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97 This chapter reports on the effects of living wages and employer-provided health insurance on job quality and workforce attachment among the home care workers in San Francisco who are employed through the Medicaid-funded In-Home Supportive Services (IHSS) program. When they work directly for consumers in their home, both publicly funded and privately paid consumer-directed home care workers are classified as independent providers or contractors. As independent providers , they are covered neither by the National Labor Relations Act nor by state public employment law. Accordingly, they do not have the right to form a union or engage in collective bargaining (Smith 2008). By 2015, home care workers will be covered under the federal Fair Labor Standards Act, which guarantees payment of a minimum wage and overtime pay, reversing the previous view that they were primarily F O U R Living Wages and Home Care Workers Candace Howes 98 t h e pay m a n d a t e s providing “companionship” rather than compensable services (Smith 2008; Forhan 2010; Gross 2013). In contrast, in the 1990s, California created quasi-governmental entities that could serve as the employer of record for IHSS workers, providing workers with the protection of employment and labor laws. The concomitant passage of the living wage mandate in San Francisco, combined with health care unions’ solid footholds in segments of California’s long-term care industry, provided a supportive environment for improving the quality of jobs in this sector and more generally in the low end of the wage distribution . The IHSS program in San Francisco had introduced an early model of an effective health insurance policy for low-wage workers in nontraditional work environments by 1999, which may well have served as a model for the Healthy San Francisco program that followed eight years later. I argue that San Francisco has set the national standard for job quality in consumer-directed home care services, a standard that has diffused throughout a number of California counties and to other states. At least for a time, San Francisco has provided a good case study of how higher wages originating in publicly funded jobs can raise the standard of living and quality of care and diffuse better practices even to the private forprofit and not-for-profit industry, and even in an industry in which workers do not have traditional labor protections. An important synergy developed between the wage and benefit trends in IHSS and the other labor mandates in San Francisco. Just as San Francisco offers important lessons about the role of mandates, the story of IHSS in San Francisco offers lessons about the significant role that large publicly funded programs employing unionized workers can play in both modeling the potential and reinforcing the effects of mandates. Moreover, the significance of the long-term care sector to the conditions of low-wage workers cannot be overemphasized. As a result of welldocumented trends in family formation and demographics, the long-term care industry is among the fastest growing industries in the country. The home health and home care industries are the fastest growing segments of this industry, and home care worker (personal care aide) is the fastest growing occupation in the country, followed immediately by home health aide (BLS 2012). In San Francisco, with a workforce of about 476,000 (CA l i v i n g wa g e s a n d h o m e c a r e w o r k e r s 99 EDD), the nearly 20,000 IHSS workers make up 4.2 percent of the entire workforce. They also make up 28 percent of low-wage workers, as measured by the bottom 15 percent of the wage distribution, and about half of the low-wage female workforce. When the private pay and largely unmeasured gray market segments of the industry are added, the significance of these jobs to the low-wage sector is even greater. Thus, the quality of jobs for low-wage workers with less than a college education is disproportionately affected by the quality of jobs in this sector. California has been at the forefront of most of the trends in the longterm care sector, including the shift from institutional to home- and community -based care and, within home care, to consumer-directed care. It is on the verge of taking the next step, integrating long-term care into the provision of health care services for low-income persons through a managed care...


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