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Caring for America$

Eileen Boris and Jennifer Klein

Print publication date: 2012

Print ISBN-13: 9780195329117

Published to Oxford Scholarship Online: May 2012

DOI: 10.1093/acprof:oso/9780195329117.001.0001

“The Union Is Us”

(p.149) 6 “The Union Is Us”
Caring for America

Eileen Boris

Jennifer Klein

Oxford University Press

Abstract and Keywords

This chapter looks at the ways that community organizing and political unionism together improved the lives of home care workers and won rights admit a renewed assault on the welfare state. President Reagan shifted the fiscal, ideological, and political ground away from national programs and state funding, cutting benefits and assaulting public employees. Oregon took advantage of his Medicaid waivers to enhance home and community care because a mobilized senior movement had paved the way for a decade. Elsewhere, labor organizers engaged in trench warfare. Beginning as part of the United Labor Unions of the Association for Community Organizations for Reform Now (ACORN), SEIU Local 880 in Chicago developed successful models to win real gains from private agencies as well as government. What began as a militant community organizing movement generated adaptive strategies for union growth in an increasingly hostile anti-labor, neoliberal climate. The effectiveness of a metro-level alliance between unions and contractor agencies, however, was most realized in New York City where the National Union of Hospital and Health Care Employees Local 1199 spearheaded a pattern setting agreement in 1988. The rights of poor women as both clients of and workers for the welfare state defined these union struggles.

Keywords:   President Ronald Reagan, Omnibus Budget Reconciliation Act of 1981, Claude Pepper, Cooperative Home Care Associates, Oregon Project Independence, ACORN, SEIU 880, Illinois Home Care, National Homecare Systems (Addus), Local 1199

On Halloween 1988, 75 Chicago home care workers shouted in front of the Evanston residence of Janet Otwell, director of the Illinois Department of Aging (IDOA): “No more tricks, treat us with dignity and respect!” For weeks Otwell had rebuffed their requests for a meeting, so these black women, members of SEIU Local 880, finally took dramatic action. Seeking to draw attention to “poverty wages and the union busting activity of vendors in the state’s home health care program,” they marched on her lawn, posted notices on her door and those of her neighbors, and caused a commotion reminiscent of the heyday of the welfare rights movement. Declared 880 President Irma Sherman: “The vendors are making a tidy profit and we are left living from paycheck to paycheck, with no health coverage and no benefits to speak of—we’re tired of their bag of tricks….”1 Since IDOA set the framework for elder home care, the union demanded a voice in policy making, along with advocates for the aged. Local 880 got the attention of the state and soon became a player in home care politics.

Community organizing and political unionism, Local 880 found, could together improve the lives of home health care workers. On the one hand, SEIU had discovered an alternative route to unionization through grassroots action. Rather than an offshoot of a preexisting local, Local 880 began as part of the United Labor Unions (ULU), a project of the Association for Community Organizations for Reform Now (ACORN). ULU represented a workforce counterpart to the neighborhood organizing of ACORN. On the other hand, given the structure of home care, as New York unions knew well, it was never enough just to win collective bargaining rights with individual agencies. To make economic gains, the union had to go to government. But with Reagan era assaults on public benefits and government employees, turning to the state for economic rights was no easy matter. Reagan shifted the fiscal, ideological, and political ground within American federalism away from national programs and state funding of social services, so political unionism would require innovative tactics and new allies.

(p.150) Ronald Reagan had spent eight years as governor locking horns with social justice advocates. As president, his agenda for restructuring and downsizing the federal non-defense budget was not just aimed at defunding hard-won social assistance programs; it also sought to undercut the power bases of urban minorities and liberals. Within months, he pushed through cuts in Aid to Families with Dependent Children (AFDC) and anti-poverty agencies, new and more restrictive payment methods for Medicare and Medicaid, massive tax cuts for businesses and individuals, and the substitution of block grants to the states for separate funding of social services and welfare.

The Democratically controlled Congress initially did little to stand in Reagan’s way. Both parties linked the economic difficulties of the 1970s to excessive public spending, government regulation, and waste, fraud, and abuse within social programs. They agreed that more market competition was the solution to health care inflation; the disciplining effects of the market would solve the problems of allocation and lack of access. Reagan expanded the project of deregulation already under way from the Carter years. “Removing government’s smothering hand” not only meant liberating private industry but also downsizing the state. In one of his first acts in office, Reagan froze all civilian federal hiring, which he promised as a step toward cutting the federal payroll by a projected 75,000. On a crest of cultural and social resentment, Reagan announced confidently, the era of governmental expansion was over.2

Reagan’s policies not only targeted the public budget but also aimed to discipline labor costs across the economy. Firing the striking air traffic controllers in August 1981, Reagan sent a message to corporations that they too could now resist workers’ demands. After that, companies began to openly use permanent replacement workers with impunity; strikes became a losing proposition in the 1980s. The combination of Reagan’s high interest rate Federal Reserve policy, toleration of steep unemployment, refusal to create a jobs program, and anti-unionism drove down wages across the nation. Americans found themselves struggling in what at the time was the worst recession since World War II, with fewer resources to fight back.3

Thus home care organizing seemed poised to take off at an inauspicious moment. Having blamed their workers for inflation, governments at all levels sought to restrain the growth of the public workforce. In the private sector, a new anti-union consulting industry provided firms with a host of resources to fight off unions, subvert the National Labor Relations Board (NLRB), and eliminate militant employees. In the early 1980s, home care organizers faced formidable obstacles.

Not the least of these hurdles came from Reagan’s embrace of home care as compatible with private solutions for public responsibilities. Issuing yearly proclamations for National Home Care Week, Reagan praised certified agencies as (p.151) well as individual caregivers for maintaining the independence and dignity of elderly people and reducing medical costs.4 He celebrated such private solutions even while eliminating the very public funds that social welfare agencies depended upon. Home care organizers had to counter such ideological appeals to independence and redeploy this rhetoric to obtain state funding.

Chicago’s Local 880 would develop successful models to win real gains from private agencies as well as government. The union learned to pressure state and local officials for pay increases and higher contractor reimbursements. What began as a militant community organizing movement generated adaptive strategies for union growth in an increasingly hostile anti-labor, neoliberal climate. The rights of poor women as both clients of and workers for the welfare state defined this struggle.

Launching the Reagan Revolution

Unions in the 1980s faced the challenge of figuring out the structures of an ever-evolving welfare state upon which their success depended. Their task became daunting because the president and Congress pushed through policy changes in so many major areas. Within the political economy of human services, workers and managers, administrators and consumers seemingly all at once confronted policy transformations in health care, welfare, tax, trade, and employment. States tried to capitalize on and at times dodge the imperatives of the New Federalism. These changes also opened social provision to profit-seeking players.

Congress permitted for-profit agencies to provide Medicare-funded home care services for the first time in 1980. It eliminated the three-day hospital stay prerequisite for home care and loosened some of the regulatory requirements for home health agencies. Claiming that nonprofit providers had impeded the growth of a home care market, some Medicare administrators argued that the use of for-profit enterprises would lead to competition, efficiency, wider access, and cost savings. Traditional agencies would have to imitate for-profit innovators or lose out.5

This particular policy change affected the entire market for home care, even though Medicare, with its requirements for medical certification, was not at this point a major payer. (Less than 1 percent of Medicare’s budget went to home care services.)6 To participate in Medicare, proprietary agencies had to offer “skilled nursing care.” Given consumer demand, however, they added homemakers and health aides, expanding the paraprofessional end of the labor market. While public funding assured a steady income, the same companies also served private-pay clients. The proprietary agencies were more likely to rely on part-time employees and temps. Growth in demand for subsidized services drew (p.152) women into this field, and yet limited hours of employment forced them to pick up more than one job to make ends meet.7

This Medicare precedent spread to other social programs. Soon Medicaid and various services for the elderly allowed for-profit contractors, who from then on became central players. By mid-decade, new proprietary chains dominated the field of home health.8 Beginning with a 1981 executive order, President Reagan had enshrined a general model for social policy that intensified reliance on the private sector to solve public problems and thereby decrease dependence on government. During the next several years, the Reagan administration transferred numerous areas of social and urban policy to “private sector action.”9 Allowing for-profit contractors seemed a small step, in keeping with developments of the 1970s, but the Reaganite restructuring of the American welfare state magnified its consequences and more fully placed its private-public contours into a neoliberal mold.

To gain greater control over social spending, Reagan used the budget reconciliation process to bypass congressional committees and convert large chunks of the social budget into block grants. Block grants represented both a fiscal and a political strategy originating in the Nixon years. As fiscal strategy, each block grant would consolidate myriad federal programs under one general category, but with a budget ceiling, so that states would have to make tough decisions about how to divvy up limited money for health care, education, and community development. Politically, the block grants approach would loosen congressional control over specific social programs by shifting political decision-making to the states.10

The Reagan administration sped up block grants with the Omnibus Budget Reconciliation Act of 1981 (OBRA), probably the most significant piece of social legislation since the Great Society. Instead of matching state expenditures, the new law capped federal outlay for almost all programs, with a 22 percent cut in federal funds across the board. Federal aid to state and local governments declined in absolute dollars for the first time in two decades. Simultaneous individual and corporate tax cuts assured a lack of additional revenue flow, even if Congress had second thoughts.11

OBRA 1981 aimed to up-end the War on Poverty—permanently. Its transformative impact lay not just in the reduced level of federal funds. It blindsided the big cities and rebuffed their recently mobilized constituencies of African Americans, Latinos, poor people, feminists, and public employees. With block grants, state governments could displace economic and social welfare programs run by big cities, especially those under Community Action Agencies (CAA) that had served as the institutional vehicle for the urban poor to challenge state and local governments. Now Reagan finally gave state officials the political relief they sought by placing the funding of community services directly under state (p.153) governments. This law further undermined Community Development Corporations, the vehicle New York City had turned to in the 1970s for home care, by prohibiting funding from the federal block grant. But many CAAs had mutated into vital deliverers of social services, with some becoming Area Agencies on Aging. Never much invested in them, states responded to federal cuts by spending less of their own money and exerting more control over agency budgets and activities. The result was a slow choke.12

Under the new block grants, states had to select which social services to reduce or eliminate. Some of them ended day care, counseling, and child protection. Administrators shifted costs to users through increased fees and eligibility restrictions until programs served only the poorest households. Through the 1982 Tax Equity and Fiscal Responsibility Act, which set stricter limits on hospital reimbursement, states also could impose deductibles, co-insurance, co-payments, or other user charges on services for the needy.13 As officials in California, New York, and Oregon—states heavily reliant on these monies—recognized, funding cuts undermined whatever benefits came with the increased flexibility of the New Federalism.14

States turned to Medicaid to make up the loss. Medicaid increasingly became their long-term care program, with a heavy emphasis on institutionalization. Elderly and disabled persons represented a small proportion of recipients, yet their expenditures consumed a substantial chunk of the Medicaid budget. At the beginning of the 1980s, 42 percent of Medicaid outlays went to nursing homes.15 Not only had Medicaid come to dominate state and local health budgeting, amounting sometimes to one-third of expenditures, it was often the largest program in the whole state budget, accounting for 20 percent of annual outlays, with the fastest-growing rate of spending.16 Under these stresses, state Medicaid directors claimed that they had to make trade-offs between the elderly and primary care for women and children.17 In turn, these pressures drove Medicaid reform onto the federal agenda.

Responding to legislators’ alarm that Medicaid spending had reached critical levels, the Congressional Budget Office proposed remedies premised on reducing costs in an era of tax cuts. While it recommended restricted eligibility, co-payments for physicians’ services and hospital stays, and individual curtailment of use, it hoped to gain the biggest savings from interjecting the state into a whole range of family decisions. Law could force relatives to take financial responsibility to “reduce federal and state expenditures for institutionalized people.” But questions of care and obligation were not so easily sorted out and the cost-benefit calculation not so clear-cut. The Congressional Budget Office wondered, for example, “Are only biologically related children responsible for their parents? … Should children be required to support their biological parents, even in instances in which these parents provided little or no support to (p.154) their children?”18 Could the state really determine, let alone enforce, who owes what to whom within families?

Resolving the ambiguities of care could not rest strictly on budget analysis. The route forward represented an opportunistic convergence between liberal advocates for the elderly and the Reagan administration. Medicaid “reform” became an early test case of Reagan’s promise to restore “the 10th Article of the Bill of Rights”—to hand back to the states anything that was not explicitly given to the federal government in the Constitution.19 At the same time, the perpetual limitations that Medicare and Medicaid placed on home care support frustrated liberals on the House Select Committee on Aging, especially Claude Pepper and Henry Waxman, who advocated that state Medicaid programs develop their own alternatives to institutionalization. As a result, the 1981 budget bill included changes to Medicaid that allowed states to redirect funds away from institutionalization into home- and community-based long-term care by applying for a waiver from federal requirements. The Department of Health and Human Services (HHS) would grant a state a three-year waiver that could be renewed for another three years. The state could provide Medicaid reimbursable home care to those who would otherwise require institutionalization, if such services cost less. Waivers could restrict recipients to “only efficient and cost-effective providers”—a new specification that dovetailed nicely with opening up government-funded services to private industry.20 Such compromise by Republicans and Democrats ended up furthering a neoliberal agenda.

Welfare Redux

Cutting labor costs proved to be the primary method for expanding the home care system. Once again, welfare policy seemed in sync with these demands. Relying on advisers from his years as governor, Reagan won two such reforms in OBRA 1981: states would be permitted to initiate Community Work Experience Programs for AFDC recipients, and they could apply for broadened waivers from AFDC rules to encourage “welfare to work.” The Reaganites failed at requiring workfare, but states steadily applied for these waivers, some 38 of them within the next six years. The Reagan administration boasted of creating “new-style workfare” that would not merely “deter loafers” but would “rehabilitate the dependent poor.”21 Reaganites and conservative governors revived rehabilitation to meet the imperatives of the privatizing welfare state.22

To reduce both welfare dependency and elder institutionalization, OBRA authorized demonstration projects to deploy AFDC recipients as homemaker–home health aides. Seven states—Arkansas, Kentucky, New Jersey, New York, Ohio, South Carolina, and Texas—with different welfare philosophies, administrative (p.155) centralization, and capacity for delivery of social services participated in the project.23 As in earlier eras, program evaluators insisted that everyone gained: trainees increased their earnings and labor market skills; clients benefited from improved mental and physical functioning; and taxpayers found their money well spent.24 The upshot was that home care more firmly became integrated into workfare. Looking back at this evolving relationship in 1992, social work scholar Davida Unterbach described it as “a public works program” where “two ‘client’ groups are united, one to help the other, both impoverished.”25

How AFDC recipients felt about these jobs varied. Activists, we have seen, dismissed them as just another form of low-paying domestic service. Other women interviewed during these demonstration projects reinforced evaluator findings. As one San Diego woman admitted, “You can work a schedule so you can be with your children. It helped me a lot. I’ll tell you, because I was so glad to get off of welfare.” Many women lived in households where various welfare benefits—Supplemental Security Income, AFDC, Medicare, and housing subsidies—enhanced their incomes. Some found in home care greater freedom than a job in an institutional setting, whether a hospital or an office. What disappointed these workers were not only the low wages but also the paucity of hours, which were often less than necessary to qualify for medical insurance or other available benefits.26

In the 1980s, government channeled work-based “rehabilitation” through private-sector jobs. Previously, the Comprehensive Employment and Training Act (CETA) had aimed at job training and job creation through public service employment; the ACORN unions initially set their sights on these workers.27 In contrast, Reagan’s Job Training Partnership Act gave federal funds to the private sector. At a time when 14 million Americans were unemployed, this program, senators insisted, would lead welfare recipients to “economic independence.” Rather than aiding these poor women to find good jobs, it helped private employers locate temporary, low-wage workers.28

An exception to this general trend developed in New York, where in 1985 a cooperative home care agency in the South Bronx began training women on welfare as home health aides, offering them an opportunity to have a stake in the enterprise. Rick Surpin of the Community Service Society established Cooperative Home Care Associates (CHCA) as an experiment in worker ownership with funding from religious organizations, the United Hospital Fund, and the National Co-op Bank. CHCA would cater to a new niche for medically related home care, such as taking blood pressure, which more rapid release of sicker people from hospitals had created.29 Through upgrading opportunities, some workers became paraprofessionals, allowing the cooperative to expand its range of services. Its future became secure after winning sub-contracts from the Visiting Nurse Association and Montefiore Hospital. By 1989, its 100 members could vote themselves an equivalent to a shareholder dividend.30

(p.156) CHCA transformed lives through training, education, and the labor itself. “There’s little techniques that they show you,” one woman explained. Popular education methods reached women with limited schooling but who had lifetime experience caring for relatives and neighbors. Ana Cuevas expressed the feeling of many members when she told interviewers in the mid-1990s, “Cooperative is an open door for a woman to become independent … to feel that she is somebody.” Nonetheless, workers and managers realized the fiscal constraints under which they labored. “I know we need a raise,” one woman admitted, “but if you can’t get it, you can’t get it, that’s all. Because Medicaid is cutting out and this is cutting out and that is cutting out. So what can you do?” This worker-owner displayed a kind of fatalism that union organizers would counter by directing member ire toward employers and by fighting for greater state funding.31

Grey Power and the New Federalism in Oregon

Not sure whether home care was cheaper, or whether the federal government would back up its new policy priorities beyond the short term, few states rushed to implement such programs. Oregon was the exception. The first state to apply for a Medicaid Home and Community-based Services Waiver, it had used federal and state funds to develop alternatives to institutionalization since 1981. Eventually, 73 percent of its Medicaid long-term care budget went to home care. Policy discussions of long-term care usually begin with the Oregon wavier, but this seemingly trail-blazing action was possible because a decade-long social struggle had won seniors the right to independence through home care.32

Oregon’s home- and community-based programs originated in homemaker and chore services, which, like almost all public health efforts, were located at the county level.33 Populous counties drew upon federal monies for social services, especially after the 1965 Older Americans Act; so did private organizations, such as the Portland-area Kaiser Permanente Health Plan.34 With Older Americans Act support, Oregonians formed viable Area Agencies on Aging (AAAs) at the county level to deliver home and community center meals to a wide range of citizens, including elderly Japanese, Jews, Latinos, and Native Americans. Senior centers provided legal counseling, shopping assistance, and chore and homemaker services.35 Nonetheless, as the decade wore on, an extraordinarily high percentage of older people remained institutionalized.

Frustrated elders began organizing through publicly funded senior centers, demanding that policy makers curb nursing home admissions, which had grown at twice the rate of population growth for those over 75. In 1973, a legislative Special Committee on Aging toured the state listening to them. To its surprise, the Committee found seniors incredibly well mobilized, with bills in hand and (p.157) prepared to lobby. Seniors urged the Committee to recognize in-home services as a viable alternative to institutionalization.36 Out of this initiative came Oregon Project Independence, enacted in 1975 as federal Social Service block funds became available, which provided people over 60 with some housekeeping, meal preparation, and personal care. It covered low-income seniors not on Medicaid through a sliding fee schedule, an important universalizing component.

Two years later, activists kept their movement going by forming the United Seniors Cooperative. They brought together the Gray Panthers, Retired Teachers’ Association, NOW’s Older Women’s Task Force, Salem’s National Council of Senior Citizens, AAAs volunteers, union retirees, and retired government staffers. In the midst of an economic recession, United Seniors’ political demands for remaining in the community, what began to be called aging in place, started to look fiscally attractive. Certainly, Oregon Project Independence was cheaper than nursing home confinement, since it depended on both low-paid workers and volunteers subsidized by the Older Americans Act.37

Lacking the institutional and financial capacity to develop these services more systematically, the state obtained two demonstration project grants from the federal government to run short-term, community-based care in four counties. While this project failed to lessen poverty, either among elderly women or workers, it apparently proved that community-based care offered tremendous savings over nursing homes.38 When the Oregon Department of Human Resources tried to limit the autonomy and activity of the AAAs and exclude United Seniors from the planning of a new state-level division, irate seniors went straight to the governor, who quickly handed the proposal over to them for revision.39

The social service infrastructure of the welfare state became a site of mobilization. Because they were organized at the county level, seniors were well situated to influence the new home care policy, even as the state transferred its caseload mostly to Medicaid. United Seniors initiated a series of open, participatory meetings at senior centers and AAAs, continuously lobbied legislators, and established conferences with state welfare administrators. During 1981, senior activists led the lobbying effort and, by the end of the summer, the legislature passed two landmark bills that together constituted the Oregon Plan. One established a new agency, the Oregon Senior Services Division, and the other announced a State Policy on Aging. The state would support elders in the least restrictive setting possible, maximizing in-home, community-based, and independent living to promote “independence, dignity, privacy, and appreciation of individuality.” The state would relocate nursing home residents capable of living elsewhere, with cost savings reinvested into community-based care.40 The organized seniors had won.

Only then did Oregon apply to Health and Human Services for its pioneering waiver in order to fund alternatives to nursing homes. Home care became a right: anyone who met the criteria would be enrolled.41 The majority of relocated clients, (p.158) however, had no home to return to and could not live alone, so the adult foster home emerged to meet this need. Proprietors could develop a supervised living situation for up to five elderly persons in a private home. In the 1980s, these homes proliferated rapidly and became a more widely used option for those who could purchase care on their own through the market. Later in the decade, the Salem Statesman-Journal observed, the “Senior Services [Division] is such a large buyer of elderly care services that its actions help shape the entire long-term care industry.”42

For those who could stay home, the state offered two possibilities, both transferring responsibility to the private sector. AAAs could contract with service providers, such as state-licensed home care agencies. Oregon also established an independent provider system, wherein individuals hired and supervised an attendant. Despite receiving wages from the state, here, too, attendants became independent contractors, not state employees. Further, the state wage and hour code, following the FLSA, exempted companionship services and household work related to the care of an elderly or infirm person, removing precisely those services—“fellowship, care, and protection” and “meal preparation, bed making, washing of clothes”—that the state had agreed to compensate through its long-term care policy. Also excluded were resident managers and caregivers in adult foster homes.43

By the end of the 1980s, the state and the AAAs faced troubling labor shortages and high turnover rates. Demand for services had risen dramatically, but the number of workers stagnated because the pay was so low. In 1989, Oregon secured a demonstration grant, proudly billed as “Who Will Care?,” to focus on recruiting and retaining long-term care workers, increasing their “self-esteem,” and standardizing training.44 Counties generated public relations remedies, including an “in-home care workbook,” “Careers in Caring” public service announcements, and employee recognition rituals. They did nothing about wages, health insurance, or immigrant support services—remedies that may have enabled low-wage workers to become more economically secure. All the emphasis was on the caring nature of the job—none on its employment aspect. As if to devalue the labor further, the Central Oregon Council on Aging established a volunteer program with unpaid students performing in-home care.45 Nonetheless, Oregon showed that the state could organize long-term care to meet the desires as well as the needs of senior citizens. Whether those who did the labor of care also could obtain recognition and dignity still remained an open question.

The New Political Economy of Home Care

Nearly all other states eventually joined Oregon in acquiring Medicaid waivers for home health care during the 1980s. But the waivers were a limited policy solution, since they were not meant to open the door to higher levels of social (p.159) spending. States had little choice but to make sure that home care was much cheaper than nursing homes. The number of people requiring the service grew rapidly, partly owing to demographic trends. In the 1980s, the elderly population increased at twice the rate of the population under age 65, reaching 28 million at mid-decade, with a historic rise in the number of persons living beyond age 75, and even 85.46 Longer life expectancy meant more people with chronic illness. Yet, during the Reagan years, states had to prove that per capita spending under a waiver would not exceed what spending would have been without it and, further, that aggregate program costs would not be higher than previously. In the name of state flexibility, federal regulations imposed tight control on the net cost of new home- and community-based services.47 In 1987, Congress placed a cap on a state’s total Medicaid long-term care expenditures.48

Fiscal imperatives of the 1980s exposed the contradictions of relying on the acute care model as an overarching framework for long-term care.49 The government no longer wanted to pay for indefinite hospital care. Before 1983, Medicare paid hospitals retroactively, after the patient had received treatment, for however long. Under the new mechanism of prospective payment, Medicare announced in advance what it would pay based on medical diagnosis. If a hospital offered treatment costing more, it would have to absorb the difference. The new approach reduced payments to providers, leading hospitals to discharge patients with greater needs earlier. The demands on home care soared.50

With entry into the home health market deregulated, the home health sector became the home health industry. Medicare-certified agencies proliferated rapidly after 1980, especially proprietary firms. For-profit agencies jumped tenfold in the first half of the decade, capturing 30 percent of the market by 1986. Their growth introduced intensified competitive pressures into home care. After the beginning of Medicare prospective payment, hospitals moved to recoup lost revenue by expanding more aggressively into home health care, opening their own agencies, subsidiaries, or joint ventures. These joint ventures might be with nonprofit charities, for-profit agencies, or even pharmaceutical companies. Large chains also emerged from two different ends of the market: health care and domestic labor. More attuned to the workings of the market than traditional visiting nurse associations, these new providers created an industrial infrastructure, including professional journals and trade associations, such as the National Association for Home Care and the American Federation of Home Health Agencies. In the mid-1980s, home health care products and services grossed an estimated $9 billion.51 Despite their private nature, these proprietaries relied heavily on public spending.

Congress began to wonder what the government was getting for its money, which amounted to nearly $3 billion dollars by 1986.52 Under the leadership of Democratic liberals, the House Select Committee on Aging announced (p.160) aggressive action to address the many grievances it had received from elderly Americans. A decade had passed since Claude Pepper and his colleagues had tried to enact home care entitlement and protection. Now once again the Committee tried to push forward a bill. A commissioned report and hearings bore a title that captured the liberal conundrum: “The Black Box of Home Care Quality.” Recognizing a new booming industry, fueled by government funds, Committee members acknowledged a government obligation to protect and regulate. The obstacle, as they saw it, arose out of “the in-home location of the services … [which] makes their actual delivery essentially invisible and therefore largely beyond the easy reach of public or professional scrutiny.” Following revelations of nursing home abuses, representatives feared the worst. They could only declare, “the quality of care in the home is a ‘black box’—a virtual unknown.”53

The Black Box hearings highlighted “exploitation” as a key problem within the home. With great urgency, Chair Edward Roybal (D-CA) framed the challenge of long-term care in the 1980s as one of consumer protection against “unreliable and poorly trained aides” and “questionable care techniques.” This consumer protection stance led to a definition of exploitation that positioned workers as perpetrators and consumers as victims. On the list of exploitations were “failure of workers to appear on time and sitting down on the job”; “inadequate or improper performance of duties,” physical harm to and abuse of clients, “tardiness or failure to spend the specified amount of time,” and “theft and financial exploitation.” Legislators perpetuated long-standing racialized stigmas attached to black women workers when they pointed to “attitudinal problems, insensitivity, disrespect, [and] intimidation” of clients. It never occurred to them that home attendants faced exploitation or that restrictive policies and lower funding had anything to do with deteriorating care.54

At the height of the Reagan era, these legislators relied on the market models infiltrating all realms of social policy, rather than asking whether budget cuts compromised quality. Committee member John McCain (R-AZ) was an exception in wondering, “Why is the reimbursement rate so low?”55 But the Committee was unwilling to debate the relationship between strategies of cost containment and quality of care. Instead, it weighed the consequences of policy intervention within restricted ideological parameters. Committee members wanted to increase consumer “choices” in the marketplace, alleging that it would improve accountability, yet discourage consumer “over-utilization.” Assuring quality required new standards, but accreditation, it was claimed, burdened proprietary agencies with an additional cost barrier. Well-intentioned regulations, the Committee insisted, would create a greater administrative burden and narrow the range of providers willing to enter the market.56

For San Franciscan Hadley Hall, who represented the social welfare community at the hearings, the inability to move past a medical model of care was also (p.161) deeply connected to the gendered nature of the labor. He urged legislators to see the labor question as central to improving quality. “[T]he reason this problem exists is because most of the work … is a mothering function activity,” he asserted. Comparing the home aide’s tasks with those of hospital and nursing home workers, Hall explained, “When we perform exactly the same functions in the home, those euphemisms become cleaning, shopping, cooking, laundry, help with personal care and transportation, and that’s women’s work and by God, we shouldn’t have to pay very much for it because that is done with love and affection.”57 Until Congress repaired the policy that “split the social from the health,” long-term care would remain an insoluble dilemma.58

In the end, Roybal’s Home Care Quality Assurance bill took the form of a “bill of rights for home care consumers” without reforming the structure of the industry or the labor conditions generated by earlier politics and policy. Thus, it included grievance mechanisms, consumer input in program evaluation, quality assurance monitoring, training certification, and a home care ombudsman to investigate consumer complaints.59 Although not passed on its own, various pieces of this bill made their way into law through the budget act of 1987. Health and Human Services followed up with new consumer protection requirements, ignoring labor protections.60

Ultimately, Congress was caught in a contradiction of its own making. Advocates wanted to help the worthy recipients of the welfare state, America’s elderly population, and even recognized that the problem lay not solely in the home but in the realm of policy. They grasped that “the limited Medicare definition of home health services no longer serves as a useful benchmark for home care. It is out of step with the changing marketplace which has recognized a broader, evolving range of needs and services essential to maintain people … in the community.”61 That limited definition, of course, came from the medical model imported directly into Medicare at its inception in 1965. It reflected not the reality of home care needs, but rather the political balance of power and professional authority at the time. Within 20 years, it clearly had become anachronistic. The question for Congress was how to bring about change. What structural, fiscal, or social arguments could be made to push aside the medical model and have government pay for assistance with daily tasks of living, services historically defined as welfare support? In the Reagan era, this challenge became ideologically insurmountable. Not only had Reagan’s assault specifically discredited welfare and social services; Democrats and Republicans alike thoroughly imbibed market discourse and the idea that too much regulation hurts the market. Although long-term care persisted on the national agenda, expanding the actual availability of home care to mass numbers of Americans remained on the cutting room floor. It did not even make it into the ultimately ill-fated Medicare Catastrophic Coverage Act, the first major amendment to Medicare, passed in 1988 and revoked one year later.62

(p.162) Consequently, Claude Pepper also introduced a separate bill that year to cover home care through Medicare, but congressional Democrats were in no mood to fight for a “big government solution.” When the powerful chair of House Ways and Means, Dan Rostenkowski (D-IL), moved to block it for reasons of personal turf, Democrats professed their love and respect for the venerable 89-year-old Pepper but brought the bill down to defeat. House leaders assured Pepper that his chance would come again. Soon afterward, America lost its fighting champion for the elderly when Pepper died in May 1989.63

Community Organizing in the Welfare State

On the ground, the Reagan revolution looked more like trench warfare. While the president fought against entitlements from the top down, women claimed rights as both clients of and workers for an embattled welfare state. They brought the home into the center of the welfare state and the union movement into the home.

In the mid-1970s, Illinois took advantage of federal monies to develop community care for the elderly. It intended to meet basic needs but did not count on the numbers of widowed, older women who soon applied for home care. A long waiting list quickly developed. When Mrs. Annie Benson, an African American in her seventies with multiple chronic conditions, found herself on that waiting list, Legal Aid—Reagan’s old nemesis—sued the state. A federal court ruled that the waiting list violated equal protection; persons on it were as entitled to services as those already receiving them. With the mandated dissolution of the waiting list, Benson’s case classified home care as a new entitlement.64 In an environment of tax cuts and budget ceilings, that entitlement could become a reality only by creating an arena of struggle in which workers refused to play their role—providing care on the cheap.

Like New York and California, Illinois initially ran its home care program out of public welfare, assisted, like Oregon, by Area Agencies on Aging.65 Home care served not only as an alternative to institutionalization, but clearly, union organizers charged, “as a way to implement a ‘workfare’ program to get people off of public aid”—although it paid so little that “some are forced back on Public Aid in their struggle to keep their families fed and clothed.” As one activist worker explained, “The State thinks they can get away with this because we are black, brown, and female.”66

In 1979 Illinois established two programs to pay for home care through its general revenues. The Illinois Department of Aging (IDOA) started the Community Care Program, which contracted with a wide range of nonprofit and proprietary agencies to offer homemaker and housekeeping services to those (p.163) over age 60. As in New York, workers became employees of vendors rather than the state. Disabled people under 60 would receive similar assistance from the Department of Rehabilitative Services (DORS). In keeping with the ethos of independence, DORS relied on a different mode: clients hired their own providers, who could be family or friends, with the state claiming to be a co-employer. Once again, government created distinctive job categories with unequal reimbursement rates for similar work. Home care remained a welfare program, open only to the needy.

Despite an apparent expansion of the welfare state, Illinois seriously underfunded home care.67 Even after Benson’s suit forced the IDOA to expand the service, the state still appropriated only $23 million in 1983, one-third of what Massachusetts, for example, spent. Reimbursements to provider agencies lagged months behind.68 Under pressure to enroll all those who applied but unwilling to raise state revenue, Illinois chose two strategies. IDOA added an income ceiling and required user fees for the first time. It also looked around for other sources of funding, applying in 1983 for a waiver to cover personal care service for those eligible for Medicaid. From 3,600 clients in 1979, the caseload grew to 17,500 with the waiver; five years later, it expanded to 27,000 elderly recipients per month.69 By 1993, IDOA vendors employed over 10,000 workers, with some 2,500 in the union. In granting such waivers, though, the federal government demanded that states keep the cost of home care measurably below that of institutional care.70

DORS operated statewide and was equally desperate for funding. It received a federal Medicaid waiver in 1984, covering 50 percent of the cost per person. The client hired, fired, and supervised the worker but DORS set the wage. For homemakers and housekeepers, DORS kept wages at the federal minimum of $3.35 through most of the decade. In the mid-1980s, an estimated 2,500 workers serviced DORS clients statewide, about half of whom worked in Chicago and Cook County. They had no hospital or medical insurance, paid vacation, compensated sick days, life insurance, or compensation for time spent traveling to and from clients’ homes, often on long bus and subway rides.71

ACORN came to town to change all of this. It started community organizing among Chicago home care workers in 1983. Key ACORN leaders and rank-and-filers came out of the welfare rights movement. Along with other radicals of the period, they had developed a sectoral analysis that linked low-wage workers with those on public assistance, including poor single mothers. ACORN formed the United Labor Unions (ULU) to organize low-wage workers outside traditional workplaces. Like the United Farmworkers, ULU sought to enhance participation, mobilization, and militancy among low-wage workers. It would “build an organization first” that could maintain itself during workplace campaigns that could take years. Members paid dues from the moment they signed up, well (p.164) before the union had certification or a contract; for people who made little, handing over that few dollars a month cemented organizational loyalty.72

Head organizer Keith Kelleher arrived from a successful campaign among fast-food workers in Detroit. A graduate of Fordham University, he came out of the Catholic social justice tradition. During his childhood, his grandmother, who had labored as a domestic, took him along while caring for “shut-ins.” Kelleher left his native New York after college and headed to Detroit with the Jesuit Volunteer Corp. Through the local Catholic Worker House, he met radical priests who connected young peace and anti-nuclear activists to labor politics, from the UFW boycott to striking newspaper workers. There he also joined ACORN, which trained him as an organizer in the late 1970s.73 When ACORN reassigned him to Chicago, Kelleher set about cultivating Catholic Church support for organizing the poor. Putting together proposals, he jokingly considered himself a “Catholic grant writer,” substituting his own lyrics to the Beatles’ “Paperback Writer.” Indeed, he succeeded in recruiting support from various Catholic social action funds, along with the Discount Foundation and others in the ACORN network. Members themselves also engaged in perpetual fund-raisers to keep the union going, including canvass collections, bake sales, raffles, dollar parties, and event fees—the money gathering techniques of grassroots politics and African American community support. Selling dinners and tickets at senior homes proved doubly advantageous: organizers could meet aides and educate recipients on the issues while raising funds.74

Kelleher not only drew upon his own organizing experiences, but he also tapped those of an already successful ULU local in Boston. Organizers there discovered hundreds of disgruntled and militant African American, Latina, and Caribbean women working below the minimum wage for agencies with contracts from the state. ULU learned where to find these workers; how to follow the money trail; and how to take advantage of the structure of home care—its ties to the welfare state and the bonds between workers and clients generated through the labor process itself.75

The Chicago organizers perfected the practice of grassroots activism. They went to the places where the workers were, rather than spending all their time trying to obtain a list of workers from reluctant government offices or contractors. They stood at bus and subway stops and roamed the hallways of housing projects and the streets of neighborhoods. As Kelleher explained: “You have to build your own list. You do this by hitting the check pickups, in services [training], and company events on a regular basis and passing the cards and making the contacts.” Building the list often meant “dumpster diving”—scavenging through the garbage dumpsters for monthly employment rosters tossed out by the agency. Member-organizers held thousands of house visits, established organizing committees, and cultivated leadership among the local women. Turnover (p.165) and isolation meant that the employer did not have much daily control over the workforce. Thus, according to Kelleher, “If you do the work and get to enough workers fast enough, you have as much access and influence … as the company does and that is the key!”76

Early on, Kelleher concluded that “the political reality is that the clients are too infirm and the companies too competitive to get together to raise the necessary hell with the government agencies, executive and legislative bodies to make the programs work the way they should.” Thus, he asked, “Who better than the homemakers themselves, acting in their own self interest and out of genuine love and concern for the clients they see every day, can carry the fight for decent, adequately funded home care programs?” The union had to organize the clients, going to where they lived. Kelleher shrewdly noted, “It is obvious that there [sic] issues are real and life and death and could help us immensely because if we don’t organize them, then the state will organize their leaders against us.” Increased state funding would allow clients more hours as well as improve worker paychecks. “The clients could also give us a tremendous boost in the public’s mind and lend us even more legitimacy and moral superiority over the state.” In short, home care organizing required an effective citizens’ organization of workers and client/consumers with churches, other unions, and community organizations as allies.77 ACORN, churches, and the AFL-CIO initially constituted its organized allies, but by 1993, the union also worked with various local disability rights and independent living groups and organized seniors, including the feminist Older Women’s League.78

In the face of home care’s tangle of public/private authority, SEIU 880 combined community organizing, legal suits, direct action, and political lobbying with agency-by-agency bargaining. It built loyalty and trust through participation in local campaigns against redlining in African American neighborhoods and for affordable housing, cheaper banking fees, and a citywide living wage ordinance. Often, monthly union meetings were as much about these community issues as about specific organizing drives or contract negotiations. ULU got members involved in political work right away. Starting with the 1984 campaign season, its members registered 1,500 new voters and did extensive phone banking for Senator Paul Simon, who won a narrow victory. From then on, 880 brought out volunteers for political campaigns, especially for the offices of mayor and governor. They helped with the reelection of Chicago’s reform African American mayor, Harold Washington.

The union remained rooted in the ACORN culture. Personal ties undoubtedly helped: Kelleher’s spouse Madeline Talbott headed ACORN in the city. But these key activists stayed behind the scenes. The union consistently cultivated rank-and-file leaders from among home attendant members, like local presidents Irma Sherman and Helen Miller. The women created a social world (p.166) around the union, with regular meetings, parties, barbeques, recognition ceremonies, letter-writing campaigns, marches, and neighborhood alliances. Monthly meetings seemed like “almost religious experiences” filled with “emotion and spirituality.” Reports described how “workers will rise and testify about how they have to work three jobs caring for others to make ends meet but no one cares for them….” They held “speakouts” and “honk-ins,” stopping traffic. They linked low wages, misuse of public funds (spent on union-busting lawyers rather than going to clients and providers), and institutional racism, deploying tropes of slavery, dignity, justice, and rights. Like home care workers elsewhere, Mary Jones, who worked for a vendor that refused to settle with the union, pronounced, “It’s just not fair! This isn’t a job—this is Slavery!”79

An involved workforce remained essential to 880’s vision of unionism. Without member participation “in all aspects of the organizing committee and the Local then you are beat before you start,” Kelleher argued, “because the economics of the industry are such that members have to be involved in every step or they will think the ‘union’ has sold them out or didn’t fight hard enough, and if they aren’t involved in the negotiations, and the march on the capitol and the meetings with the legislators, they will never understand it or believe you.” Only an active membership could hold the staff more accountable.80

Still, Local 880 and ACORN ran up against the public-private conundrum that shaped home care employment. Vendors claimed that the state was the employer or co-employer, and the state argued that the vendors were the responsible party. As one worker at a 1985 public hearing complained, “We are volunteering ourselves, but there is no consideration (to us) as employees. The clients think they are our boss, and in a way they are. We have no guidelines.” Another testified, “They say we are not state workers. We don’t know who we are. We go to work, but we have no one to complain to. We are unidentified.” The state considered itself merely the agent of the client who received vouchers to pay attendants, who came under the Domestic Workers Law. But the state determined from the outset “that (the) federal minimum wage would be used.”81 Once again, workers felt they were treated like maids or servants.82 Yet, when the union tried to gain redress for wage and hour violations, it found itself stymied by the 1975 FLSA companionship restrictions. The union had to prove that the worker spent most of her time on domestic tasks. It had to deny the emotional labor involved in home care.83

ULU 880 won its first victory at National Homecare Systems (NHS). While the union grew in members throughout the 1980s, NHS remained the only shop under contract, anchoring the union during its formative period. It produced the first generation of leadership, women such as Irma Sherman and Doris Gould. Here they honed their tactics: recognition actions, member bargaining, direct action, political pressure, and strategic use of consumer “choice.” The NHS contract established standards—not only for wages and benefits but also through a (p.167) “Dignity and Respect” clause, grievance procedure, and even a union shop. The union and company formed a workable partnership in fighting for increased funding from the state. NHS became the model, as Local 880’s workers at other agencies fought for years to win recognition and contracts.

NHS began as McMaid, Inc., typical of the new “temp labor” companies emerging in the mid-1970s to dispatch cleaners to homes and offices. When entrepreneur Andrew Wright purchased McMaid in 1979, the company already offered in-home services to elderly public aid recipients in Chicago. Over the next few years, this segment of the business expanded rapidly, especially with state contracts for “chore housekeepers.” McMaid combined flexible low-wage employment with a rigid, authoritarian, and paternalistic management.84 Supervisors called middle-aged, black female employees “girls” and required the wearing of special uniforms. In the fall of 1983, the company formed a new division, National Home Care Systems (soon National Homecare Systems), to service contracts with the Illinois Community Care Program.85

With a cadre of just 15 to 20 paid members, out of a total workforce of 225, the union dramatically made its presence known soon afterward. In October 1983, an organizing committee, led by employees Sherman, Gould, and Juanita Hill, showed up at the McMaid/NHS office on payday, and gathered workers willing to listen to their testimonials of mistreatment and disrespect. “We’re fired up,” as they put it. Sherman, Gould, Hill, and others marched into the offices chanting, singing, and demanding a meeting with the boss. When the executive director came out, Sherman announced that their union was ULU 880, and asked him to sign a “Recognition Agreement.” He declined, called the police, and retreated to his office amid louder chants. Their union had become public; the workers had made their point. This event was the first of many “recognition actions.” Local 880’s collective self-assertion of the union served as an adaptive strategy to deal with the limitations of the NLRB, which by the 1980s had become essentially dysfunctional as management perfected ways to contest every aspect of the organizing process, undermine union elections, and stall bargaining. As lead organizer Kelleher explained, “We didn’t wait for the employer to formally recognize us, but forced the employer to deal with us without official recognition.” The members made it a union, not the state.86

In this case, the union won a formal NLRB election fairly quickly in December 1983; after mild legal protest by the company, the NLRB certified the union two months later and ordered negotiations to commence. Members chose coworkers to serve on the bargaining committee, and soon after elected Sherman their president. Once a nurses’ aide, Sherman formerly was a steward for the early hospital workers’ union in Chicago, the Health Employees Labor Program. Forced to retire from hospital work for medical reasons, Sherman now became a militant, eloquent leader for home care.87

(p.168) The trench warfare, it turned out, would be fought over settlement of a contract. Management evaded, vacillated, and subverted for another year and a half; 880 filed charges with the NLRB against the company for refusing to bargain, only to be sent back into another round of irresolution. Members continued to sign up, pay dues, attend meetings, and serve on organizing and bargaining committees. Being part of the bargaining committee not only enabled these women, most of whom were black, to articulate their specific demands; it also gave them the opportunity to face their white male bosses as equals. Their newsletter, The Homemakers’ Voice, reported: “[Director] Olson knows now that we’re not illiterate, we read our demands to him one by one…. He knows we mean business and we’re just as smart as he is!”88 This was an empowering experience, even as the company stonewalled.

Still without a contract a year later, union members realized they had to ratchet up the pressure. Drawing upon the welfare rights tradition, 880 creatively deployed tactics that crossed public and private domains. When negotiations broke down in June 1985, NHS employees picketed Andrew Wright’s posh Barrington Hills estate. Seeing his swimming pool, multiple garages, and horse stables, Lillie Mae Thomas wondered whether “that’s our money he’s spending on that house and all those cars!”89 Workers also threatened to ask clients to transfer to another agency. In the care work sector, moving consumers from one agency to another had a similar impact to a strike, without leaving those cared for stranded. The Local then gambled on a strike vote, agreeing to walk out on July 1. Notice of the impending stoppage went out not only to the company but also to IDOA. Wright now faced the prospect that the state would drop him as a problematic contractor. A week after paying a visit to his home, the combination of direct action and appeal to the state forced NHS to sign a contract.90

When Local 880 announced victory, it put the union shop at the top of its list of achievements. Everyone who worked 21 hours or more would be required to join the union and pay dues. Well aware that raises were linked to the state budget, 880 astutely included a particular contract reopener: any time the state raised the rate paid to the company, then the contract automatically reopened and the union could negotiate a wage increase.91

They had won a big victory—their first contract—but given the political economy of home care, it was just step one. While negotiating the “private” contract and organizing other shops, 880 put a “raise the rate” public budget campaign in motion, explaining to members, “ULU Members from all over the city have been meeting with the politicians who control the MONEY that the Company you work for gets from the government.”92 Even before the contract settlement, workers voted to take busloads of union members to Springfield to meet with legislators, IDOA staff, and Republican Governor Jim Thompson. (p.169) Member Mary Jones explained, “We have to take it to the top! … Big Jim is the man in charge of this, and he has to hear us!”93

For such battles, ULU locals learned that they needed greater political clout and a larger support network. Wade Rathke, who founded ACORN and ran the New Orleans chapter, negotiated their merger into SEIU. After a member vote, Chicago’s unit became SEIU 880 during the summer of 1985. SEIU affiliation meant, as Kelleher admitted, that “you didn’t have to suck up to foundations. These people just wanted to know, how many are you organizing. They spoke our language.”94 ULU saw SEIU as kindred: it had shown a commitment to organize those left behind by the increasingly sclerotic AFL-CIO and, at the time, allowed autonomy for its locals. Kelleher turned to Gene Moats, president of Joint Council #1 in Chicago, to pressure state and local politicians, obtain lawyers and legal advice, and run interference with other unions. Well into the next decade, the ULU/ACORN network—Rathke, Kelleher, and others—remained intact within SEIU, allied with its director of organizing, Andy Stern, who would become the International’s president in 1995.95

Armed with SEIU resources, Local 880 cut its own political path. It continued with direct action tactics more familiar to welfare rights than to the late-twentieth-century labor movement. Toward the end of 1985, 70 members picketed the governor’s office and won a new state Home Care Task Force, which would enable all players to develop policy guidelines and to coordinate demands for increased reimbursement rates.96 Such political remedies institutionalized the potential of provider agencies and the union to work together in the arena of the welfare state.

One other key factor helped the union win its first contract. A new NHS executive director, Mark Heaney, came on board in May 1985, and he, too, understood the political economy of home care. Where Wright and the previous executive took an ideological hard line against the union, Heaney approached the situation as a pragmatist. He grasped both the potential threat from the union’s appeal to the state and the strategic advantages of “partnership.” Heaney realized that the union’s political organizing and disruption could cost NHS its state contract. After the June 1985 settlement, Heaney developed a respectful, personal rapport with Kelleher; he kept communication open, worked with the union to implement a health insurance plan, and sought out the points where NHS could use the union to increase its client base.97 Heaney was not an unequivocal friend of the union, but he recognized that they had a common interest in protecting the state’s social welfare budget, fighting tax cuts, and disciplining the market.

Where those interests overlapped, the partnership worked. Heaney served on the Governor’s Task Force, too, where he joined the union in pushing to increase the state reimbursement rate. Described by the union as the first substantial raise (p.170) in four years, this 1986 boost helped secure an even better second contract from NHS and affected thousands of other home care workers around Illinois.98 Amid Reagan’s open warfare on the welfare state, the for-profit, corporate NHS distributed postcards to all staff employees to write to the legislature and the governor to support proposed tax increases. “The Aging network is indeed a network and we must all work together to support increased funding,” Heaney wrote.99 By the early 1990s, NHS top management even appropriated the language of justice and comparable worth. Pointing out that Illinois paid more to “a janitor to clean floors and toilets” than to homemakers and aides, NHS owner Andrew Wright asserted “that a gross injustice exists in the reimbursement rates paid for homecare services and that a rate adjustment is due….”100 To coordinate collective bargaining with the state budget process, NHS shared information with the union on hours billed to the state for chore housekeepers and homemakers, and both union and company cooperated to force shady agencies out of the market. In that sense, the union helped to stabilize its industry by setting best practices, rewarding firms that met its labor standards, and policing non-union employers, much as unions like the United Mine Workers and Amalgamated Clothing Workers did earlier in the century.

Cooperation, though, remained circumscribed, especially concerning the balance of power between company and union. NHS and Local 880 did not exactly lobby together. The union sent its people to Springfield, while the company or Association of Home Care Providers worked their own channels of influence. When it came down to dividing up the rate increase between wages and profits, they became adversaries again.101 Meanwhile, the union continually filed grievances against the company on minimum wage violations.

One of the most important changes the union won through the Governor’s Task Force was the end of competitive bidding. In the early years of the Community Care Program, IDOA proceeded like any other state agency: it chose the lowest bids. But underbidding the state’s top reimbursement rate meant suppressing wages to the bare minimum. Since for-profit and nonprofit providers competed in the same market, they equally drove wages down to the poverty level. Elder care, though, was not quite like other state work. With reimbursement rates so low, agencies came and went rather quickly.102 By ending this process, the union put a floor under wages across the industry and gave consumers more stability.

Winning better compensation also meant working the politics of federalism at all levels. In 1986, Local 880 members traveled to Washington, D.C., for a national joint meeting of SEIU with ACORN. They heard Jesse Jackson applaud their efforts to unionize low wage workers, pressured the American Bankers Association to negotiate credit for poor people, and protested against apartheid at the South African embassy—all actions in keeping with embedding union politics in a larger (p.171) poor people’s movement. Most significantly, they met with Congress. Lobbying their local representative, Charles Hayes, paid off in terms of political access if not immediate policy change. Hayes became an advocate for increased Medicaid reimbursement rates, the first step toward higher wages. In Congress, he promoted Local 880’s proposals: greater funding for adequate client hours and living wages, but also prohibitions against vendor discretion “to hire anti-union consultants—(union busters)—denying low income people their right to organize.” The union announced, “Now that we’ve won commitments at the national level, we must, as Local 880 President Irma Sherman says, ‘bring it home, and make our local politicians respect People Power!’” So the local turned out members for public meetings of the Governor’s Task Force on Home Care to push for contracts that put less downward pressure on wages and created incentives for choosing vendors that accepted collective bargaining.103

Through Heaney and Kelleher, NHS and the union leveraged the four-way relations of state-consumer-worker-company to mutual advantage. When NHS sought to provide homemaker services to families in Chicago public housing, Heaney asked Local 880 and ACORN to write letters of endorsement to the Department of Children and Family Services. Kelleher agreed, since it meant more union jobs.104 After new Medicaid rules clarified home care clients’ right to choose a provider agency or switch to a new one, Local 880 mobilized consumers to switch away from union-busting agencies to companies like NHS.105

Nonetheless, maintaining a union shop was difficult. NHS could rely on the structural pitfalls of the job to keep turnover high and union membership in flux. The company did not keep the check-off list current, evaded sending names of new employees to the union, and often failed to deduct union dues from paychecks. The company further devised a new position, the “permanent temporary,” to keep workers out of the bargaining unit. It required perpetual vigilance on the part of 880 staff and workers to sustain the union.106

The staff worked hard as well to cultivate a rank-and-file steward system. Genuinely invested in participatory unionism, 880 sought to adapt the traditional shop steward to service labor in a sector where there was no common shop. They recruited stewards from all agencies and DORS, even if there was no union contract, and offered regular steward training sessions. Stewards helped workers with grievances and moved petitions. They kept up with members by phone. They also planned the agenda of the monthly membership meetings, which were impressively well attended, drawing between 75 and 150 people. But given all that it took to sustain the union and its political work, staff lamented that they could never find enough stewards to take over from them, at least until the end of the twentieth century.107

Expansion outside Chicago generated new conflicts. When NHS sought contracts for other Illinois towns and counties, it sometimes openly fought the union. In (p.172) places like East St. Louis, the workforce in surrounding towns, trailer parks, and rural areas predominantly consisted of poor whites. These workers had their own, if different, traditions of resistance. Where ACORN had a strong presence, it lent significant support and resources to 880 organizing drives in the late 1980s. Elsewhere, the company would be successful in drumming up racialized fears about outside agitators from Chicago.108

The state budget cast a long shadow, yet prompted innovation. When fiscal crisis deepened in 1991, NHS pushed for concessions, insisting that it was at the mercy of state budget cuts. Local 880 tried to turn the pressures of budget politics into a tool to build the organization for the next round of collective bargaining. Unable to win immediate wage increases for current members, 880 experimented with new tactics to leverage the power it had in Chicago. Kelleher suggested to Heaney, “Since the company is asking for concessions and asking for fairness and cooperation in negotiations, we believe it is only fair that National allow workers across the state to freely decide for or against the union.” By the 1980s, labor law allowed employers extraordinarily wide latitude to interfere with union organizing campaigns and to discourage workers from voting to join. Thus locals sought ways to extend the base where they were organized without having to run that mostly losing gauntlet, a strategy that came to be known as “bargaining to organize.” SEIU attorneys proposed a “legal recognition agreement” in which the company consented to neutrality during organizing. Once a majority of workers had signed union cards (card check), the employer either accepted the union or agreed to an accelerated NLRB election.109 The use of neutrality agreements and card check turned into a national strategy within home care organizing, which made sense, given NHS’s presence in California as well. With hostile employers hijacking the NLRB process, the neutrality agreement would become the quintessential tactic for labor organizing in a conservative age, eventually becoming one of SEIU’s hallmark approaches.

The union sought to influence the entire regional labor market for home care, but still required one substantial group of workers to realize this “density” strategy. Illinois’s Department of Rehabilitative Services (DORS) delivered home care not through contractors, but rather through individual personal care attendants or PCAs. With thousands of clients, the number of DORS attendants equaled those of all the IDOA vendors combined. Without them on board, the state had an enormous reserve pool of labor.

In 1985, the State Labor Relations Board determined that the department and individual client were co-employers, which left the PCAs in limbo, like the independent providers in California. The state set the terms of employment, including salaries, service plan, and assessment. It processed the payroll, withholding FICA, unemployment, and worker compensation. Clients, however, had “the sole responsibility to hire, dismiss, train, supervise and discipline (p.173) workers,” even if state counselors advised them in this process. Without jurisdiction over both joint employers, the State Board refused to treat attendants as public employees, undermining SEIU’s claim for a Chicago and Cook County bargaining unit.110

The local proceeded with its organizing project anyway. The state comptroller’s office maintained records of checks issued to the attendants, available for public viewing. Local 880 organizers combed through these and painstakingly built their list. As luck would have it, Kelleher’s father had been a pioneer at Publishers’ Clearing House and coached him on how to set up computerized direct mail. Through such means, organizers reached middle-aged women like future president Helen Miller, a transplanted rural Mississippian who had labored in laundries and factories. Her husband was a union man, and she was among those women whose efforts sustained the black church. Soon she was going along on house visits and, like other DORS workers, participating in the life of the local through membership meetings, fund-raising events, canvassing, and lobbying days. These members led a legislative campaign for a Homecare Workers’ Bill of Rights, collecting pledges from legislators.111

                   “The Union Is Us”

Figure 6.1 Workers and consumers march on Illinois State Capitol, Springfield, 1992. WHI-85573, SEIU 880 Manuscript Collection, Wisconsin Historical Society.

                   “The Union Is Us”

Figure 6.2 Giant penny demonstration at the State Capitol, Springfield, 1992. WHI-85567, SEIU 880 Manuscript Collection, Wisconsin Historical Society.

Demonstrations became public performances, complete with props like a burial casket, live turkey, and giant penny. They bore witness to the refusal of administrators and elected officials to meet with or take seriously the demands of workers and clients. When Secretary of Labor Lynn Martin visited Chicago in (p.174) May 1991, for example, 880 greeted her with the sign, “We Do Our Job. You Do Yours. Enforce Minimum Wage Laws!”112 Chants and songs took center stage at protests that brought together workers and clients already mobilized through various networks (community, ethnic, disability, and age). These performances strengthened the identity of the home care provider and consumer, as well as serving as spaces to launch lobbying and push elected officials. Workers and consumers confronted state officials with the expectation that labor laws had to be extended to the growing care work economy. Public action made visible this “invisible” constituency, warning politicians to take notice of potential voters. It also exposed the vagaries of the social welfare budget.113

The union organized members through electoral districts, so accountability was no idle threat. It mobilized a wide network of friends to pressure the agency, including the Catholic Campaign for Human Development and Carol Moseley Braun, then Assistant Majority Leader of the State House and later the first black woman elected to the U.S. Senate.114 Between 1985 and 1990, through member lobbying and political friends, the union managed to win pay hikes to just above minimum wage.115 Kelleher later reflected, “Legislators recognized us as a union even if the state did not.”116

DORS actively discouraged workers from joining the union. So Helen Miller and the others persisted “just like people did before the NLRA,” Kelleher noted.117 With the help of SEIU lawyers, the local compiled a list of potentially (p.175) serious and embarrassing labor standards violations, and with the political clout of SEIU’s Gene Moats, gained dues check-off and a “Meet and Confer” agreement in October 1990 at the end of Governor Thompson’s term. The state, in theory, had to discuss with the union wages, hours, and working conditions, and provide lists of workers monthly.118 The “Meet and Confer” was a breakthrough, but it was no union contract. DORS administrators would only deal with grievances and the issuance of checks.119 The “Meet and Confer” gave the union an institutional foothold within the state, but as a limited resolution, it required perpetual renewal.

When fiscal crisis hit the state in 1991, the union’s “Raise the Rate” turned into a “Stop the Cuts” campaign. The union had won a major rate increase in 1989, which translated into better contracts from agencies, yet now it was caught in a double squeeze. A federally mandated increase in the minimum wage went into effect that year, but the state refused to raise its own reimbursement rate to accommodate the higher minimum wage, leaving agencies in a crunch. NHS thus sought concessions and suspended the health insurance plan. Just as workers would finally win a boost from a higher wage, NHS adapted to the state’s intransigence by cutting hours.120

Waiting lists for homemakers and attendants soared, creating a political crisis. In 1991, a thousand elderly clients lost home care. DORS’s director feared that militant disability groups and gay activists, the latter turning to home care to cope with the AIDS epidemic, would target the state after it refused new applicants early the next year. ADAPT fulfilled that fear by launching confrontational protests in Chicago. Disability rights activists brought suit, with the result that a federal court prohibited the state from denying eligible Medicaid recipients in-home services, thus forcing the department to accept applications six months later.121 In 1992, the union could only express relief at stopping future cuts.

By then, SEIU Local 880 had about 3,600 dues-paying members and five contracts. While the total may seem small, it won an award from SEIU, two years in a row, for the highest percentage of increase in membership in the central states’ region. Still, Kelleher acknowledged that Local 880’s modest success fundamentally reflected the “difficulties of labor organizing in the 1980s.” Members as well as staff were aware of the constraints of unionism tied to the welfare state. They talked about organizing consumers to switch to union companies but noted that the tactic could also “break the bank by straining the already tight state home care budget.”122

Budget battles pitted the legislature against the governor, exposing the precariousness of political unionism without collective bargaining. In 1992, home care workers and clients could celebrate the legislature’s passage of a cost of living adjustment and back pay for DORS personal attendants, over Governor Jim Edgar’s veto. Subsequently, in 1994, SEIU backed the Republican Edgar for (p.176) reelection as the lesser evil; he delivered by approving a “fair share” agreement that guaranteed that all workers in the DORS unit either would join the union or pay for its services. Local 880 suddenly surged to 10,000 workers, breaking new ground through direct recognition from a state government. Less than four years later, however, the political winds turned; the same governor negated the fair share agreement, and DORS membership plummeted by nearly half. A militant 880 repeatedly secured wage gains and other benefits, but it required a new, massive fight almost every year.123

Soul Power, Union Power, and Political Power in New York

The effectiveness of a metro-level alliance between unions and agencies was realized not in Chicago but in New York. In early 1988, the New York Home Care Union Coalition, led by the National Union of Hospital and Health Care Employees Local 1199, and the Home Care Council of New York City, composed of 60 nonprofit vendor agencies, won a pattern-setting agreement by securing increased state and city funding. Along with the American Federation of State, County, and Municipal Employees (AFSCME), the hospital worker union undertook a two-pronged strategy: press agencies to raise wages and add health benefits and together get the state to increase Medicaid reimbursement so that the agencies could fulfill the terms of the contract. Also essential was having the city, which awarded agency contracts, approve rate hikes.124 New York unionists, like SEIU in Chicago, found a winning strategy that at its best kept members mobilized, maintained coalitions with elder and disability groups, promoted collective bargaining, and enhanced the provision of necessary services.

                   “The Union Is Us”

Figure 6.3 Cover, HealthPac Bulletin, Fall 1988. Photo by George Cohen, with his permission. Courtesy of Robb Burlage.

Since 1958, when a group of left-wing pharmacists and drug clerks set out to organize the city’s hospital workers, 1199 was as much a political as a union movement. It fully identified with the civil rights struggle. In just over a decade, its overwhelmingly poor, female, black, and Latina/o workers built a union that swept through a sector once entirely ignored by the labor movement and excluded by the labor law. In organizing hospital dietary, housekeeping, maintenance staff, orderlies, aides, and clerks, 1199 relied upon “union power, soul power”—a symbiotic relationship with community civil rights activists.125 From 1963 throughout the 1970s, it turned workplace organizing drives into political campaigns that won bargaining rights from the same state that funded and oversaw hospitals. Whether organizing public or “private” employers, 1199 knew that the state mattered. Like AFSCME before it, 1199 learned how to pressure politicians.126

(p.177) In some key respects, 1199 was still very much an industrial union, used to organizing many workers in one place. Though recognizing a group other than the traditional white and male constituency of industrial unions, leaders did not sufficiently acknowledge that the work itself also differed. Despite the intimate and interactive nature of care work, 1199 initially paid little attention to consumers and rarely deployed a strategy based on quality of care. Perhaps because management long had exploited the humanitarian mission of hospitals, 1199 concentrated heavily on living wage demands. “Organizing,” leader Moe Foner said, “is key and everything else is peripheral”;127 but lack of attention to the particular dimensions of this labor reflected a traditional adversarial (p.178) understanding of the employment relation that initially impeded home care organizing.

Provision of home care in New York remained fragmented, and the city still was incapable of meeting the need—despite obtaining a disproportionate share of federal spending. With the quickening discharge of patients from hospitals under the new Medicare reimbursement system and with growing Medicaid rolls, the number of persons receiving home care rose to nearly double those in nursing homes. Medicaid paid 83 percent of home care for New York City; home attendants accounted for nearly 90 percent of that cost in 1984 alone. The workforce continued to resemble the city’s laboring poor: nearly all women, with 70 percent black or Latina and an increasing number, nearly half, immigrant and Caribbean. These mostly middle-aged women, many without high school degrees, were often eligible for, but did not necessarily receive, AFDC and Medicaid. “Many workers struggle with the persistent threat of homelessness and hunger,” reported social work professor Rebecca Donovan, the first to systematically survey 1199 members. They traveled from one borough to another to care for other poor women.128

After a failed attempt to merge with SEIU in 1982, 1199 became SEIU’s chief rival in New York City. Home care was a logical extension of its efforts: in the continuum of care work, hospital aides and dietary workers often became home attendants or homemakers on weekends or at night.129 By the mid-1980s, 1199 represented a third of unionized home care workers, some 20,000 women in 22 agencies. AFSCME had another 6,000, with most of the remaining 24,000 workers in SEIU. Yet, after several years of collective bargaining, wages had risen only 80 cents above the minimum. Paid vacation, sick leave, pensions, and job security were nearly nonexistent. When 1199’s 1987 contract ended, most earned less than $7,000 a year, well below the poverty line for a family of four.130

Collective bargaining stalled as “the invisible hand at the bargaining table belong[ed] to the city and state.”131 As was the case in Illinois, the terms of vendor contracts with the city and state ultimately curtailed private agencies from negotiating much of a wage increase. If a hospital strike was a bitter pill to swallow, a strike by home care workers would be even more so. With around 50,000 separate, uncoordinated work sites and tens of thousands of frail and disabled clients dependent on attendants, workers could not easily walk out on their own.132

Factionalism and racial polarization within 1199 in the mid-1980s certainly did not help matters. The retirement of the founding generation of Jewish Communists generated a succession crisis. With home care workers folded into the hospital division, the union was ill equipped to confront vendorization. After a nasty struggle, the multicultural and militant “Save Our Union” faction took over in 1985 and soon gained a majority vote to establish a separate home care division.133

(p.179) Unionized home care workers in New York City steadily grew in the 1980s, but the social movement begun by SEIU’s Cecil Ward and his corps of women organizers that sought to revalue the gendered labor of care, empower women of color, and increase the quality of public benefits stumbled. Both 1199 and AFSCME saw that substantive gains would come only if they stepped outside the NLRB bargaining structure; they launched a political campaign, mobilizing the grassroots in the process. When these unions approached the SEIU local to join them, Gus Bevona—its corrupt president—refused.134 Here SEIU could not carry the movement forward, partly because the International allowed an autocratic leader unchecked reign over this local. The Bevona leadership did not recognize the essential elements that made unionizing different in home care: the service needs of clients, the community networks that linked these women, and the welfare state location of the labor.

AFSCME and 1199 would move on without this once pioneering union. These New Yorkers were less confrontational than SEIU 880, but they too appealed to public opinion and garnered political support. Beginning with rallies outside City Hall in 1987, they enlisted presidential candidate Jesse Jackson and Cardinal John O’Connor for their cause.135 The unions had Manhattan Borough President David Dinkins hold a public hearing on the plight of the home care worker. Under the banner of the Campaign for Justice for Home Care Workers, they launched an educational drive to garner public support, with the slogan, “We Care for the Most Important People in Your Life.” The nonprofit vendors and nearly every liberal politician joined them. Together, the unions pressured the governor and the mayor. After receiving no response the first time, they doubled mobilizing efforts, brought in more politicians, religious leaders, and bigwigs, and set off a full-scale press blitz.136

This coalition of workers and their employers claimed that they were not asking to compensate home attendants “for the patience, the persistence, the loving concern it takes to do their jobs.” Instead, they requested “just a living wage.” In a series of advertisements run in the New York Times in March 1988, they appealed to the ethical sense of the public. The advertisements gave voice to previously silent caregivers, although they also invoked the tropes of pity that disability activists fought against. Readers learned of women like Cynthia Dilligard, who looked after AIDS patients “with a measure of compassion fueled by her strong faith,” and Francella Beavers, whose 90-year-old, wheelchair-bound client says, “She anticipates my every need.” Such portraits reinscribed the home care worker as a saint rather than welfare cheat, a servant to a higher calling, who soothed the poor, helpless, sick, and friendless, and thus deserved respect, dignity, and just compensation. The active testimony of workers, infused with religious idioms, asked the city to act like Moses leading his people to the promised land and away from poverty.137 The campaign intersected with (p.180) Reagan’s rhetoric of service to the needy but redirected such tropes toward state intervention.

On March 31, 1988, after unprecedented negotiations between Governor Mario Cuomo’s office and the unions, the state allocated the highest level of new funds for home care ever obtained. The agreement granted both unions a 53 percent wage increase, health insurance, guaranteed days off, and prescription drug coverage. Workers would begin receiving $5.00 an hour, although wages remained 35 percent less than their nursing home and hospital counterparts.138 1199 predicted a tremendous impact, with an additional $315 million annually into poor neighborhoods; improved quality of life for 145,000 people; a new minimum wage standard; and real implementation of “welfare to work” for higher wages and health benefits. Moreover, the settlement affirmed the significance of home care for the city’s health system and reestablished the position of 1199 as “once again an important force in the city and state.”139

Worker mobilization had returned as part of the repertoire and radicalism of the union, with 1199 activating some 15 percent of its membership in this home care campaign, a high participation rate for such an atomized workforce.140 Then, in 1989, Dennis Rivera emerged as the face of the union, elected with newly empowered home care votes. Less than a decade before, Rivera had arrived on the mainland from Puerto Rico already as a committed union organizer. He became a prominent spokesman for working families by building a revitalized 1199 into a political powerhouse during the last decade of the twentieth century.141

Adopting the political philosophy of AFSCME, New York’s home care unions learned that protecting and expanding the public budget was essential to enhancing the lives of workers. With all parties coming together in 1988, the New York campaign offered a model for other home care organizing, which sociologist Immanuel Ness has named “political action as labor market action.”142 Coalition with nonprofits rested on mutual dependence on state and city monies and a shared interest in the fiscal structure of the service. The campaign both turned home care workers into the deserving poor and directly referenced middle-class anxiety about the fate of their own elderly relatives and their own old age. Finally, it utilized the moral authority of the Catholic Church and the mantle of social justice through the presence of Jesse Jackson and other clergy and civil rights leaders. The strength of unions in New York distinguished this resolution from the long battle that SEIU would begin that very year in the less labor-friendly environment of Los Angeles, where former United Labor Union organizers sought to replicate the model that Kelleher and his members forged in Chicago.

(p.181) Reflecting in 1993 on the previous decade of struggle during the Reagan era, Kelleher questioned: “Many people would say, is this really worth it—All that work and all that time and all that money to organize these folks and get bad contracts?” They were building a union movement amid the most open assault on the welfare state, the right to organize, and labor standards since the Progressive Era. Still, he answered confidently, “I, of course, would say yes…. When you look at all those projections for future employment put out by the Bureau of Labor Statistics, home care workers, security guards and janitors are always the top three. Welcome to the future.”143 (p.182)


(1) . “For Immediate Release: Homecare Workers Give Halloween Message to Director of Aging,” October 29, 1988; Gale S. Thetford to Keith Kelleher, October 31, 1988, both in Box 3, folder 2, Records of SEIU Local 880 (Chicago), Wisconsin Historical Society (WHS), Madison, WI (880 Records).

(2) . Ronald Reagan, “Remarks At the Conservative Political Action Conference Dinner,” March 20, 1981; “Remarks at a Conservative Political Action Conference Dinner,” February 26, 1982, http://reagan.utexas.edu/archives/speeches/; “Memorandum Directing a Federal Employee Hiring Freeze,” January 20, 1981, in John T. Woolley and Gerhard Peters, The American Presidency Project [online]. Santa Barbara, CA: University of California (hosted), Gerhard Peters (database), at http://www.presidency.ucsb/ws, accessed June 6, 2009.

(3) . Judith Stein, Pivotal Decade: How the United States Traded Factories for Finance in the Seventies (New Haven: Yale University Press, 2010), 262–267.

(5) . Carol Hall Ellenbecker, “The Competitive Experience in Home Health Care: Changes in Organizational Behavior and Service Delivery Since the Omnibus Budget Reconciliation Act of 1980,” unpublished Ph.D. dissertation, Brandeis University, 1988, 17–18, 24.

(6) . U.S. Congress, House of Representatives, Select Committee on Aging, Subcommittee on Health and Long-Term Care, Building a Long-Term Care Policy: Home Care Data and Implications, 98th Cong., 2nd sess. (Washington, DC: GPO, December 1984), 4.

(7) . Ellenbecker, “The Competitive Experience in Home Health Care,” 164–165.

(8) . American Bar Association, The Black Box of Home Care Quality, A Report Presented by the Chairman of the Select Committee on Aging, House of Representatives, 99th Cong., 2nd sess., Comm. Pub. No. 99–573, August 1986 (Washington, DC: GPO, 1986), 15 (hereafter Black Box Report); Carroll L. Estes, “The Reagan Legacy: Privatization, the Welfare State, and Aging in the 1990s,” in States, Labor Markets, and the Future of Old-Age Policy, John Myles and Jill Quadagno, eds. (Philadelphia: Temple University Press, 1991), 67–68.

(10) . George Peterson et al., The Reagan Block Grants: What Have We Learned? (Washington, DC: The Urban Institute Press, 1986), 1–7.

(11) . Randall R. Bovbjerg and Barbara A. Davis, “States’ Response to Federal Health Care Block Grants: The First Year,” Milbank Memorial Fund Quarterly 61:4 (1983), 528; Robert Agranoff and Alex N. Patakos, “Intergovernmental Management and Federal Changes, State Responses, and New State Initiatives,” Publius 14 (Summer 1984), 50.

(12) . The Reagan Block Grants, 70, 81–84.

(13) . Agranoff and Pattakos, “Intergovernmental Management,” 68–71; Bovbjerg and Davies, “States Response,” 551–552; The Reagan Block Grants, 43–59; Jonathan Oberlander, The Political Life of Medicare (Chicago: University of Chicago Press, 2003), 124.

(14) . Bovbjerg and Davies, “States Response,” 536.

(15) . Thomas Buchberger, Medicaid Choices for 1982 and Beyond (Washington, DC: GPO, 1981), xii; Jonathan Engel, Poor People’s Medicine: Medicaid and American Charity Care since 1965 (Durham: Duke University Press, 2006), 114, 164.

(16) . Bovbjerg and Holahan, “States Response,” 3, 7; Agranoff and Pattakos, “Intergovernmental Management,” 71.

(17) . Colleen Grogan, “A Marriage of Convenience: The Persistent and Changing Relationship Between Long-Term Care and Medicaid,” in History and Health Policy in the United States, Rosemary Stevens, Charles Rosenberg, and Lawton Burns, eds. (New Brunswick: Rutgers University Press, 2006), 215.

(p.266) (18) . Buchberger, “Medicaid Choices,” 44, 1.

(20) . U.S. House, Building a Long-Term Care Policy, 3–4; Agranoff and Pattakos, “Intergovernmental Management,” 71, 76.

(21) . Gareth Davies, “The Welfare State,” in The Reagan Presidency: Pragmatic Conservatism and Its Legacies, W. Elliot Brownlee and Hugh David Graham, eds. (Lawrence: University Press of Kansas, 2003), 213–214.

(22) . Carol De-Ortiz, “The Politics of Home Care for the Elderly Poor: New York City’s Medicaid-Funded Home Attendant Program,” Medical Anthropology Quarterly 7 (March 1993), 15.

(23) . Margot Cella, Evaluation of the AFDC Homemaker-Home Health Aide Demonstrations: Operational Costs of Demonstration Activities (Cambridge, MA: Abt Associates Inc., December 1987), 1–2, 7–8, 19, 26; De-Ortiz, “The Politics of Home Care,” 15.

(24) . Stephen H. Bell, Nancy L. Burstein, and Larry L. Orr, Evaluation of the AFDC Homemaker-Home Health Aide Demonstrations: Overview of Evaluation Results, December 1987 (Cambridge, MA: Abt Associates, December 1987), 26–28, 66, 68, xiv.

(25) . Davida Unterbach, “Friends of the Family: A Socio-Economic Profile of Unionized Home Care Workers,” unpublished Ph.D. dissertation, Social Welfare, CUNY, 1992, 166.

(26) . Margaret Ann Baker, “The Paid Caring Relationship: Workers’ Views and Public Policy Regarding Paraprofessional Home Care for the Elderly,” unpublished Ph.D. dissertation, University of California, Berkeley, 1987, 134, 174–176, 181.

(27) . Keith Kelleher, “ACORN Organizing and Chicago Homecare Workers,” Labor Research Review 80 (1985), 36.

(28) . Sarah F. Liebschutz, “New Federalism Modified: Jobs and Highways in New York,” The Journal of Federalism 14 (Summer 1984), 87–88, 92; Michael B. Katz, The Price of Citizenship: Redefining the American Welfare State (New York: Metropolitan Books, 2001), 66.

(29) . Ruth Glasser and Jeremy Brecher, “‘We Are the Roots’: The Culture of Home Health Aides,” New England Journal of Public Policy 13 (Fall/Winter 1997), 113.

(30) . Jonthan Rowe, “Up from the Bedside: a Co-Op for Home Care Workers,” The American Prospect 2 (Summer 1990), 88–92.

(31) . Glasser and Brecher, “We Are the Roots,” 128, 113, 122–124.

(32) . Robert Kane, Richard Ladd, Rosalie Kane, and Wendy J. Nielsen, Oregon’s LTC System: A Case Study by the National LTC Mentoring Program (Minneapolis, MN: Institute for Health Services Research, University of Minnesota, 1996); Ellen O’Brien and Risa Elias, “Medicaid and Long-term Care,” Kaiser Commission on Medicaid and the Uninsured (Washington, DC: Kaiser Family Foundation, May 2004), 12; Statement by Roger Auerbach, “Reforming the Delivery System,” Oregon Department of Human Resources, Senior & Disabled Services Division Before the Senate Special Committee on Aging, March 9, 1998, http://aging.senate.gov/public/events/hr12.htm, accessed March 2003.

(33) . Statement of Dr. Ellen Winston in U.S. Congress, Senate, Special Committee on Aging, Subcommittee on Federal, State, and Community Services, Hearings: Services to the Elderly on Public Assistance, 89th Cong., 1st sess., August 18–19, 1965 (Washington, DC: GPO, 1965), 5.

(34) . Jean Doris Freeman, “Community Organization to Meet the Needs of Older Adults,” unpublished Master’s thesis, University of Oregon, 1972, 16; Arnold V. Hurtado, Merwyn R. Greenlick, and Ernest W. Saward, “The Organization and Utilization of Home-care and Extended Care Facility Services in a Prepaid Comprehensive Group Practice Plan,” Medical Care VII:1 (1969), 30–40.

(35) . Statement of Laverne Moore in U.S. Congress, House of Representatives, Select Committee on Aging, Hearings: Impact of Reagan Economics on Aging Women: Oregon, 97th Cong., 2nd sess., September 1, 1982 (Washington, DC: GPO, 1982), 45–46.

(p.267) (36) . Report of the Special Committee on Aging, 58th Assembly—Oregon State Legislature (Salem, Oregon, January 1975), 11, 13; Elizabeth Kutza, “Long-Term Care in Oregon,” Institute on Aging, Portland State University, 1994, in authors’ possession.

(37) . Interview by Paige Austin with Richard Ladd, Administrator of Seniors Services Division from 1981–1992, February 18, 2003, notes in authors’ possession.

(38) . U.S. House, Hearings: Impact of Reagan Economics on Aging Women, 45; Kutza, “Long-Term Care in Oregon”; Interview by Paige Austin with Douglas Stone, SDPD, February 18, 2003, notes in authors’ possession.

(39) . Kutza, “Long-Term Care in Oregon,” 3, 16–17.

(40) . Interview with Ladd; Kane at al., “Oregon’s LTC System.”

(41) . Kane et al., “Oregon’s LTC System”; Interview by Paige Austin with Cynthia Hannum, Administrator of SDPD’s Office of Licensing and Quality Care, March 3, 2003, notes in Klein’s possession; U.S. Congress, Senate, Special Committee on Aging, Joint Hearing, Board and Care: A Failure of Public Policy, 101st Cong., 1st sess., March 9, 1989 (Washington, DC: GPO, 1989), 2–4; Bovbjerg and Davis, “States’ Response to Federal Health Care Block Grants,” 545; The Reagan Block Grants, 43; 111.

(42) . “Oregon Matches Care with Needs,” Salem Statesman-Journal, May 29, 1988.

(43) . Oregon Bureau of Labor and Industries, Division 20: Wages, Procedural Rules, 839-020-0004 and 839-020-0150.

(44) . Who Will Care? A Model Collaborative Project (Salem: Oregon Senior and Disabled Services Division, 1992).

(45) . Who Will Care?

(46) . U.S. Congress, House of Representatives, Select Committee on Aging, Subcommittee on Health and Long-Term Care, The Attempted Dismantling of the Medicare Home Care Benefit, 99th Cong., 2nd sess., April 1986 (Washington, DC: GPO, 1986), 10.

(47) . Randall R. Bovbjerg and John Holahan, Medicaid in the Reagan Era: Federal Policy and State Choices (Washington, DC: The Urban Institute Press, 1982), 60–61.

(48) . Theresa A. Coughlin, Leighton Ku, and John Holahan, Medicaid since 1980: Costs, Coverage, and the Shifting Alliance Between the Federal Government and the States (Washington, DC: The Urban Institute Press, 1994), 117.

(49) . Marty Lynch and Carroll L. Estes, “The Underdevelopment of Community-Based Services in the U.S. Long-term Care System: A Structural Analysis,” 201–213, and Estes et al., “The Medicalization and Commodification of Aging and the Privatization and Rationalization of Old Age Policy,” 45–59, both in Carroll Estes and Associates, Social Policy and Aging: A Critical Perspective (Thousand Oaks: Sage Publications, 2001).

(50) . About 5 million elderly Americans, and perhaps another 2–3 million under age 65, needed home care service in 1984. Oberlander, The Political Life of Medicare, 120–126; U.S. House, The Attempted Dismantling of the Medicare Home Benefits, 4–5; U.S. House, Building a Long-Term Care Policy, 6.

(51) . Andrew Sasz, “The Labor Impacts of Policy Change in Health Care: How Federal Policy Transformed Home Health Organizations and Their Labor Practices,” Journal of Health Politics, Policy, and Law 15 (Spring 1990), 195–196. The gross revenue statistic comes from American Bar Association, The Black Box Report, August 1986 (Washington, DC: GPO, 1986), 2.

(52) . Ellenbecker, “The Competitive Experience in Home Health Care,” 111; Black Box Report, 2.

(53) . U.S. House, Select Committee on Aging, Hearing: The Black Box of Home Care Quality, 99th Cong., 2nd sess., July 29, 1986 (Washington, DC: GPO, 1987), 3–4; 28 (hereafter Hearings: Black Box); Black Box Report, “Introduction: The Problem,” 1; 7.

(54) . Black Box Report, 5; Hearings: Black Box, 29.

(55) . Hearings: Black Box, 20; 22.

(56) . Black Box Report, 7–9; 28–30; 41.

(57) . Hearings: Black Box, 88–89.

(58) . Ibid., 63.

(60) . Katherine Lohr, Medicare: A Strategy for Quality Assurance, Vol. II: Sources and Methods (Washington, DC: National Academy Press, 1990), 241.

(61) . Black Box Report, 40.

(62) . Jill Quadagno, One Nation Uninsured: Why the U.S. Has No National Health Insurance (New York: Oxford University Press, 2005), 149–159.

(63) . Julie Rovner, “Pepper Bill Pits Politics Against Process,” CQWR, June 4, 1988, 1491; Rovner, “Long-Term Care Bill Derailed—For Now,” CQWR, June 11, 1988, 1604; Rovner, “Singing His Praises, House Says No to Pepper,” CQWR, June 11, 1988, 1605; Quadagno, One Nation Uninsured, 176–179.

(64) . Community Care: Annual Joint Report to the Governor and the Illinois General Assembly on Public Act 81–20, September 1983 (Springfield: Department of Aging, 1983), 5; Community Care, September 1985 (Springfield: Department of Aging, 1985), 4.

(65) . Kelleher, “ACORN Organizing and Chicago Homecare Workers,” 41.

(66) . “Introduction,” “Discount Foundation Application Summary,” n.d., c. 1986, 3, Box 2, folder 31; “Mildred Young’s Testimony for Taskforce Hearing,” August 17, 1988, Box 3, folder 11; Press Release, “Homecare Workers Slam State on Union Busting Vendors, Poverty Wages, and Institutional Racism,” n.d., but probably August 16, 1988, Box 3, folder 11, 880 Records.

(67) . “Chicago and Washington, D.C., Homemakers Organizing Project, Proposal Submitted to Discount Foundation, December, 1983,” 3, Box 2, folder 31, 880 Records.

(68) . Ibid., 3–4.

(69) . Community Care, September, 1983, 5, 8; Community Care, September 1984 (Springfield: Department of Aging, 1984), conveyance letter; Community Care, September 1988 (Springfield: Department of Aging, 1988), 3.

(70) . “Health Care Division Organizing Plan 1993,” 2, Box 4, folder 41, 880 Records.

(71) . SEIU International v. State of Illinois, Hearing Officer’s Recommended Opinion and Dismissal, State Labor Relations Board, Case No. S-RC-115, October 24, 1985, 2–4, 9–10, Box 11, folder 3; Keith Kelleher to All Staff and Leadership, July 9, 1985, Box 4, folder 35, 880 Records.

(72) . “Discount Foundation Application Summary,” n.d., c. 1986, 1; Kelleher, “ACORN Organizing and Chicago Homecare Workers,” 33–46.

(73) . Keith Kelleher, “A History of SEIU Local 880, 1983–2005,” Unpublished Manuscript (2005), 11–21, in authors’ possession.

(74) . “Discount Foundation Application Summary,” c. 1985, 1–2; Memo to: Interested Parties From: KK with Attached Songs, Box 4, folder 35; “Client Campaign,” in “Progress and Plans to Date,” July 9, 1985, 3, Box 4, folder 35, 880 Records.

(75) . Vanessa Tait, Poor Workers’ Unions: Rebuilding Labor from Below (Boston: South End Press, 2005), 116–119; “Discount Foundation Application Summary,” n.d., c. 1986, 1.

(76) . “Local 880 Industry Profile/Organizing Model for Homecare Sector,” February 5, 1993, in Box 4, folder 41, 880 Records; Kelleher, “A History of SEIU Local 880,” 26, 49.

(77) . “Discount Foundation Application Summary,” c. 1985, 1–2; Memo on “Progress and Plans to Date,” February 27, 1985, 3; Memo on “Progress and Plans to Date,” April 27, 1985, 4, Box 4, folder 35, 880 Papers.

(78) . To Jerry Shea From Keith Kelleher on “May 1st Long Term Care Town Hall Meeting,” April 29, 1993, Box 6, folder 50; Long Term Care Workers Project, “Steering Committee Minutes,” September 17, 1991, in Box 6, folder 6, 880 Records.

(79) . Press release, “Homecare Workers Demand End to Slave Wages!,” March 28, 1985, Box 3, folder 1, 880 Records; “Local 880 Industry Profile/Organizing Model for Homecare Sector,” 6.

(80) . “Local 880 Industry Profile/Organizing Model for Homecare Sector,” 11.

(81) . Juanita Bratcher, “Health Workers Hit Pay Rate,” Chicago Defender, March 12, 1985; SEIU Local 880 Grievance Form, Frankie Sparks, with attached letters, 1990–1991, Box 14, folder 52, 880 Records.

(p.269) (82) . “Theneita Anderson’s Testimony for Taskforce Hearing,” August 17, 1988, Box 3, folder 11, 880 Records.

(83) . Affidavit Thelma Brown, April 2, 1986; William Ghesquiere to Herbert Cohen, April 4, 1986, Keith Kelleher to Nelson Keilt and Herbert Cohen, April 25, 1986, Box 4, folder 42, 880 Records.

(84) . Valerie Vaughan to Employees, January 5, 1982, Box 15, folder 37, 880 Records.

(85) . McMaid would continue to provide private paid maid and janitorial services but no longer provide home care services. George Olson to CCP Case Management Units, September 29, 1983, Box 15, folder 36, 880 Records; Edwin Darby, “McMaids Cleans Up by Cleaning Up,” Chicago Sun Times, April 27, 1989. On issues of disrespect and mistreatment, see for example, Kelleher, “Local 880 Industry Profile/Organizing Model For Home Care Sector,” February 12, 1993, 2, Box 8, folder 49, 880 Records.

(86) . Keller, “A History of SEIU Local 880,” 27, 51; “Union Wins YMCA Election, Company Stalls,” Local 880 Voice, November/December 1985, 880 Records.

(87) . Keith Kelleher to All Staff, “United Labor Unions Local 880 YE/YB Report,” December 30, 1983, Box 8, folder 41; Keith Kelleher to Andrew Wright, February 20, 1984, Box 11, folder 41; “Chicago Local 880 Year End/Year Begin Report,” January 1985, Box 8, folder 41, 880 Records. Background on Sherman from authors’ telephone interview with Keith Kelleher, June 15, 2009, notes in authors’ possession.

(88) . “McMaid Negotiates,” The Homemakers’ Voice, Chicago, Illinois, [c. March 1984].

(89) . “McMaid Workers Picket Owner’s House,” The Homemakers’ Voice, Chicago Illinois, n.d.

(90) . Kelleher interview.

(91) . “N.H.S. Contract Victory. Strike Is Off,” The Homemakers’ Voice, “Special Contract Issue,” n.d., 1; Mark Heaney to Keith Kelleher, June 10, 1985, Box 11, folder 41; Kelleher to Mr. Olson/Heaney, June 17, 1985, Box 11, folder 41, 880 Records.

(92) . “State Reps Support,” The Homemakers’ Voice, January 1985.

(93) . “Union Members Going to Springfield,” The Homemakers’ Voice, March 1985.

(94) . Tait, Poor Workers’ Unions, 122.

(95) . See correspondence with Gene Moats, Box 1, folder 33; “Confidential Memorandum” To: Keith, From: Wade 3/2/93, Box 4, folder 41, 880 Papers. See also Kelleher, “A History of SEIU,” 18.

(96) . “Union Members Going to Springfield”; “Service Employees International Union Local 880 Year End/Year Begin Report—1986,” January 2, 1987, Box 8, folder 41, 880 Records.

(97) . See correspondence between Mark Heaney and Keith Kelleher, 1985–1993, Box 11, folders 41–46, 880 Records.

(98) . “Year End/Year Begin Report—1986.”

(99) . Heaney to National Homecare Systems Staff—Office and Field, June 5, 1987, Box 11, folder 42; Heaney to SEIU Local 880 Bargaining Committee, June 3, 1991, Box 11, folder 44, 880 Records.

(100) . A. Wright to Mark Heaney, December 1, 1993, Box 11, folder 46, 880 Records.

(101) . Kelleher Interview.

(102) . Kelleher, “A History of SEIU Local 880,” 24; “Year End/Year Begin Report—1986,” 5.

(103) . “Convention Highlights,” Local 880 Voice, August/September 1986; Charles Hayes to Irma Sherman, July 30, 1986; “Statement of Representative Charles A. Hayes to Chairman Edward R. Roybal,” July 29, 1986, both in Box 3, Folder 8, 880 Records.

(104) . Heaney to Kelleher, July 2, 1987; Kelleher to Heaney July 3, 1987; Kelleher to Department of Children and Family Services, July 3, 1987; Madeline Talbott, Regional Director Illinois ACORN, to Department of Children and Family Services, July 6, 1987, Box 11, folder 42, 880 Records.

(105) . “Year End/Year Begin Report—1986”; Heaney to All Field Staff, October 27, 1986, Box 11, folder 41, 880 Records.

(106) . Myra Glassman to Mike, April 13, 1987; Myra Glassman to Mike, April 28, 1987; Kelleher to Sandra Nimtz, July 23, 1987; Corinthian Welch to Keith Kelleher, June 9, 1987, Box 11, folder 42; Myra Glassman to Detonya, November 8, 1988, Box 11, folder 43; “Local 880 SEIU Year End Year Begin Report December 28, 1988,” 2, Box 8, folder 41, 880 Records.

(p.270) (107) . “Local 880 Service Employees International Union, AFL-CIO, CLC, Year End/Year Begin Report, December 30, 1987,” Box 8, folder 41, 880 Records; Kelleher Interview.

(108) . Kelleher to Mark Heaney, February 1, 1991; Heaney to Kelleher, February 12, 1991, Box 11, folder 44; Various Union Members to Brothers and Sisters, January 15, 1992, Box 11, folder 45; “Local 880 SEIU Year End/Year Begin Report, December 30, 1989,” and “Local 880 SEIU Year End/Year Begin Report, December 29, 1990,” Box 8, folder 41, 880 Records; Kelleher, “A History of SEIU Local 880,” 57–60.

(109) . Kelleher to Heaney, April 15, 1991, Box 11, folder 46; Kelleher to Heaney, July 26, 1993, and Attached Concepts on Accretion, Box 11, folder 46, 880 Papers. On NLRB and employer latitude, see David Brody, “On the Representation Election,” in Labor Embattled: History, Power, Rights (Urbana: University of Illinois Press, 2005), 98–109.

(110) . State of Illinois, Before the State Labor Relations Board, DORS vs. SEIU, Case No. S-RC-115; “Petitioner’s Post-Hearing Brief,” S-RC-115, 13, both in Box 11, folder 3, 880 Records.

(111) . Kelleher, “A History of SEIU Local 880,” 39–43, 49–51.

(112) . Les Lester, “SEIU Urges Probe,” Chicago Defender, May 9, 1991; “SEIU Local 880 Action on Lynn Martin—Agenda,” Box 7, folder 2, 880 Records.

(113) . “Year End/Year Begin Report,” January 1, 1986, 4; “Year End/Year Begin Report,” December 31, 1991, 8–9, Box 8, folder 41, 880 Records.

(114) . Sharon Jacobson to Susan Suter, October 27, 1986; Carol Moseley Braun to Suter, December 1, 1986, both in Box 1, folder 2, 880 Records.

(115) . To: Harry Kurshenbaum from Keith Kelleher, Re: DORS Background, February 1, 1993, Box 11, folder 15, 880 Records.

(116) . Kelleher, “A History of SEIU Local 880,” 51.

(117) . Ibid., 49.

(118) . “Year End/Year Begin Report, December 29, 1990”; Kelleher, “A History of SEIU Local 880,” 75–77.

(119) . Memo to Kurshenbaum, Larry Engelstein to Eugene Moats, November 14, 1989, Box 11, folder 5; Memo to Gene Moats From Keith Kelleher Re: Meeting with Janice Salini, et al, March 24, 1992, Box 1, folder 32, 880 Records.

(120) . Heaney to Insured Field Staff, October 8, 1991, Box 11, folder 44; Sherry A. Carroll to Kelleher, February 24, 1992, Sherry A. Carroll to Kelleher, March 9, 1992, Kelleher to Carroll, March 11, 1992, box 11, folder 45; “Local 880 SEIU Year End/Year Begin Report, December 28, 1991,” and “Year End/Year Begin Report, January 1, 1993,” Box 8, folder 41, 880 Records.

(121) . Audrey McCrimon to Joan Walers, March 10, 1992; Access Living, “Major Victory for the Disability Community in Illinois,” August 20, 1992, both in Box 11, folder 13, 880 Records; Ray Sons, “Elderly Poor Pinned by Budget’s Brutality,” Chicago Sun Times, August 23, 1992; Neil Steinberg, “Disabled Stage New Battle Here,” Chicago Sun Times, May 17, 1992; “Disabled to Get Home Aid,” Chicago Sun Times, August 20, 1992.

(122) . Kelleher to SEIU Health Care Department, “Organizing At Scale: Homecare Organizing Opportunities in and Around Illinois,” August 21, 1992, Box 3, folder 37; “Year End/Year Begin Report 1990” and “Local 880 YE/YB Report, December 30, 1987,” Box 8, folder: 41, SEIU Records.

(123) . Editorial, “Give Home Care Workers a Raise,” Chicago Tribune, November 18, 1992; Kelleher, “A History of SEIU Local 880,” 89–90, 110–111.

(124) . Barbara Caress, “Home Is Where the Patients Are: New York’s Home Care Workers’ Contract Victory,” Health/PAC Bulletin 18 (Fall 1988), 4–14; Immanuel Ness, “Organizing Home Health Workers: A New York City Case Study,” WorkingUSA 3 (November–December 1999), 59–95.

(125) . Leon Fink and Brian Greenberg, Upheaval in the Quiet Zone: A History of Hospital Workers’ Union Local 1199 (Urbana: University of Illinois Press, 1989), 209.

(126) . Fink and Greenberg, Upheaval in the Quiet Zone, 44–45; 74–78; 102; 114.

(p.271) (127) . Fink and Greenberg, Upheaval in the Quiet Zone, 202.

(128) . Unterbach, “Friends of the Family,” 4, 74, 161–164; Ronald Sullivan, “New York Shifts Care for Elderly to Their Homes,” NYT, May 4, 1987; Rebecca Donovan, “Poorly Paid Home Health Care Workers Subsidize an Industry,” NYT, June 2, 1987.

(129) . The UDW National Executive Board to John Sweeney, March 22, 1984, 2, SEIU, President’s Office, John Sweeney, Box 191, folder: “Local 7—1984,” SEIU Records.

(130) . Unterbach, “Friends of the Family,” 6, 101; Caress, “Home Is Where the Patients Are,” 4, 9; Rebecca Donovan, Paul A. Kurzman, and Carol Rotman, “Improving the Lives of Home Care Workers: A Partnership of Social Work and Labor,” Social Work, 38 (September 1993), 582; Ness, “Organizing Home Health Workers,” 72, 92, n.6; BNA, “Union Coalition Negotiates Agreement For New York City’s Home Care Workers,” Daily Labor Report, 1-13-88, A-2.

(131) . Sam Roberts, “For Attendants, Poverty at Home and on the Job,” NYT, July 27, 1987.

(132) . Donovan et al., “Improving the Lives of Home Care Workers,” 583.

(134) . Caress, “Home Is Where the Patients Are,” 9.

(135) . Michael Oreskes, “Jackson and Cardinal Back Union Bid,” NYT, May 29, 1987; “Home Health Workers Seek Gains,” Health/PAC Bulletin (Summer 1987), 29.

(136) . Caress, “Home Is Where the Patients Are”; Plight of the Home Care Worker, Report of the Manhattan Borough President’s Hearing on April 29, 1987 (New York: City of New York, January 1988); BNA, “Union Coalition Negotiates Agreement.”

(137) . “The Care-Givers—Part I,” March 14, 1988; “The Care-Givers—Part II,” March 18, 1988; “The Care-Givers—Part III,” March 21, 1988; “The Care-Givers—Part IV,” March 23, 1988; “New York’s Home Health Care Crisis,” March 27, 1988, all in NYT.

(138) . Caress, “Home Is Where the Patients Are,” 4–14; Donovan et al., “Improving the Lives of Home Care Workers,” 579; Ness, “Organizing Home Health Workers,” 68.

(139) . “The Home Care Campaign: Impact and Significance,” 4/11/88, Box 1, folder 3, 880 Records.

(140) . Ness, “Organizing Home Health Workers,” 73–74.

(141) . “Dennis Rivera,” description at http://www.riverkeeper.org/about-us/our-board/dennis-rivera/, accessed July 11, 2009.

(142) . Ness, “Organizing Home Health Workers,” 63.

(143) . Kelleher, “Local 880 Industry Profile/Organizing Model for Homecare Sector.”