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Stuck at the nursing home door:
Organized labor can't seem to get beyond the institutional model

By Marta Russell

Marta Russell is author of Beyond Ramps: Disability at the End of the Social Contract.

The money
Do the math
Crips are profitable
In November, voters in the liberal city of San Francisco approved a $299 million bond issue to rebuild one of the largest publicly-run nursing homes in the nation. "Proposition A," to rebuild the 130-year old, seismically unsafe Laguna Honda, passed by well over the two-thirds margin needed. It was one of the most expensive bond issues ever approved by the city's voters.

Laguna Honda is the largest nursing home in California. It's also the employer of 1,000 members of the Service Employees International Union Local 250.

The campaign to rebuild Laguna Honda began two years ago. Backers of Proposition A spent about $700,000 to influence voters to pass the measure, says the San Francisco Examiner, and of that amount, $93,000 came from labor unions.

The political action committee of San Francisco's FDR Democratic Club of seniors and people with disabilities had come out against rebuilding Laguna Honda. The Independent Living Resource Center of San Francisco, the city's independent living center, argued for a commitment of "resources to community living options."

The bond issue exposed a chasm between the goals of the independent living movement and the goals of a union which has only recently gotten involved in in-home services.

Disability activists felt betrayed by the union's drive to rebuild Laguna Honda. The union had "crossed the picket line," as one put it. They charge the SEIU, which represents workers in both private and public nursing homes, with "remaining entrenched in institutional-care models of service delivery"; they say the union has a vested interest in protecting union jobs in the institutions.

According to an article in the San Franciso Chronicle, Laguna Honda "is not just a source of jobs to the union. The publicly run center is a model for how unions think workers in this industry ought to be compensated for the unpleasant, often back-breaking chores they perform."

The SEIU represents nursing home and "home healthcare" workers in various settings, both in California and across the nation. Recognizing that low worker wages and lack of healthcare benefits play a major role in both the scarcity of attendants and high turnover in this line of work, the SEIU, the World Institute on Disability and California's independent living centers united in 1992 to force the state to upgrade its In Home Supportive Services, a program based on what the state called the "independent provider" model. The "independent providers" are the attendants themselves; they're considered self-employed and work directly for the disabled person who hires them. Their pay, which is approved by the disabled person they work for, comes from a combination of federal, state and county funds, and is usually no more than the $5.75 per hour minimum wage. The important thing about California's independent provider legislation, say activists, is that it lets people with disabilities select, direct and terminate their own attendants.

In the mid-1990s, San Francisco, San Mateo, Alameda, Contra Costa, Los Angeles and Santa Clara counties opted to set up Public Authorities to serve as the designated "employer of record" for these independent attendants, for collective bargaining purposes. (Sacramento is currently in the process of setting up a Public Authority as well.) The SEIU became the union for these workers.

Workers at Laguna Honda -- "orderlies," the Chronicle calls them -- reportedly make $14 to $15 an hour "and enjoy a full complement of benefits.

"Turnover at Laguna Honda is negligible, compared with rates of 100 percent in some private nursing homes," reported the Chronicle.

Laguna Honda's high wages are unusual. Average pay for a nursing home worker is $7 an hour, and few would argue that nursing home aides don't need better pay. The issue is one of pay parity: that $7/hour average is $1.25 more per hour than IHSS workers receive; $14 an hour is well over double what most in-home workers make.

Seniors and people with disabilities in California today find it almost impossible to find or keep attendants. When nursing home aides can systematically get higher wages than in-home workers, it doesn't require much analysis to realize that workers will go for the job that pays better. The bulk of both nursing home aides and IHSS workers come from the ranks of high school dropouts, immigrants, single mothers, and waitresses. Many are working two jobs to make ends meet.

Over the last three years, only one county has significantly raised pay for IHSS workers: San Francisco. Last year SEIU Local 250 and disability activists joined forces to demand a fair wage, and last July Mayor Willie Brown signed a $9/hour wage agreement with 6,500 San Francisco in-home workers, with full-medical benefits (See D. R. Nation, The Ragged Edge, Sept./Oct. 1999). But the vast majority of the 180,000 workers across the state -- serving approximately 200,000 people with disabilities -- still earn the minimum wage of $5.75 per hour. They get no benefits, no vacation, and no sick pay. In a interview last summer on Los Angeles' KPFK radio, Democratic Assembly member Gilbert Cedillo, the former general manager of SEIU Local 660, praised the strategic success of unions in getting more money for nursing homes, but failed to mention that IHSS workers had gotten the shaft in the governor's budget (see accompanying story).

Local 660 represents more than 42,000 Los Angeles County workers, ranging from librarians to health care workers to janitors. Yet Cedillo, a member of the Budget Committee and the Appropriations Committee, didn't even mention in-home workers.

Local 250 says it agrees that "non-institutional care" must be expanded, and it has worked to raise attendants' pay in San Francisco. Yet its position paper on the rebuilding of Laguna Honda warned that "we should not make the mistake of assuming that the shift away from institutional long-term care settings to community-based care models will satisfy the dramatically increasing demand for long-term care."

In testimony before the Senate Special Committee on Aging nearly two years ago, the national SEIU, representing nearly a million nursing home workers across the nation, voiced concern about substandard care at nursing homes. "Our members witness first-hand the abuses that hinder their ability to give nursing home residents the care they deserve," said SEIU International President Andrew Stern. "Nursing homes are cutting back on staff and supplies at the same time that the number of older, sicker patients entering these homes is greater than ever before."

Senior groups have in recent years become increasingly vocal about deplorable conditions in nursing homes, yet Stern's singular focus on jobs and staffing seems reactionary. It ignores the central issue: few people ever want to live in a nursing home. Why does the SEIU not go beyond "reform" and push to progressively change the paradigm of long-term care to the "independent provider" model?

If the average cost is $40,000 a year or more to keep someone in a nursing home (or $90,000 in the case of Laguna Honda), then people with disabilities should be allowed to use that money for services at home. With such an amount, workers can certainly get paid a decent wage -- with benefits. Such a move would benefit SEIU's workers far more than increasing wages in institutions.

The majority of nursing home and home care corporations operate for profit. To maximize profit, they cut corners in quality of care and keep worker pay low to show their owners and investors as high a return as possible on their money. Home care corporations charge the state $16.50 an hour and pay the worker little more than minimum wage.

Corporate managers and owners reap 6-digit salaries and bonuses, while workers, paid below a living wage, are given more tasks than they can physically, emotionally or safely handle. This is a corporate agenda, one that exploits both labor and disabled peoples' bodies for the benefit of the few at the top.

Disability activist Patrick Connally talks about what he calls "the harvesting of people to fill beds": "Pro-institution professionals justify their lockup of people without an involved family, people who need accessibility, people who talk too much, people who are not the beautiful disabled," he says. "All can be safely hidden" -- and those who hide them can "gain social status."

Under this "money model of disablement," the disabled human being is a commodity, around which social policies are created or rejected based on their market value. A rejection of the nursing home corporate paradigm means a rejection of the logic that human labor and disabled people's bodies should be reduced to commodities for sale. The "independent provider" model of in-home services gets rid of the "disabled person as a market commodity": there's no "profit" involved in the transaction between the worker and the disabled individual. Money that would go to profits is freed to be used to raise wages and provide benefits.

Standing strong on principle, Local 250 says it doesn't support for-profit nursing homes. That can be understood in the context of progressive unions' accurate perception that the profit motive takes dollars away from both quality care and worker take-home pay. But progressives' understanding seems to stop at the door of state-run institutions, which are viewed as bastions of liberalist social services and often represent the culmination of long union struggles to organize the state workforce.

Supporters of institutions do so because it's one way to avert a loss of funding that perpetuates the system which both employs and validates them. But fears about job losses have often diverted organized labor from a longer-range understanding of issues. Unions' preservation of jobs in logging, for instance, have rammed up against the goals of the environmental movement. As with the environmental movement, labor must understand that it too will benefit by making personal assistance services the dominant long term care model in the nation. Union workers themselves become disabled; many will require long term care as they age. How many workers would really like to live in the institutions they now work for?

The same negligence, substandard care, physical and emotional abuse and rape that unions say occur in for-profit nursing homes also occur in state-run institutions. Abuse is epidemic in all institutions; and in agency-run home care as well. At least with the independent-provider model, people can select and direct their attendant themselves -- and fire an unsatisfactory or abusive one.

Promoting social justice for workers means joining the struggle for living wages and health care. Promoting social justice for people with disabilities means advancing real choice to live where one wants, rather than condoning the current system which commodifies disablement for profits,perpetuating institutions to warehouse undervalued members of our society.

The money
According to HCFA, in 1996 Medicaid spent $29.6 billion on nursing homes and $10.9 billion on "home health."
The Medicaid Community Attendant Services and Supports Act -- MiCASSA-- would change the institutional bias of the current Medicaid long term care delivery system. The bill was introduced in the Senate November by Sen. Tom Harkin (D - Iowa).

Do the math...

Laguna Honda gets
per year per "bed," reports the San Francisco Examiner.

Home care corporations charge the state
an hour.
Corporate managers and owners reap
Workers get little more than the

The "independent provider" model of in-home services gets rid of the "disabled person as a market commodity": there's no "profit" involved in the transaction between the worker and the disabled individual. Money that would go to profits is freed to be used to raise wages and provide benefits.

Crips are profitable

The corporate solution to disablement -- institutionalization in a nursing home -- evolved from the cold realization that people with disabilities could be commodified; we could be made to serve profit because federal financing (Medicaid funds 60 percent, Medicare 15 percent, private insurance 25 percent) guarantees an endless source of entrepreneurial revenue.

When a "bed" is occupied in an institution, it generates $30,000 to $82,000 in annual revenues for nursing home corporations (Laguna Honda gets $90,000 a year per bed, reports the Examiner). Electronic brokers on Wall Street count that bed as an asset to a companies' net worth. People with disabilities are "worth" more to the Gross Domestic Product when occupying a bed in an institution than when they're living in their own homes.

-- Marta Russell

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