Recently, Craig Klugman wrote a thought-provoking blog entry over at bioethics.net on long-term care options for elderly persons. While humane ones do exist that are designed for human flourishing, such as a new chain of purpose-designed communities where elderly folks have access to developing new skills in the visual and performing arts, these are often very expensive.
More often, facilities which provide in-patient nursing care still significantly “warehouse” their residents, providing medical care but treating the elderly as people waiting for death rather than persons who can still grow and learn and contribute. National Public Radio has an ongoing investigative news series called “Home or Nursing Home: America’s Empty Promise to Give the Elderly and Disabled A Choice.” In that series, NPR reporters chronicle many of the same kinds of difficulties Klugman discusses in his blog entry. Long-term care facilities have notoriously high staff turnover rates, in part due to difficult working conditions but also due to low pay. In-home careworkers are similarly poorly paid. 90% of these direct care workers are women, and earn an average of approximately $17,000/year. This is due in part to the fact that the federal law governing wage and overtime protections, the Fair Labor Standards Act (FLSA), explicitly does not cover home care workers. Even facility-based care workers receive very little pay.
Readers of this blog may be familiar with long-standing arguments within feminist theory about the value of dependency work (AKA caregiving) to society, namely that society cannot function without it (see Eva Kittay’s Love’s Labor for starters). Given this fundamental role of dependency work in society, it is often argued that much is owed to those who do this work. Thus, the fact that so little is given while so much is asked is in fact unfair rather than merely unfortunate. Such arguments, along with basic concerns about labor fairness, prompted an attempt through 2011-12 to revise the FLSA standards in a way that might well move some in-home care workers into coverage by the FLSA. An NPR story earlier this year chronicles that effort, and describes the overall situation nicely. However, this effort does little to address the plight of facility-based dependency workers.
Efforts to provide a more just system of compensation for dependency workers, whether in homes or in facilities, may well lead to higher quality, better-trained workers due to less turnover and longer-term relationships with those for whom they care. But there remains the question of who will pay. As Klugman notes, the out-of-pocket cost of care is high. As the NPR article from earlier this year notes, coverage by government safety net medical programs such as Medicare is imperfect and has limited reimbursement levels.
We ought to do better by our elderly. We either are them or, if lucky to live sufficiently long, will become them. As a group, the elderly cared for the young when the young could not care for themselves. And the work of caring for dependent persons—whether young or old, temporarily or permanently—is critically important work to our society which we nonetheless reward badly if at all (I have not even touched on the toll of unpaid dependency work). Doing better by dependency workers may lead to doing better by dependent persons, as well as being a simple matter of fairness to all concerned. And yet, rising wages and benefits for the former will mean rising costs for the latter at a stage when many are on a fixed income, at best. Ought society to take on this burden of justice? If so, how? Regulation alone—say, through revision of the FLSA—will not cut the cake: it does nothing to make better, more fair provision of care affordable.
In an ideal world, we would treat both dependency workers and dependent persons better. But in a cost-aware world, in a nation with an increasing mainstream aversion to taxpayer-supported aid programs, are the needs of dependency workers and the needs of dependent persons at odds? Can the needs of both be fairly met? Is this a zero-sum game? What practical measures can we take to ensure that it is not a zero-sum game?