Struggling to Provide: A Portrait of Alameda County Homecare Workers
Alameda County employs nearly 8,000 homecare workers to help disabled and elderly persons live independently. Over one-third of these workers and their families—about 2,800—earn incomes that are below the official Federal poverty threshold. Many more struggle to meet basic daily needs and have to make difficult choices between caring for themselves and caring for others.
Through California’s In-Home Supportive Services (IHSS) program, homecare workers provide assistance to a vulnerable population of 250,000 elderly and disabled clients statewide. IHSS services make it possible for clients to remain independent and to live safely in their own homes and communities. Without this service, many consumers of homecare would have to go to costly institutions such as nursing homes.
Despite their important role, homecare workers receive such low wages and poor benefits that it is difficult for them to stay in this job. The current wage, $9 an hour, is well below what a worker needs to support a family in the nation’s fifth most expensive housing market. While basic health insurance is available for the homecare worker, there are no vision or dental care benefits, no benefits of any kind for family members, no paid time off and no retirement benefits.
Because IHSS jobs offer such low wages and benefits, many workers have to work more than full-time and take multiple jobs. Any unexpected expense, temporary loss of a client or reduction in hours can be a financial calamity for the homecare worker and his or her family.
Furthermore, the precarious financial status of homecare workers makes it more difficult to quickly resolve the problems that may keep them out of work. Every crisis for the homecare worker is a potential crisis for the IHSS consumer, especially when, as in Alameda County, there is a shortage of workers and substitutes are difficult to find.
Recent evidence from San Francisco County shows that providers and clients alike gain from higher wages and better benefits. After substantial wage and benefit improvement s over a three year period, the San Francisco IHSS workforce grew nearly 40 percent. Many of the new providers have come from neighboring counties like Alameda, where the wages and benefits are lower.
Struggling to Provide is based on a recent survey of homecare workers in Alameda County that illustrates the insecure conditions in which many homecare workers live. Key findings from the survey include:
Homecare workers and their families struggle to make ends meet.
- Over one-third, nearly 2,800 workers and their families, live in poverty. Their average family income is only $22,270.
- Seventy-one percent of homecare workers say they barely had or did not have enough money to meet their basic needs at the end of the month.
- Any sudden loss of work or hours can tip a homecare worker’s family into financial crisis. Many homecare workers work full-time hours or more.
- Two in five (41%) work more than one job.
Many homecare workers work full time hours or more
- Two in five (41%) work more than one job.
- Forty-five percent work more than 35 hours and 23% work more than 50 hours a week.
- Homecare workers work, on average, 36 hours a week between all of their jobs.
Homecare workers are primary breadwinners for their families.
- More than two-thirds of homecare workers contribute the majority of their families’ total income.
- On average, their earnings make up 60% of the total family income. Homecare workers lack essential job benefits.
Homecare workers lack essential job benefits.
- IHSS only provides basic health insurance for the employee, and provides nothing for his or her immediate family.
- Only one in five homecare workers have vacation, sick days or holidays.
- The vast majority of homecare workers have no employer-paid dental (87%) or vision insurance (82%).
IHSS does not provide any retirement benefits.
- The majority of homecare workers are over 40 years old and 28% are over age 55.
- Only 14% of homecare workers have any kind of retirement plan, leaving older workers at risk of living in poverty as seniors.
- In addition, many are recent immigrants who will have limited social security benefits.
Higher wages and benefits can alleviate Alameda County’s provider shortage and increase quality of care.
- Alameda County consumers suffer an inadequate supply of experienced workers.
- The labor shortage forces consumers to use emergency rooms or nursing homes when they are seeking a new provider or their provider is unable to work.
- Higher wages increase the supply of labor and the length of time a consumer can retain the same provider.
- Consumers get better care when providers in their own community can make a long-term commitment to doing IHSS work.
Making homecare work in Alameda County a more family-sustaining occupation will allow more workers to make a long-term commitment to providing IHSS care and increase the overall quality of care. It will also help alleviate poverty.
Thus, we recommend that the Alameda County Board of Supervisors:
- Increase IHSS wages to at least $10.50 an hour, so that homecare wages conform to the City of Oakland’s Living Wage. This increase will lift 1,200 people in homecare families out of poverty;
- Provide paid time off to ensure that homecare work is mentally and physically sustainable, and that providers need not continually choose between caring for themselves and caring for others;
- Create dental and vision insurance plans so IHSS workers can afford adequate dental and vision care without creating financial hardship for their families;
- Create a pension plan for homecare workers that will ensure that they are able to retire without being forced into poverty;
- Create a task force to study the extent to which unpredictable loss of hours can threaten provider family stability and to consider possible measures such as a fund for emergency loans or other means of assistance.
A Critical Service
Homecare Workers: Providing a Critical Public Service
Homecare workers provide support services to low-income disabled persons and seniors who are unable to live safely at home without help. California’s In-Home Supportive Services (IHSS) Program provides state, county and federal funds to consumers of homecare so that they can hire a caregiver of their own choosing. The provider can be a friend, a family member or a person unknown to the consumer. Without homecare services, many of these disabled and elderly consumers would be forced out of their communities and into nursing homes or other public institutions.
Homecare workers assist consumers in many of the activities of daily living, including housecleaning, bathing, dressing, meal preparation, shopping and getting to and from medical appointments. At times the job can be difficult, strenuous and even dangerous. IHSS providers go into the homes and neighborhoods of the consumers. They lift consumers and sometimes handle biomedical hazards, such as blood and human waste.
Given the unique and important relationship between the IHSS providers and the consumers, it is critical to understand what homecare workers need to sustain high quality, long-term services. While much is known about the needs of homecare consumers, relatively little is known about the needs of the providers as employees and supporters of their own families. This report summarizes the preliminary findings of a survey project designed to provide a basic understanding of the lives of homecare workers.
A Diverse Workforce
Who Are Homecare Workers?
IHSS providers are likely to be older women of color, including many recent immigrants. Most IHSS workers have been providing care for less than three years. However, a core group has made homecare a career, some for more than ten years. Many of these caregivers have been caring for their friends, family and community members all of their lives.
A substantial majority of homecare workers (80%) are women. Fifty-five percent are age forty and older. Only 13 percent are younger than thirty. (See Figure 5 later in this report.)
Homecare workers are racially and ethnically diverse and live in family households.
Table 1 shows that approximately half are African-American, a quarter are white, 13 percent are Chinese and 7 percent are Latino. Another 12 percent consists of people who mostly come from other Asian countries.
Immigrants play an important role in providing homecare in Alameda County. More than one out of three Alameda homecare workers (35%) are foreign born, coming mainly from China, Southeast Asia and Mexico.
Homecare workers have strong ties to their communities and families. Ninety percent of providers care for someone of their own ethnicity or culture. About 52 percent of IHSS workers in Alameda County currently provide services to a member of their own family. Another nineteen percent live in the home of an IHSS client to whom they are not related.
Three quarters (75%) of homecare providers live in a family-based household. On average, just under four people live in each of these family households, and 45 percent of them have children under age 18. Furthermore, about 60 percent of the households that have children under 18 have more than one child, and in nearly half (45%) the provider is over 40 years of age.
While turnover is high, there are also many workers who have made a career of homecare.
Twenty percent of homecare workers report providing IHSS care for less than a year, and over half have been providing IHSS care for less than three years.  A 20 percent annual turnover rate is relatively high for an occupation that depends on a close, trusting relationship between provider and consumer. On the other hand, a substantial group (29%) has been giving care for more than five years, and 12 percent have been doing IHSS work for more than 10 years (see Figure 1). This indicates that many providers have made homecare a career.
Paycheck to Paycheck
Most Homecare Providers Work Full Time, But Struggle to Make Ends Meet
More than one-third of the families of IHSS providers live below the poverty line, the threshold set by the Federal government for minimum family subsistence. By the end of every month, the typical homecare worker has worked full-time, often at more than one job, and has earned the majority of his or her family’s income. But the typical homecare worker family has spent all of their money on basic needs and has little or nothing left over. Workers with children have almost no discretionary income to shield their children from emergencies or provide them with clothes and supplies for school.
Homecare Worker Families Struggle To Make Ends Meet
Homecare worker families bring in an average income of $22,270 a year. Two-thirds of households with more than one member have more than one income. Despite multiple incomes, more than one-third of homecare worker families earn incomes that place them below the Federal poverty threshold. 
Furthermore, the Federal poverty rate does not account for regional differences in the cost of living. If the higher cost of living in Alameda County were taken into account, the poverty rate would be even higher.
At the end of each month, one in four homecare workers (25%) report that they do not have enough money to cover household expenses (see Figure 2). Another 46 percent say that they barely have enough. Only 6 percent say they have any money left after paying their bills.
Homecare workers report that 40 percent of their income goes toward s housing. Federal housing guidelines suggest that families paying more than 30 percent of their income on housing are rent burdened. Homecare workers face the added challenge of finding decent, affordable housing in the East Bay, the nation’s fifth most expensive rental housing market.
Table 2 shows that providers with children report average expenses that eave almost nothing left over at the end of the month. This basic family budget does not include other important expenditures such as clothing, educational materials, savings or a contribution to a retirement fund.
A Majority of Homecare Providers Work Full-Time or More
Many homecare workers have other employment in addition to caring for IHSS clients. Forty-one percent hold more than one job. On average IHSS providers work a total of 36 hours a week, slightly more than full time and more than the average American worker.  Forty-five percent work more than 35 hours a week and twenty- three percent work more than 50 hours a week. Moreover, most homecare workers report that they work more IHSS hours than they are paid.
In addition to working many hours, homecare providers have to spend much of their time getting to work. One in five providers work for more than one client so they must travel from one consumer’s home to the next. Some homecare workers must travel to their clients’ houses more than once a day. Nearly 30 percent rely on public transportation systems to do so. They are not paid for their travel time.
The Families of Homecare Providers Depend on Their Earnings
Homecare workers are likely to be the “bread winners” of their families. On average, homecare workers make $1,124 a month between all their jobs. Their earnings make up 61 percent of their family income.
On average, homecare workers make $932 a month at their IHSS homecare jobs. These wages make up 50 percent of the total family income (see Figure 3). Since most homecare workers live paycheck to paycheck and because they are the primary income earners in the family, any disruption of work can be financially devastating. IHSS providers are particularly vulnerable to circumstances beyond their control, since they do not determine how many hours they work nor how long they stay with a consumer. If a homecare worker loses a client, for whatever reason, he or she may experience severe hardship until a new IHSS consumer is found.
Lack of Benefits Force Workers to Make Tough Choices
Like many low-wage, service sector jobs, Alameda County homecare work offers few of the basic benefits that ensure that workers can meet their personal and family care needs.
No Paid Time Off
Homecare workers currently receive no paid time off for sickness, family emergencies, holidays or vacation. Homecare workers assist a vulnerable population that sometimes cannot go a day without care or cannot afford other types of services, making it difficult for workers to schedule sudden absences or extended time off for a vacation.
Only 20 percent of homecare workers report receiving any paid holidays or vacations from another job. Only 17 percent report receiving sick leave from another job (see Figure 4).
Alameda County’s Public Authority offers a basic health insurance plan that covers the homecare worker only. Over half of homecare workers who have children under 18 do not have employer paid insurance for their children.
The majority of homecare workers must finance dental and vision care without insurance. Only 13 percent of homecare workers have dental insurance for themselves through other jobs. Only 18 percent have vision care through other jobs. These out of pocket expenses can be substantial, especially if workers forgo preventive care that insurance would provide.
IHSS work provides no retirement benefits. Only 14 percent of homecare workers have pension or retirement plans through other jobs. This is of particular concern for the homecare workforce because the majority of workers are over 40 years old and many are nearing the end of their working lives. Twenty-eight percent of homecare workers are over 55 years old. Nine percent are over 65 (see Figure 5).
Considering that more than a third of all provider families already live in poverty, many more will find themselves living in poverty as seniors or be forced to continue working past retirement age— unless they can get retirement benefits from this or another job.
Consumer Care at Risk
Consumers Suffer When Homecare Provider Wages are Low
Consumers suffer when workers are in short supply. A 1998 survey by Laura Reif,  documents the effects of a labor shortage on consumers in San Francisco. Sixteen percent of consumers reported that they made an avoidable visit to an emergency room or were admitted to a hospital or a nursing home because a regular provider was not available and they could not find a replacement. Nineteen percent of all consumers reported that they had had difficulty finding a regular provider after they have been authorized to receive services or when their regular provider was ill. 
Alameda County suffers a shortage of IHSS workers.
By the best measure of the supply of providers–the ratio of IHSS workers to every 1000 people in the county population–Alameda County suffers from a shortage compared to the neighboring county of San Francisco. The Alameda ratio is 40 percent below that in San Francisco.
In 1999, the Public Authority set up an innovative Rapid Response Program to provide emergency replacement workers to IHSS consumers residing in Oakland when their regular provider could not work. But in an evaluation of the program done in 2000, Reif  found that because of the labor shortage in Alameda County, 84 percent of the consumers who used the program were seeking a provider to fill a regular need rather than a true emergency coverage.
Higher wages help resolve shortages and improve the quality of care.
Recent evidence from San Francisco indicates that labor shortages are resolved as wages rise. Over a 3-year period, Candace Howes  found that as wages rose from close to the minimum wage and nearly doubled to $10 an hour, the number of IHSS providers in San Francisco increased by 39 percent. In fact, some of the increase in supply has come from providers who are traveling to San Francisco from neighboring counties that pay lower wages. Twelve percent of San Francisco providers now come from other counties, including from Alameda County. 
Howes found that as the wage rose, more consumers found providers that they preferred, such as family members, neighbors and members of their own ethnic group, rather than unfamiliar providers. Howes also found evidence that the length of time providers stayed with the same consumer was getting longer. It is generally appreciated that consumers get better care when there is an adequate supply of experienced providers coming from their own communities who are able and willing to make long-term commitments to the consumer and to the job.
Conclusions and Recommendations
Homecare workers live from paycheck to paycheck, struggling to make ends meet for themselves and their families. They differ from IHSS consumers, who are generally poor and health challenged, only by a matter of degrees. Any serious medical problems or family emergencies may tip their lives into crisis.
Homecare workers help to meet the basic needs of their clients, yet their own basic needs often go unmet. Wages are low and benefits are inadequate. As a consequence, there is high turnover and a shortage of IHSS providers in Alameda County. This shortage hurts consumers who cannot find new providers or a replacement when their provider takes time off for illness or family needs.
Homecare workers are likely to be the most important source of earnings in their families. IHSS wages alone make up 50 percent of all family income, on average. Increasing homecare workers’ wages will help alleviate poverty in Alameda County. Raising IHSS wages to the current City of Oakland living wage rate of $10.50 an hour would decrease the poverty rate among homecare families by 20 percent. This represents 1,200 people living in homecare provider families who would be lifted out of poverty.
Recently, wage and benefit improvements in San Francisco resulted in a larger supply and greater stability of the homecare workforce. Consumers who had gone without needed services were better able to find providers they knew and trusted. Higher wages also resulted in longer relationships between a consumer and his or her provider, a sign of higher quality care.
We recommend that the Alameda County Board of Supervisors take the following actions:
- Raise homecare provider wages to the Oakland Living Wage rate, which is currently $10.50 an hour. This would follow the example of San Francisco, where homecare workers are covered by that City’s living wage ordinance.
- Provide homecare workers with paid time off for vacations, sick leave and holidays. This will allow homecare workers to care for their families, take care of emergencies and take care of their own health needs, while still making ends meet.
- Create dental and vision insurance plans so IHSS workers can afford adequate dental and vision care without creating financial hardship for their families.
- Create a pension plan for homecare workers that will ensure that they are able to retire without being forced into poverty.
- Create a task force to study the extent to which unpredictable loss of hours can threaten provider family stability and to consider possible measures such as a fund for emergency loans or other means of assistance
 This proportion is similar to findings from an earlier survey of San Francisco consumers, which found that 97 percent of consumers used a provider of their own ethnicity. See RTZ Associates. 2001. San Francisco IHSS Consumer Evaluation of Quality of Care: Survey Findings. Oakland: RTZ Associates.
 These numbers are consistent with similar findings for San Francisco (Howes 2002) where the annual turnover rate over a three year period averaged 20 percent. See Howes, Candace. 2002. The impact of a large wage increase on the IHSS homecare workers in San Francisco County. Paper prepared under the auspices of the University of California Institute for Labor and Employment and the University of California Center for Labor Research and Education, January.
 The poverty rate was calculated using the Federal Poverty guidelines, the self-reported household income and the self-reported number of family members in the household. The survey question did not specify whether income was before tax or after tax. We assume that respondents reported their annual family income in before tax dollars.
 U.S. Department of Housing and Urban Development, Fair Market Rents 2002.
 The Bureau of the Census considers a 35 hour a week job to be full time employment. The BLS says the workweek for production or non-supervisory workers on private payrolls has consistently averaged 34 to 35 hours over the last decade (New York Times, 4/4/02, p.A14).
 Reif, Laura and Rick Zawadski. 1998. San Francisco In-Home Supportive Services: Consumer Evaluation of Quality of Care. Oakland: RTZ Associates.
 These statistics are confirmed in a survey conducted by Harder and Associates in 2000, that found that 18 percent of the IHSS recipients in Alameda County had difficulty finding a regular IHSS provider. See Harder & Company Community Research. 2001. Consumer and Worker Needs Assessment. Oakland: Public Authority for In-Home Supportive Services, Alameda County.
 California Department of Social Services, In-Home Supportive Services: IHSS Providers, Characteristics of Caregivers in the In-Home Supportive Services Program, October 2001, p. 9. Providers per 1000 in the population is a better measure of adequate supply than the ratio of providers to consumers because the number of consumers is constrained by the supply of providers. Consumers who need the service will often apply but then be unable to find a suitable provider.
 Reif, Laura. 2001. Consumer Evaluation of the Rapid Response Program, Evaluation report of a research demonstration funded by a Robert Wood Johnson Foundation grant to the Public Authority for IHSS in Alameda County. New Brunswick, NJ: Robert Wood
Johnson Foundation, March.
 Howes (2002).
 Calculations made by RTZ Associates, using data for San Francisco County, drawn from California’s Caseload Management, Information and Payrolling System (CMIPS), February 2002.
 RTZ Associates. 2001. San Francisco IHSS Consumer Evaluation of Quality of Care: Survey Findings. Oakland, CA: RTZ Associates