- Caring for America: Home Health Workers in the Shadow of the Welfare State by Eileen Boris and Jennifer Klein
In Caring for America, Eileen Boris and Jennifer Klein go beyond an exploration of the history of a profession to offer perspective on the politics and values that defined health care in the twentieth-century United States. The authors illuminate how a publicly funded, locally and privately administered welfare state developed and operated; how race and gender shaped work, labor standards, and expectations of so-called service providers; and how social activism and unionization looked in a postindustrial society.
Boris and Klein locate the roots of home health care in the 1930s, when New Deal reformers faced the twin problems of pervasive poverty and comparatively high rates of chronic illness. Visiting housekeeping programs aimed not only to decrease institutionalization [End Page 588] among sick and impoverished people who required help with a variety of daily chores, ranging from child care to personal hygiene, but also to bolster a certain brand of domesticity and “service” among workers—predominantly poor, African American women. One of the most important legacies of the New Deal era, according to the authors, was that home aides were excluded from the wage and hour rules contained in the 1938 Fair Labor Standards Act (FLSA), largely because of the devaluation of female-dominated, care-related work.
In the 1940s, hospitals, doctors, and nurses argued that medical professionals, not welfare administrators and social workers, were best suited to oversee home-based services. Motivated by the goals of promoting “continuity of care” and maintaining institutional beds for patients who could be cured, rather than those who harbored longterm chronic illnesses, physicians created hospital-affiliated home health programs. Meanwhile, as part of their larger battle for professional authority, and in order to define their work as distinct from menial labor, nurses sought to ensure that home aides would perform no health-related caregiving, but only housework and the like. In the emerging medical model, the authors argue, home aides’ services were deemed “informal, voluntary, and open-ended.” (p. 62)
Boris and Klein analyze a variety of formative federal policies and, by marshaling a plethora of archival findings, trace their impact on the local level. The Hill-Burton Act of 1946, the Social Security Act amendments of 1950, and the Vocational Rehabilitation Act of 1954, the authors argue, each increased government funding for healthrelated initiatives. In so doing, the authors note, they helped foster the growth of a “medical-institutional complex,” and accelerate the medicalization and privatization of home care. (p. 41)
In the 1960s, the War on Poverty and a variety of laws—the Kerr- Mills Act, the Manpower Development Training Act, Medicare, and Medicaid—built upon already established patterns. Federally funded home care initiatives relied on a catacomb of state and private agencies. Like New Deal reformers of old, Great Society liberals looked to the home health profession as a means of ending dependency on the state; they hoped it would encourage poor women to maintain gainful employment and give up welfare payments. But, Boris and Klein demonstrate, they faced a newly militant welfare rights movement that emphasized that poor people deserved dignity along with a living wage.
As activists focused on workers’ rights and professional stability and growth in the 1960s and 1970s, they faced formidable barriers. The authors provide an interesting case study of the efforts of the “Rolling Quads,” a University of California Berkeley student group, to show how the interests of increasingly vocal disability rights advocates could be at odds with those of home health workers. The Rolling Quads argued [End Page 589] that consumers should be able to choose their home care providers and be free to employ friends to do the work. In so doing, they bolstered an image of home care as unskilled labor and helped lay the groundwork for an independent contractor model that made it more difficult for home aides to secure...