0:08

Hello there.

0:09

Rosey again, and this is our

0:11

fourth episode exploring the real stuff

0:13

that inspired the welcome to Vanguard

0:15

Estates series. Today,

0:17

we are talking about money.

0:20

And I will say off the bat here that this episode

0:22

is mostly going to talk about the economics

0:24

of care work in the United States.

0:27

which is not necessarily how

0:29

it works globally. So yes,

0:31

international listeners. I know we're doing

0:33

a US focused episode. I am sorry.

0:36

This is how it is. The story that you heard is set

0:38

in the US and there's just like no way for

0:40

us to cover how this works everywhere. So

0:42

With that apology slash disclaimer out

0:44

of the way, let's talk about

0:47

money. First, we're gonna talk about

0:49

how expensive it is to get care.

0:52

And then we're gonna talk about how hard it

0:54

is to work in the care industry and make

0:56

a reasonable living. So sort of two

0:58

sides to the same coin.

1:00

As part of my research

1:02

for welcome to Vanguard Estates, I spent a

1:04

lot of time on Reddit reading

1:06

posts from people struggling to help support

1:08

their loved ones. And a lot

1:10

of the scenarios and conundrums that you

1:12

heard in these various storylines, and welcome

1:15

to Estates, came from real

1:17

situations that I found in these threads.

1:19

And that includes, by the way, the incredibly

1:22

predatory loan that the father

1:24

signs up for in one of the storylines.

1:27

Last week, you heard all about

1:29

the various technologies that can be useful

1:31

for folks as they age. And

1:33

when I asked Lori Orlev, our industry

1:36

analyst, you heard her on last episode about

1:38

the barriers that keep people from using

1:40

technology. She immediately said

1:43

money. Well,

1:44

one of the challenges of course, is

1:46

always cost.

1:48

So the wealthiest part of a market

1:50

can probably afford all of the technologies

1:52

I've described quite easily

1:54

it's becoming harder and harder for

1:56

the middle tier of the financial

1:59

market

1:59

for people.

2:01

to afford

2:02

many of these technologies. And at the low

2:05

income end of the market, it's

2:07

difficult to move forward any of them.

2:09

And this answer was about technology, but

2:11

it could also be about pretty

2:13

much everything when it comes to

2:15

senior care. Wealthy people can afford

2:17

it and everybody else has to kind of

2:20

scrape around and hope for

2:22

the best. It costs a lot

2:24

just period.

2:26

This is Devon Bodey. She's a community

2:28

development specialist for the Federal Reserve

2:31

Bank of New York. And in order to be able to

2:33

talk with us today, she had to offer this

2:35

disclaimer. my opinions

2:37

are my own and they do not

2:39

represent the Federal Reserve Bank in New

2:41

York or the Federal Reserve Estates.

2:43

At

2:43

her last job at the Aspen Institute

2:46

Security Program, Devon wrote a report

2:48

called the True Cost of Caregiving.

2:51

every year or so

2:53

we do an expert survey

2:55

that basically ask, what

2:58

are the financial financial

3:00

issues that are most important to

3:02

families, to people, to human

3:04

beings, or another way that we usually

3:06

put it as what is the issue that keeps

3:08

you up at night? And in

3:11

two thousand nineteen, we did this survey.

3:13

And for the first time, one of the

3:15

top three answers was caregiving.

3:18

The report looks at three kinds of

3:20

care, child care, adult care, and

3:22

elder care. We are obviously going to focus

3:24

on that. Last one, elder care. but

3:27

it is not always easy to tease apart

3:29

the three for reasons that we're gonna talk about

3:31

in a minute. So before we get

3:33

into this, let's just set the stage with a

3:35

couple of numbers. According to the US

3:37

Census Bureau, by twenty thirty, there will

3:39

be one billion people on this

3:41

Earth who are over sixty five.

3:44

In the United States, there are currently about

3:46

fifty million people in that age

3:48

group, sixty five and older. And you've

3:50

probably heard about this, right, that there

3:52

is a silver tsunami That

3:55

is my favorite term for it that I have read.

3:58

Instead of our population looking like a pyramid

3:59

with more younger people, the bottom

4:02

and then kind of dwindling down to fewer

4:04

older people. Right now, it looks

4:06

like more of a diamond with like

4:08

kind of a bulge in the middle.

4:10

Eventually, that bulge will find its way

4:12

to the top and we will have essentially

4:14

an upside down pyramid with

4:16

more older people than younger ones.

4:19

I was

4:19

looking at some data

4:22

earlier and it basically stated

4:24

that the number it contracted

4:26

actually that the number of people

4:28

in the United States who are aged

4:30

sixty five

4:31

and older is

4:32

projected to more than double

4:34

between twenty fifteen and twenty

4:36

sixty. And

4:37

then again, for people

4:39

aged eighty five and older, the population

4:42

growth is expected to increase from

4:44

six million to twenty million

4:47

in two thousand and sixty. So this

4:49

is just gonna be a a very

4:51

large need in the future.

4:53

The implications

4:54

of this are really wide reaching,

4:57

culturally and politically. But

4:59

for our purposes, we are going to focus on the

5:01

question of caring for that big

5:03

group of aging folks. Because at

5:05

some point or another, pretty much

5:07

all of those people will need

5:10

care of some kind. And

5:12

there are two main types of care that we're

5:14

gonna

5:14

talk about. The

5:15

first being family caregivers. Family

5:18

caregivers are Generally,

5:20

family members who are providing care, whether

5:22

that is to a child, to a

5:24

loved one, to their parents who are

5:26

aging or someone who needs

5:28

help within their family.

5:30

This is unpaid work. These are family

5:32

members stepping in and taking this

5:35

on. There's more than

5:37

fifty million people providing

5:39

unpaid care to a child or an

5:41

adult. And this is

5:43

just to give a clear picture, this is

5:45

nearly one in five people in

5:47

the United And

5:49

there is one big commonality

5:52

among these family caregivers.

5:55

They are mostly women. And

5:58

as we stated in the report, an

5:59

estimated six and ten family

6:02

caregivers are women

6:04

or at least were women at the time

6:06

that this

6:06

report was written.

6:08

The

6:08

COVID-nineteen pandemic has really

6:10

exacerbated this statistic. When

6:13

schools shut down and child care facilities

6:15

shut down and many adult care facilities

6:17

shut down, it was disproportionately women

6:20

who wound up dropping their careers who

6:23

care for the family

6:24

and actually report

6:26

by the Nationalists Law Center,

6:28

which did a did

6:30

a quick analysis of the Bureau of Labor

6:32

Statistics at the time found that

6:34

over two

6:34

million women left the

6:36

labor force between February

6:38

and October twenty twenty.

6:40

And even more troubling

6:42

is that woman of color typically

6:44

play the largest role with

6:47

black and Latino women providing

6:49

caregiving at higher rates than

6:51

white women. We

6:53

saw this happen in our story. Right? Our

6:55

narrator winds up having to make a choice between

6:57

work, school, and caring for

6:59

their father. And this is what

7:01

Nikki had to do for her mom too.

7:03

I quit my job. I

7:05

was working in the fashion industry as

7:08

an account executive for

7:10

a swimwear company that was, like, standing

7:12

into a big clothing line. And

7:15

I had quit so that I

7:17

could be my mom's full time caregiver.

7:19

And So I was able

7:21

to lean off of my savings for

7:23

about four to six months,

7:25

and I did try to do

7:27

freelancing and part time jobs,

7:30

but in in the interim of the four to

7:32

six months. But going

7:34

outside and working was not sustainable,

7:38

having to make the decision between I'm

7:40

gonna go work my job and earn a

7:42

wage or I'm going to stay

7:44

home that's such a hard decision

7:46

because at the end of the day, we all have

7:49

rents to pay, bills to pay.

7:51

We all have these different financial

7:53

responsibilities. And

7:55

in many cases, these folks are actually

7:57

caring for both ends of the

7:59

family of

8:00

this entire population about

8:03

twenty eight percent of family caregivers are

8:05

providing

8:05

care to both

8:06

an adult

8:07

and a child. And this is known as

8:09

the sandwich generation

8:12

This happens because in the US,

8:14

care, both for children and for

8:16

adults and elders, is

8:18

really expensive. And

8:20

that brings us to the second type of care, which

8:23

Devon calls direct care.

8:25

And

8:25

direct care is

8:27

basically just a realm of care

8:29

where it provides

8:31

for older adults and people living with disabilities.

8:35

This can usually include personal care

8:37

aids, or home health case

8:39

or nursing assistance.

8:41

There are about five point

8:43

seven million direct care workers

8:45

in the United States today. We're

8:47

gonna come back to those folks who they

8:49

are, what that work is like, and what their

8:51

economic situation is in a little

8:53

bit. But if you want to hire someone

8:55

like this, or to live in a facility

8:58

with staff or anything like

9:00

that. It is really expensive.

9:03

In twenty twenty, the median annual cost

9:05

range for non medical in home

9:07

care. So that's things like helping with

9:09

cooking and laundry and kind of like the

9:11

day to day stuff. That costs about

9:13

sixty thousand dollars annually.

9:16

Community and assisted living, so things

9:18

like shared living quarters with some

9:21

supervision and medical management, that

9:23

costs anywhere between twenty thousand

9:25

and fifty five thousand dollars a

9:27

year. Then there are nursing

9:29

homes. which provides

9:30

room and board at

9:32

a in a higher level of supervision. This

9:35

is the most expensive nursing

9:37

homes are ninety thousand into

9:39

one hundred and two thousand.

9:41

And so just taking

9:43

in those costs altogether, it's

9:45

kind of staggering. And

9:47

this is on an

9:49

annual basis.

9:51

No.

9:51

I don't know about you, but I personally

9:54

don't have like twenty thousand

9:56

dollars every year just sort of

9:58

hanging around.

9:59

And

9:59

most people don't.

10:02

Even the lowest range of

10:04

annual cost is more than thirty of

10:07

median family income in

10:09

thirty states. And

10:11

in a lot of cases, insurance

10:13

doesn't cover this stuff. Some people

10:15

have success getting financial support through

10:17

Medicare or Medicaid or other programs,

10:20

but not everybody does.

10:22

It's also often hard to figure out what

10:24

even exists in your state or

10:26

region in terms of financial support.

10:29

So

10:29

what it says currently is really

10:32

a patchwork of

10:33

systems that help support

10:36

family needs.

10:37

and not to say that what

10:39

exists right now is bad, but it

10:41

is very complicated. It can

10:43

really relies on the state that you

10:45

live in and relies on

10:47

the employer that you work for.

10:49

And unfortunately, because of

10:51

this, millions of households fall

10:53

into gaps in our care system,

10:55

some people simply can't afford

10:58

to pay out of pocket, and some

11:00

people lack access to government

11:02

programs that can help them meet

11:04

rising costs. In the

11:06

interviews for the report, Devon

11:08

says that she heard stories of people going into

11:10

pretty deep credit card debt to pay

11:12

for care. they

11:13

delayed major life

11:15

purchases, and they

11:16

tapped into their emergency

11:18

savings, and even more troubling, they

11:20

tapped into their retirement funds.

11:23

Then there

11:23

are those who we talked about earlier, the

11:26

family caregivers. And that's

11:28

expensive too.

11:29

Family caregivers spent an average

11:32

of six thousand nine hundred

11:34

of their annual income or about

11:37

twenty percent on out of

11:39

pocket

11:39

costs related to caregiving.

11:41

Not to

11:41

mention the burnout that we talked about

11:44

on the first episode. And the fact that

11:46

these folks don't aren't able to pursue

11:48

the jobs and careers that

11:50

they've had before.

11:51

And like we talked about on the second

11:54

episode, these impacts are

11:56

not evenly distributed. People

11:58

of color were

11:59

were and are more likely

12:02

to receive lower quality

12:04

care and to have lower

12:06

financial resources to

12:08

actually form the care. And then additionally,

12:11

fewer culturally appropriate

12:14

care options there was

12:16

actually a study in two thousand

12:18

eleven by in the

12:20

International Journal of Health Services

12:22

that

12:22

show that the elimination

12:25

of health disparities

12:25

for people of color reduces

12:28

indirect costs associated with

12:30

illness and premature depth,

12:32

which is really important.

12:35

So what does a better way look

12:37

like? If we wanted to go big, rethinking our

12:39

entire medical industrial complex and health

12:41

system and insurance in the United States

12:43

would be great. But maybe

12:45

let's start a little smaller.

12:47

There is some low hanging fruit that could

12:49

make a difference really quickly.

12:52

So

12:52

in the report,

12:54

what we find that can

12:56

help build a more adjusted medical care

12:58

system includes having

13:01

more access to federal and state

13:03

subsidies This will mostly

13:05

help protect families from the

13:07

high unaffordability of direct

13:09

care. It prevents them from

13:11

spending down their own savings and going

13:13

into debt.

13:14

In New York State, for example, there's a

13:16

program called the Consumer Directed

13:18

Personal Estates Program or

13:20

CDPAP. This program

13:22

basically allows for people who are

13:24

eligible for Medicaid to select,

13:27

train, and direct their own

13:29

caregivers. And what that really means is that if

13:31

you have a family member or a

13:33

friend who actually wants

13:35

to provide care, you

13:37

can hire them and get them trained

13:39

through this program. So instead of having

13:41

to quit their job and not have an income,

13:43

they could actually get paid to

13:45

do this work. Another thing

13:47

Devon and her team identified in their

13:49

report is making it easier to

13:51

actually qualify for programs

13:53

like Medicare. So

13:56

there are federal and state insurance

13:58

programs, including Medicaid,

13:59

Medicare,

14:02

social security, disability insurance,

14:04

and more. They all should have very flexible

14:07

eligibility goals that allow more

14:09

families

14:09

to be able to access subsidized

14:12

care. This

14:13

is something that Washington State is trying

14:15

to do now. In twenty nineteen, they

14:17

passed the Long Term Care

14:19

Trust Act. And

14:21

the bill provided a lifetime

14:23

benefit of up to thirty six thousand five

14:25

hundred dollars for people who need

14:27

assistance with activities of daily

14:29

living. And the

14:30

eligibility for that benefit is

14:32

far more flexible than in a

14:34

lot of other places. The

14:36

true benefits of this long term

14:39

care trust act in Washington

14:41

is that it gives families

14:43

another option when

14:45

they are unable

14:48

to success, Medicaid, Medicare,

14:50

and the existing disability

14:53

supports that really help

14:55

people fund the long term

14:57

care needs that people will

14:59

have. This kind of

15:00

thing was actually part of the American

15:03

families plan put forth by president

15:05

Joe Biden. the

15:07

American families plan. It

15:10

really had some

15:11

important care infrastructure

15:13

essentials. One of them

15:15

being about

15:16

four hundred billion dedicated

15:18

to expand access to quality and

15:21

affordable home or community based

15:23

care for aging relatives and

15:25

people with disabilities. So a provision

15:27

like that would be

15:29

really, really life changing for a

15:31

lot of families just by

15:33

improving access in the first

15:35

place. As

15:36

you perhaps know, that

15:38

plan did not make the

15:40

cut in Congress. So for

15:42

now, Americans are going to continue to

15:44

struggle to figure out how to pay for

15:46

the care that we are all

15:48

going to need at some point.

15:50

And that was Davon's big

15:52

takeaway from working on this

15:54

project. that this isn't a

15:56

niche thing. This isn't something that we can

15:58

just kind of ignore. Everyone

16:00

will need care at some

16:02

point in their lives.

16:04

from infants to

16:06

adults to elders. Care

16:08

is

16:08

in a universal need. It's the

16:11

backbone of our economy.

16:12

The

16:12

sooner we realize that this is

16:15

universal need, I

16:16

think the more we'll be done

16:19

to build some more ethical care

16:21

infrastructure.

16:22

As it

16:23

stands, it's really,

16:25

really hard to find and pay for

16:27

quality senior care.

16:29

and it doesn't seem like

16:31

it's going to get any

16:32

easier. And I

16:34

think that the failure of Joe Biden's

16:36

American families plan actually

16:38

highlights one of the reasons why.

16:40

When you look at the arguments made online

16:42

against that bill, against

16:44

spending that money, It often

16:46

boils down to the idea that

16:48

care work isn't real

16:50

work. And that is

16:52

an insidious belief think

16:54

many people don't even realize

16:57

perhaps that they have. This idea

16:59

that, like, well, of course, you wouldn't

17:01

pay people to care for their family. That's

17:03

just like, what you do. That's not real

17:05

work. But that idea

17:07

is not only rooted in some pretty dark

17:09

history. It's also one

17:11

that creates seriously bad

17:13

working conditions for both family

17:15

caregivers and professional ones.

17:17

So when we come back, we are going to

17:19

talk about the employee side of this

17:21

coin and what it's like to actually try and

17:23

make a living providing care

17:26

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19:02

Okay. So it

19:04

is hard to get care in the United

19:06

Estates. but it's also hard

19:08

to give care. The people

19:10

working in direct care, working as home

19:12

health aids or nursing home employees, are

19:15

often underpaid overworked and

19:17

just like straight up exploited.

19:19

I think the most shocking thing

19:21

is care workers are among

19:23

the lowest paid in our nation. They do not

19:25

earn a living wage. And

19:28

if you look into data,

19:30

you know home

19:31

care workers earn a median of fourteen

19:34

dollars per hour, just right

19:35

around twenty nine thousand per

19:38

year. So in addition

19:40

to being some of the lowest paid workers

19:42

in our nation, care workers

19:44

also experience very inconsistent

19:47

work hours marginal label

19:49

protections. And from what we

19:51

hear, limited opportunities for

19:53

career growth and just general

19:55

long term mobility. Not

19:58

only are these workers paid incredibly

20:00

low wages, they are also

20:02

often excluded from

20:04

workplace protections.

20:06

there's just such a vast history

20:08

of gender and race that

20:10

plays into the dynamics of

20:12

why domestic workers maybe are

20:15

left out of very simple rights

20:17

that are granted to a lot of

20:19

workers today, and it will perhaps

20:21

not surprise you that that history

20:24

has a whole lot to do with both

20:27

sexism and racism. So

20:28

women of color, in particular, they've

20:31

provided childcare and

20:33

worked since, you know,

20:34

the sixteen hundreds with many

20:36

black women being forced to care

20:38

for the children of their enslavers.

20:41

That lead the foundation for the idea

20:43

that this work was not worth

20:45

paying for. During the

20:47

civil war, nursing emerged

20:49

as a job that mostly women did.

20:52

And for the confederacy, that actually

20:54

included enslaved women.

20:56

When slavery was abolished, women

20:58

were affected to step into the roles that enslaved people

21:00

were doing, that included care work.

21:02

And often, these were actually the

21:04

very same women who had done

21:06

this work under slavery forced into

21:09

unethical employment contracts with

21:11

wealthy white landowners. Since

21:13

the civil war, women have

21:15

clawed their way into the paid

21:17

workforce despite endless efforts

21:19

both overt and more subtle to

21:21

keep them out. And the fields that

21:23

were a little easier to get into as

21:26

a woman tended to be

21:28

these caregiving professions? So

21:31

women were in the past

21:33

and continue to be very prominent in

21:35

caregiving roles. whether that was

21:37

family caregiving or professional caregiving,

21:39

a lot of these roles involved child

21:41

care, nursing, domestic

21:44

work. That insidious

21:46

history, the one that built care work

21:48

on a foundation of enslavement,

21:50

has meant that even now,

21:52

care workers don't get the same kinds of

21:55

protections and pay as other

21:57

industries that don't have the same

21:59

history. In nineteen

21:59

thirty five, the US passed something called

22:02

the National Labor Relations Act

22:04

and then three years later, similar law called the Fair

22:06

Labor Standards Act

22:08

that

22:08

protects workers from harassment,

22:11

from over time

22:13

withholding from unfair hiring

22:15

and firing practices.

22:17

That's Dr.

22:17

Alana Leaglaser, an assistant professor

22:19

of Anthropologie at St. John's University.

22:22

So these two laws were in theory

22:24

great for workers, except that

22:26

they said that the protections they

22:28

outlined do not apply

22:30

to domestic workers. because

22:32

it takes place in the home and because

22:35

there are all these impressions about who does

22:37

it and whether or not it

22:39

constitutes real work, that kind of thing.

22:41

One

22:41

of the key demands of the civil rights

22:43

movement in the nineteen sixties was for

22:45

labor protections to be extended to

22:47

these kinds of jobs that work largely

22:49

done by black workers. In the

22:51

nineteen seventies, activists had some success

22:53

at getting these laws amended.

22:56

But there are still places where labor protection

22:58

laws exclude care work. That's

23:00

actually how Alana got interested in

23:03

this topic. I'd

23:04

come out of some labor union

23:07

organizing and was interested in those

23:09

questions, but also had a strong kind of

23:11

feminist bent and really

23:13

wanted to ask questions about where working women were

23:15

fighting for improved

23:17

wages, better conditions on

23:19

the job, better, maybe, political

23:21

recognition. And I came to this organization in

23:23

New York called Domestic Workers

23:25

United. That is a

23:27

activist organization representing

23:29

home health care workers, child care

23:32

providers, and house cleaners throughout New

23:34

York. And for about ten

23:36

years, they lobbied the

23:38

New York state legislature to

23:40

pass a series of

23:42

laws that are codified as the New

23:44

York domestic worker bill of rights.

23:45

Over

23:46

half of the people who work as home

23:48

health aids in the United States are women

23:51

of color. And nearly forty

23:53

percent of them were born outside the

23:55

United Estates. And many of these

23:57

workers are employed by private

23:59

companies and classified as independent

24:01

contractors, which means they don't

24:03

get health insurance or other

24:05

benefits. These companies don't actually have very much overhead.

24:07

They basically just have a computer and

24:09

a rolodex of workers.

24:12

they

24:12

typically charge something

24:15

like two times the

24:17

rate of what they pay to the people who

24:19

work for them. So they might

24:21

charge your eye, twenty dollars

24:23

an hour to care for our

24:26

loved ones, and then the person

24:28

actually doing the work might see ten

24:30

dollars or eight dollars an hour of

24:32

that amount, even though again,

24:34

there's not -- there isn't

24:36

overhead enough to account for

24:38

that gap. And in

24:39

some cases, the workers actually have to pay

24:41

the company for their placement.

24:43

And the way

24:45

that it works In many cases, though not all, is

24:47

that the job seeker themselves pays

24:50

a small portion of

24:52

their first week's pay.

24:55

to the placement agency. So the

24:57

income generating component of the job

24:59

placements agency actually

25:01

is on the backs of the workers.

25:03

Often,

25:04

these firms don't seem

25:06

to really care if their workers are

25:08

treated well. And that

25:09

also extends to incidences

25:13

where the home healthcare workers

25:15

report, you know, being mistreated, not

25:17

being able to access food on the job,

25:19

not being able to find a safe and

25:21

comfortable place to sleep. being berated,

25:23

being locked in the homes where

25:25

they spend sometimes one, sometimes two,

25:27

sometimes three weeks working twenty four hours

25:29

a day.

25:30

The Ain't Iowoman

25:31

campaign, which is a group of workers

25:33

who organize for the rights of laborers,

25:35

including home health aids in New York

25:38

City has a series of testimonials on

25:40

their site about the ways that these companies

25:43

exploit their employees.

25:45

One caregiver, Rureet Lin Wang, says

25:47

that quote, long term twenty four

25:49

hour care work made me anxious, nervous,

25:52

sleep deprived with aching limbs

25:54

and waist, high blood pressure, and stomach

25:57

disease. You could say that I too become

25:59

a patient. Another worker, Wheeling

26:01

Chen, said that the company that she worked

26:03

for, quote, told home

26:05

attendants, do not give water to patients at

26:07

night, do not get up from bed to change

26:09

their diapers. ignore the patient when

26:11

they call for help. End

26:12

quote. Right now, eight

26:14

Iowomen is organizing to try and end

26:16

twenty four hour care shift

26:18

in New York City, which often wind up stretching

26:20

to as long as seventy two hours for

26:23

these workers without any

26:25

breaks. And Alana says that in her

26:27

research, she found that some of these employers

26:29

treat their workers essentially

26:32

as disposable. this agency

26:33

in particular and others like it,

26:35

particularly preyed upon people who

26:37

had relatively recently immigrated to

26:40

New York and had few other options because they were waiting

26:42

for paperwork to go through or were

26:44

waiting for official documentation

26:46

that might make working

26:48

elsewhere more feasible.

26:50

And since the firm

26:50

is getting a kickback with every new

26:53

placement, it makes sense that they don't

26:55

mind cycling through workers at

26:57

this rate. These firms

26:59

illustrate something that Alana has called the

27:01

uberization of senior care.

27:03

This idea has two parts.

27:05

The first is what we talked about. All these industries,

27:07

senior care, included, are trying

27:09

to save costs by misclassifying workers

27:12

as independent contractors.

27:15

the apps or companies control access to these

27:18

workers and take a cut, but they don't

27:20

offer their workers any kind of

27:22

protections or benefits. The

27:24

second piece of the uberization of an

27:26

industry is surveillance. We

27:28

talked last week about the ways that facilities

27:30

will install cameras without really talking

27:32

to their patients. But it's worth noting that

27:35

often facilities are installing cameras

27:37

without talking to their workers

27:39

either. And in many cases, these

27:41

cameras are there to

27:43

watch employees as much as they are to watch patients.

27:45

There are these real

27:46

time locating systems where

27:49

nurses' movements are literally tracked

27:51

throughout a like acute haired hospital

27:53

or a long term living facility. In the

27:55

past,

27:55

workers would be required to call

27:58

and clock in using a

28:00

patient's home phone. Now there are apps

28:02

that track them through their entire

28:04

visit and cameras that watch them

28:06

while they're in the room.

28:09

technologies that track direct care

28:11

employees are often justified in two

28:13

ways. The first is by arguing

28:15

for efficiency. saying that

28:17

we need to maximize every single

28:19

second of time that a worker has

28:21

and we can do that by tracking their

28:23

every move. if you have listened to

28:25

this show at all, you probably know.

28:27

I feel about that argument, which

28:29

is in part that there is often very

28:31

little evidence that tracking people act

28:33

actually leads to increased efficiency. And

28:36

in the case of care

28:38

in particular, perhaps

28:40

shooting for maximum efficiency

28:43

should not be the goal. There ends

28:45

up being a

28:45

kind of objectification of

28:48

the elderly people in their

28:50

care. bodies because they're sort of moving through these processes as

28:52

quickly as they possibly can.

28:54

And then that leaves the emotional,

28:57

relational, cognitive needs

28:59

of elderly patients

29:01

unattended to because it's simply

29:04

infeasible. The second

29:05

reason you see people arguing for tracking

29:07

workers is the idea that employees need to be

29:09

tracked because of course, they are going

29:12

to do a bad job if they

29:14

are not.

29:15

the surveillance and the tracking and the

29:18

reporting of work tasks,

29:20

of work hours tends

29:22

to have a strong

29:24

kind of surveillance

29:26

component that assumes the people

29:28

who do these jobs are

29:30

going to clock out early or

29:32

are going to fail to complete important

29:35

tasks that the patients and their care

29:37

rely on them for, or that they

29:39

will take advantage of the system.

29:42

A

29:42

lot of knows this firsthand because for a few years,

29:44

she actually worked for an elder care

29:46

company herself. And she

29:48

says that that experience helped

29:50

her know what to ask when

29:53

interviewing fellow workers. I

29:55

knew that, you know, for example, I haven't

29:57

gone a day without

29:59

being struck by the woman that I

29:59

take care of if she hits me every

30:02

time she sees me. So I was,

30:04

you know, all of a sudden asking people

30:06

who did care work in the home? Have you ever

30:08

been struck? Have you ever been pinched? Have you ever

30:10

been bitten? Now, for a

30:12

long time, I think that there has been kind

30:14

of an antagonistic relationship,

30:16

between disability activists who

30:18

might reside in some of these places, and

30:21

the worker activists representing

30:24

these workers. So for example, when I spoke with

30:26

Kate Swaffer about cameras, her

30:28

first reaction was that they could be useful

30:30

to catch cases of abuse in

30:32

nursing homes, perpetuated by

30:34

the staff. if

30:35

I was the

30:37

family member or legal guardian,

30:42

what

30:42

I have been. Obviously, I said that early,

30:44

I've been one for three people.

30:46

I wished I had surveillance cameras

30:49

in their rooms. you know, we've got footage in Australia

30:52

of a a care worker

30:53

smothering someone's

30:55

face with pillows.

30:57

This

30:58

does happen and it's

31:00

terrible and should absolutely not

31:03

happen and catching these people is

31:05

worth trying to do. We're gonna talk more

31:07

about the conditions in nursing homes

31:09

next week. But it's also worth noting

31:11

that cases of direct abuse

31:13

like this at the hands of

31:15

care workers are maybe not as common

31:17

as we might think.

31:19

Elder abuse is way underreported.

31:22

I think that people often

31:24

imagine they think about their abuse,

31:26

horrendous physical and sexual abuse in

31:28

nursing homes by staff. Right? And

31:30

that's a huge problem.

31:33

But especially when we're studying

31:35

surveillance technology, the reality of

31:37

abuse among older adults is that

31:39

it's far more common at the hands of family

31:41

of spouses and adult children

31:43

than it is by

31:44

personal aids or

31:46

workers. That's

31:46

doctor Clara Barahji the social work

31:48

professor who studies aging and technology.

31:51

And so there's

31:52

a kind of presumption that

31:54

the women who do this work

31:57

might cut corners or might not provide an

31:59

adequate level of care even though there's

32:01

almost no evidence of

32:03

widespread patterns of that kind of

32:05

neglect or time theft,

32:07

and there's very little evidence

32:09

of widespread incidences of abuse,

32:11

you know, for example.

32:13

I think the key thing

32:13

that I wanna say here is that this doesn't

32:16

have to be an eitheror

32:17

situation. These two

32:18

groups actually have way more in

32:21

common than they do that separates

32:23

them. Both groups are suffering while the

32:25

people who run these institutions and

32:27

companies are making money.

32:29

a baseline assumption that workers must

32:31

be surveilled in order to not be

32:34

abusive or neglectful. It doesn't

32:36

exactly make for a great work

32:38

environment. I mean, like imagine this. Imagine if you got to work and your

32:40

boss was like, okay. My assumption is

32:42

that you are a terrible person and a

32:44

terrible worker who will probably abuse and

32:46

neglect your post and so I

32:48

am going to watch every single thing you do so that I can

32:50

catch you. It doesn't really like

32:53

make you want to put your heart

32:55

and soul into a job. Does

32:57

it? We talked last week about the ways in

32:59

which constant surveillance can impact

33:01

a patient, but it also impacts

33:03

the care they receive and

33:05

the working conditions. when

33:07

a technology, like a camera, for

33:10

example, in a nursing home resident room,

33:12

is used pretty clearly to

33:14

surveil the worker. it can send a message that they're not trusted

33:16

to provide for the patient's best

33:19

interests. And then the ethical

33:20

concern is that could

33:22

erode ethical concerns is that could erode

33:24

their

33:24

sense of being the trusted responsible care

33:27

provider. Another thing that nursing

33:29

homes or care facilities will do to

33:31

save money is to employ only a

33:33

small number of people who aren't

33:35

adequately trained in the job, and

33:37

then it's sort of up to families and residents

33:39

to employ additional people who

33:41

have less training to fill the

33:43

gaps. Anna says that she

33:45

experienced this herself. She was hired

33:47

essentially to provide social care

33:49

for a conversations, hanging out with

33:51

her, keeping her cognitively stimulated,

33:54

and so

33:54

I wasn't, like, clued into

33:57

or trained in how to also address some of the physical

33:59

aspects of her condition that

34:01

were present and they were present throughout the

34:03

time I spent with her

34:05

and because of the very very narrow

34:08

scope that my role entailed because of

34:10

this kind of process of having like

34:12

essentially I was

34:14

paid to fill in one little hole in what would have

34:16

previously been a much more integrated care

34:18

work position.

34:22

it ended up meaning that the times that she was with me, she

34:24

was not getting adequate physical

34:26

care because I hadn't been

34:28

trained to do it or expected to

34:31

do it. And I was particularly struck by

34:33

the fact that no one except

34:35

for other workers on the floor

34:37

mentioned to me what her

34:39

physical needs were.

34:41

Technology comes into play here too.

34:44

In some places, there is one nurse

34:46

on call watching a wall of

34:48

screens with feeds into

34:50

people's rooms. responding only if there is an

34:52

emergency. Actually, the way that

34:53

Kaiser Permenente does it, they

34:55

have nurses observing

34:58

these, like, closed circuit television another Estates. And

35:01

then they call the floor

35:03

nurse and say, hey, did you know that

35:05

room 302 needs

35:08

help getting to the bathroom or whatever it is. And there's like, related problem

35:11

where there's constantly buzzers and

35:13

alarms going off

35:16

because that patients are so heavily surveilled in both

35:18

long term living and acute care facilities. And

35:20

so they like to start tuning out

35:22

these alarms because they're so

35:25

frequently going off an error. And so it's

35:28

like like that kind of like over stimulation

35:30

problem where you're just becoming

35:32

accustomed to having all of your

35:34

patient's alarms buzzing at once, and then you actually go

35:36

to check on it and nothing has

35:38

happened. So there's a real

35:40

desensitization to

35:42

these these bells and

35:44

whistles that all of the surveillance

35:46

technology give

35:47

off to, like, alert

35:49

someone to come help. All of

35:51

this reduces both the workers and older people in

35:53

these situations to sort of cogs

35:55

in a machine. to

35:57

things that be maximally efficient,

36:00

constantly surveilled, and constantly

36:02

scrutinized. And it

36:04

matters that these workers are treated

36:06

fairly. I mean, just because the baseline

36:08

everyone should be paid fairly and treated

36:10

well at work. But also

36:12

because if workers are

36:14

underpaid, miserable, and

36:16

being exploited, Their work isn't going to be very

36:18

good. The health of

36:20

patients

36:20

is so intricately connected to the working

36:24

conditions of caregivers,

36:26

whether it's nurses or doctors

36:28

increasingly doctors are subject to the

36:30

same kind of capitalist efficiency

36:33

policies that nurses and home

36:35

health care and elder care providers have long

36:37

been subject to

36:39

And what

36:39

that means is that every

36:42

interaction becomes a

36:44

business transact rather than an act of

36:46

care. A lot of told one story about the

36:48

woman she was caring for and a situation in

36:50

which she needed a

36:52

diaper change. she did not

36:53

want a diaper change. And that's

36:56

such a private and personal and an

36:58

invasive experience.

36:59

In this

37:00

moment, as a care provider,

37:02

you have to wait into some murky

37:04

ethical waters. Right? On the one hand,

37:06

you want to respect this person's autonomy.

37:08

On the other hand, there are risks to letting someone spend too

37:10

much time in a soiled diaper. At

37:12

the time, Alana was able

37:16

to ask for help from the certified nursing assistant on staff

37:18

and they worked it out. But

37:20

in a future where these places keep

37:22

shifting further and

37:24

further towards efficiency and

37:26

surveillance, that negotiation

37:28

looks really different. My

37:30

prediction is that

37:32

the cost saving imperatives

37:34

that the kind of emphasis on efficiency,

37:36

that the understaffing, the

37:39

pruning of workers repertore

37:42

of, like, duties

37:45

and tasks, worsens those kinds

37:47

of conflicts because it's

37:49

just there's so much more pressure to get things done quickly so

37:51

that you don't have time

37:54

for, like, more nuanced coaching and

37:56

discussion or

37:58

more kind of flexible negotiation. I'm

38:00

like, okay, now is not the time to change that

38:02

diaper. I can come back, you know, or I can

38:04

get someone else who you're more comfortable

38:06

with. Earlier in

38:06

this episode, we talked about the demographic trends

38:08

in aging and about how in

38:10

the next few decades there will be

38:13

a huge increase in people who

38:15

need care. Meanwhile, the actual number

38:18

of people who work in the direct care

38:20

industry is decreasing, and

38:22

it's not really hard to understand why.

38:24

Right? We just talked about how this industry pays really poorly and

38:27

often includes exploitative workplace

38:30

conditions. One solution

38:32

that people raise is outsourcing, which brings

38:34

us back actually to Missy from last

38:37

episode. Care dot coach

38:39

health advocates are not based in the

38:41

United States. And we hire them like in

38:42

the Philippines and Latin American countries for

38:45

Spanish. Victor likes

38:46

to

38:47

brag about the rigorous hiring

38:49

process these workers go through. Howard Bauchner: Yeah,

38:51

a lot of

38:52

these are secret sauce because as far as I know,

38:54

we're the only company in the world that actually,

38:56

like, does exactly this. But the the

38:59

overall of it is that it's a quite

39:01

a sophisticated process. We end up

39:03

hiring one percent of

39:06

our applicants. So it's,

39:07

like, easier to get into, like,

39:10

you see Berkeley or Stanford or

39:12

something something like that?

39:13

Potential workers

39:14

go through a bunch of steps and

39:16

screenings and trainings. And here is what he said when I

39:18

asked how much a care dot coach

39:21

employee gets paid?

39:24

I

39:24

will compare it to what a

39:26

registered

39:27

nurse who got a

39:29

bachelor's degree in nursing.

39:31

would make if they commute it

39:33

a couple hours a day to a

39:35

local hospital in the Philippines and work the

39:37

grueling twelve hours shift, that's

39:40

what

39:40

what they mean they make.

39:42

According

39:42

to Indeed dot com, the average

39:44

salary for a nurse in the Philippines

39:46

is twenty one thousand pesos a month,

39:48

which is about three hundred and seventy dollars.

39:51

comes out to an annual salary of about

39:53

five thousand dollars. Which ends

39:55

up being very cost effective

39:57

here in the US. If you

39:58

are part of the FlashForward Book Club, you might remember that we

40:00

read a book called ghost work all

40:02

about remote, largely international workers

40:06

at the power dynamics at play in those kinds of jobs,

40:08

which is complicated and

40:10

fraught. But there are lots of things that

40:11

these remote

40:14

workers can't do. Lots of people, millions

40:16

of people need in person

40:18

care. And across the United

40:20

States, people are finding that they're simply are

40:24

not workers taking those jobs. People who used to

40:26

be employed by these elder care firms

40:28

are deciding to move on.

40:31

often if they can transitioning to better paying

40:34

healthcare jobs, but sometimes

40:36

leaving care

40:38

work entirely. And again, this

40:40

is only going to get

40:41

worse, unless

40:43

we

40:44

do something. And

40:45

there are things to do. both

40:48

culturally changing how we think about

40:50

senior care and politically

40:52

demanding that these workers and programs

40:54

get the funding and pay

40:56

they deserve.

40:57

In general, I think we tend to shove the idea of aging

41:00

off into its own little

41:02

box. But this is really all

41:04

about care.

41:06

caring for one another in all kinds of

41:08

stages of life. And if we

41:10

reevaluate how we think about care,

41:14

who does it and what it's worth, we can start to imagine

41:16

a better future of aging.

41:19

My kind of

41:20

real big pie

41:22

in the sky kind of romantic vision of

41:24

these things is that you were it

41:27

possible to have a society organized

41:30

around caring for one another, caring for ourselves rather than sort

41:32

of spending every waking moment, selling

41:34

our labor power so that we can afford

41:36

to eat and have a home

41:39

that there would be, like, ample easy

41:41

resources for a kind

41:44

of seamless aging process

41:46

or seamless process of illness and wellness that didn't have to

41:48

be isolating or

41:50

alienated and that didn't result

41:52

in that kind of fracturing of

41:54

our sense of our physical needs from our

41:57

emotional or cognitive needs. Next

41:59

week, we're going to try

42:00

and sum all of this up. So

42:03

what does it look like to age in the future? Where

42:05

do you want to grow old? Why is

42:07

there still such a big gap between

42:09

what people want and what

42:12

people get? And what can be done

42:14

about it?

42:21

That's all for

42:24

this

42:26

episode. FlashForward is hosted by me,

42:28

Rose Eveleth, and produced by Aussie

42:30

lina Skidman. The intro music is by Asura, and the outro music

42:32

is by Hasulonia. The episode art is

42:34

by Maddie Luchansky. Come back next

42:36

week for our

42:38

final episode in this series

42:40

about the real stories and research that inspired welcome to Vanguard and Steaks.

42:44

Until then.