charles Healy, New York City Human Resources Administration, Home Care Services Bureau, April 20, 2001. 41 For example, an agency that allocates 25% of its office rent to the home attendant program while only using 10% of its space for home attendant purposes has inappropriately shifted 15% of its rental costs to HRA.

26

Recommendations

1. Provide home attendants and housekeepers with a living wage and

reliable benefits. The City employs thousands of home care workers to

provide life-enriching services to the elderly and disabled. The fact that we

have chosen to provide these services through a system of independent

contractors does not relieve the City of its responsibility. The City and State

should take action to raise home attendant and housekeeper wages sufficiently

to lift them out of poverty. The City and State should also fund health

benefits adequately to provide home care workers access to comprehensive

health benefits that are reliable from one month to the next.

2. Shift toward full-time salaried employment. The hand-to-mouth existence

of home care workers results not only from meager wages, but also from

meager and irregular hours. While some home attendants work more than 80

hours a week, far more work 30 hours or less. Even those hours are threatened

when a client passes away or goes into the hospital. The City should

restructure home attendant agencies to create a core workforce of full-time

salaried positions which could be supplemented, when necessary, by part-time

workers.

3. Allow home attendants to earn overtime pay. Federal law allows the State

to exclude home care agencies from paying overtime – an exploitative

gimmick for cutting corners on wages. The State should require home care

agencies to pay time-and-a-half overtime and fully fund the additional

expense through Medicaid.

4. Abolish sleep-in shifts. It is not fair or appropriate for the City to require

home attendants to work twelve hours and then remain available for the other

twelve hours without pay. These “sleep-in shifts” should be abolished except

in limited cases, and those should pay full hourly wages.

27

5. Lift wages and benefits at for-profit agencies. For-profit home attendant

agencies have been allowed to provide low wages and limited benefits. All

home attendant agencies should meet a fair minimum standard for both wages

and benefits. The Human Resources Agency (HRA), which oversees the

home attendant program, claims that new contracts scheduled to take effect

July 1, 2001 will establish such a minimum standard. Yet the terms for these

contracts allow HRA significant latitude in defining ambiguous phrases like

“comparable wages and benefits.” All agencies should be held to a wage and

benefit structure at least as good as the average non-profit agency.

6. Level the playing field between non-profit and for-profit agencies. For-

profit agencies have been allowed more operating discretion with less

oversight than their non-profit counterparts. Not surprisingly, their

administrative costs are substantially higher than most non-profit agencies.

While HRA should not single out for-profit agencies for scrutiny, it should

conduct program and field audits of all agencies with high administrative

expenses. In addition, HRA makes distinctions between for-profit and non-

profit agencies for purposes of fiscal oversight. HRA officials cannot account

for these apparently arbitrary distinctions, and other government agencies –

such as the City Department For the Aging – successfully manage home care

programs without such distinctions. They should be abolished.

7. Transform the crazy-quilt of long-term care programs into a seamless

system. Today, no fewer than five separate government-funded home care

programs operate in New York City, not to mention institutional care provided

in nursing homes and adult care facilities. Such a fragmented system is

wastefully expensive, incomprehensible to senior citizens and their families,

and potentially dangerous to seniors in fragile medical conditions who need to

make the right choice rapidly. The City and State should work together to

harmonize these programs – and ensure that all of them meet minimum

standards for wages, benefits and working conditions.

28