The Depreciation of Care at Home

Nancy Folbre is an economics professor at the University of Massachusetts, Amherst.

At the next birthday party for your grandparents or yourselves, consider what the following public policies all have in common:

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Medicare pays for many expensive medical procedures that don’t significantly prolong life, but does not cover the costs of custodial care for patients with diseases that can’t be medically treated, such as Alzheimer’s or dementia.

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Medicaid is far more likely to pay for nursing home care for the indigent elderly than to pay for home- and community-based services that would enable them to remain in their own homes. While some states do far better than others in this regard, at least 25 states and the District of Columbia cut spending on such services between 2007 and 2010.

Plans to offer families affordable long-term care insurance — whose benefits would include stipends for family members providing care — were recently dropped from President Obama’s health care plan.

Paid workers who care for individuals needing assistance in their own homes are not guaranteed a federal minimum wage or overtime protections because they are not covered by the Fair Labor Standards Act.

All these policies take for granted family care, and forms of paid work that resemble family care, assuming that they don’t merit public support or regulation. Yet the aging of the population means that the demand for home-care services is growing even as the supply of young people shrinks.

Marital instability, geographic mobility, increased childlessness and the demands of paid employment all reduce the likelihood that family members will be able to fully meet care needs.

Women, who made up about 67 percent of all caregivers for adults at last count, may become increasingly unlikely to take on responsibilities that their brothers and husbands resist sharing. They may also prove reluctant to enter an occupation that is underpaid and not subject to federal labor regulation.

Paid home and community-based services tend to be more cost-effective than nursing homes, partly because they can help organize and enable support from family members and friends. There is little evidence that they “crowd out” family care; on the contrary, families tend to use paid help when care needs exceed their own capacity, supplementing the total hours of care provided without reducing their own efforts.

Paid home-care workers take on a variety of tasks, including preparing meals, feeding, bathing, doing laundry, changing sheets, ensuring pills are taken and providing reassurance and companionship.

But an outmoded administrative rule excludes them from coverage under the Fair Labor Standards Act on the grounds that they are “merely” providing companionship.

Pressure on both family and public budgets intensifies resistance to changing this rule, for fear of increased costs. But the small number of home-care workers who are providing companionship and nothing more could be excluded.

Modest overall cost increases would be countervailed by reductions in turnover and improvements in care quality. Overtime restrictions would provide incentives to hire new workers and reduce unemployment. Many states are already on board (21 mandate a minimum wage, and 15 require overtime payment).

Current and future family caregivers should favor better federal protections for paid home care workers out of respect for the value and dignity of caregiving itself.

President Obama, who recently suggested a number of administrative rule changes in other policy areas, should urge Secretary of Labor Hilda Solis to extend coverage of the Fair Labor Standards Act.

And everyone who hopes to grow old should demand more support for caregiving at home.