A version of this article was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School, as part of a digital symposium, Build Back Better? Health, Disability, and the Future of Work Post-COVID. The author draws both from experience as a poverty lawyer for Maine seniors and from texts discussed in local study groups, including Maine DSA’s social reproduction series and the Maine AFL-CIO’s current labor reading group. The argument below – that the understaffing of care work demands a unified working class struggle – is especially salient to Maine, home to the oldest population in the U.S., where a disproportionate share of care workers are immigrants, women, and people of color. An earlier Pine & Roses article expands on the political economy of aging in Maine.

The future of work will largely be the future of care work. Health care is rapidly becoming the largest employer in the U.S., expanding to serve the fastest growing demographic, aging seniors. As a lawyer for seniors in need of free legal services, I see my clients struggle to access care made scarce by the for-profit care industry’s understaffing and underpaying of workers attempting to meet the growing need. The future of work and of aging will be shaped by struggles over care from both giving and receiving ends, perhaps against those profiting in between.

COVID-19 has highlighted important trends. The first outbreak in the U.S. spread between nursing homes. Underpaid care workers, forced to work at multiple facilities to survive, unintentionally spread the virus between facilities. Like most nursing homes, these facilities are for-profit, maximizing profits by cutting labor costs. Understaffing has plagued nursing homes since well before the pandemic, to the detriment of both patients and workers.

Yet many of my clients are fighting for beds in long-term care facilities, despite the deadly conditions inside. They need an increasing level of support not only medically, but also with activities of daily living, managing finances, and mental health and social services. In theory, all this care could be delivered in seniors’ homes and communities. The disability rights movement has long struggled against unnecessary institutionalization in state hospitals and nursing homes, winning wide recognition of the principle of aging in place. Yet I see clients driven into institutional facilities when the promise of aging in place meets reality: they cannot afford to hire homecare workers and Medicaid rates are insufficient to attract would-be care workers to demanding and dangerous jobs. As in nursing homes, homecare understaffing pre-dated but was intensified by the pandemic.

The need for care work will only continue to expand as baby boomers get older and sicker. How will younger generations provide this care? To answer this question about the future of care work, it is helpful to examine its past. How did we get to this point of underpaying and understaffing the care work we increasingly need?

In the bygone era of the family wage, care needs were met primarily by unpaid family members. This past should not be idealized. As Nancy Fraser put it, the family wage, attained mostly by white males in manufacturing jobs, was built on “constituent exclusions” of the broader global working class, such as low-waged agricultural and domestic workers more likely to be men and women of color. It also “naturalized heteronormativity and gender hierarchy” between the wage earner and housewife, not recognizing her care provision as work but rather as a natural expression of femininity.

But the falling wages and rising costs of the last fifty years mostly ended the family wage and the housewife as full-time unpaid care worker, a history documented in Gabriel Winant’s work on the rise of the health care sector in the wake of deindustrialization. To be sure, women still perform unpaid care work, but commonly do waged work, too, becoming less available for the former and leaving a void of care provision in homes and communities.  

This void set the stage for commodifying care work. According to Winant, the intensifying “pressure to warehouse the huge elderly population” led to a boom in for-profit nursing home chains and homecare agencies. The industry capitalized on steady funding streams: seniors’ assets and Medicaid, Social Security, and VA benefits.  It also exploited cheap labor: Women were seen as natural care workers, especially immigrants and women of color, with gendered, racialized assumptions about the value of care work justifying systemically low wages.

And here we are. The commodification of care, its profits dependent on underpaying workers, led to the scarcity of care that my clients, and more baby boomers everyday, experience.  

Care worker organizing for higher wages and better treatment has been on the rise in recent years. But these efforts have met fierce resistance not only from state governments enforcing austerity and anti-union court decisions. More incongruously, some disability rights advocates have opposed care worker unionization for fear that higher wages will make care less accessible. Commodified care and budget austerity have pitted care workers against the people they care for.

An alliance between care receivers and care givers against the for-profit care industry would change this dynamic. Models exist thanks to radical organizing often led by people of color who, always already excluded from the family wage, have longer histories of working and organizing in waged care. The Young Lords and Black Panthers notably organized health practitioners and patients together to advance the common cause of care providers and communities in need of care.  

My analysis suggests the common cause of care givers and receivers begins with de-commodifying care, not by restoring the patriarchal family wage, but by socializing the cost of care work without the added cost of profits. But even without capital extracting profit before paying care workers, there will be struggle over care costs.  Socializing the cost of care work will be funded by taxes, and with capitalists adept at avoiding taxation, ordinary people will remain in the contradictory position of wanting to minimize care wages even as low wages make care scarce. The common cause must be broader than de-commodifying care.  

Ultimately, as Tithi Bhattacharya elucidates, every labor struggle over wages implicitly includes a struggle over what social goods workers and their communities are entitled to, for example, what level of health care or retirement they can afford with those wages. Paying care workers adequately requires the entire working class receive wages or benefits high enough to afford well-paid care workers. A struggle for better pay in the care industry, and a struggle for better access to care, are both only partial struggles. They will continue to be pitted against each other until brought together as the unified struggle of all who care and need to be cared for.