1. INVISIBLE SWEATSHOP
THE PLIGHT OF HOME CARE WORKERS
IN NEW YORK CITY
A Report by
Mark Green

2. Public Advocate for the
City of New York
June 2001
INVISIBLE SWEATSHOP
THE PLIGHT OF HOME CARE WORKERS
IN NEW YORK CITY

3. A Report by
Mark Green
Public Advocate for the
City of New York
Tom Hilliard
Senior Analyst for Health Policy
June 2001

4. 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

5. 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

6. 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

7. 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.
i

8. 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
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,
ii

9. 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
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
iii

10. 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 –
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.
iv

11.  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
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
v

12. 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.
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 –
vi

13. 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.
vii

14. 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
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

15. 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
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
2
Michael Sparer, Medicaid and the Limits of State Health Reform, Temple University Press,
1996, p. 110.
2

16. 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
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.
3
Robin Herman, “Demand for Home-Care Workers is Rising in City,” The New York Times,
October 2, 1981.
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

17. 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
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

18. 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
7
A Profile of Older Americans: 1999, American Association of Retired Persons and U.S.
Administration on Aging, 2000.
5

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

20. • 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

21. 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

22. 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

23. 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

24. 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

25. • 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

26. 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
13

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

28. 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
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
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.,
15
“I just eat what I have to eat. Lucky
I’m diabetic, so I just eat vegetables.”

29. 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.
About one-quarter of non-profit home attendants (26%) work 30 hours or
less each week.27
Table One
Weekly Hours Worked by Non-profit Home Attendants, April
2001
Hours Employee
s
Share 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.
p. 82.
27
Sandata, April 20, 2001. Sample of non-profit home care agencies representing approximately
85% of total caseload.
16

30. 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
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.
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.
30
Sandata, April 20, 2001. Sample of unionized home care agencies representing approximately
85% of total caseload.
17

31. 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-
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
31
Home Care Council.
18
“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.”

32. 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
19
“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.”

33. 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.
20
“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.”

34. 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
34
DC 1707 sends its members to the Consortium for Worker Education for similar purposes.
21

35. motivate workers to improve their skills, provide greater job satisfaction, and give
managers a valuable tool for improving service to their client population.
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.
22

36. 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.
23

37. 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 Two
Comparison of median hourly non-profit and for-profit wages
and benefits
Category 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 0.00
Total direct expenses 10.62 8.82 1.80
Administrative salaries 0.59 0.89 -0.40
Other indirect expenses 0.49 0.71 -0.22
Total indirect expenses 1.08 1.60 -0.52
Total expenses 11.70 10.42 1.28
Source: 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.
24

38. 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
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,
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.
25

39. 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:
• 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
26

40. 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.
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.
27

41. 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.
28

42. 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.
29