Rachel Wick, Blue Shield of California Foundation: Respecting the Work That Makes All Other Work Possible

Van Ton-Quinlivan

Welcome to WorkforceRX with Futuro Health where future focused leaders in education, workforce development, and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

The worsening shortage of direct care workers remains a topic of great concern for policy makers as well as a wide array of organizations in the private and nonprofit sectors. Today, we’re going to learn about a new report from Blue Shield of California Foundation that explores this problem. With me is Rachel Wick, the foundation’s senior program officer, to discuss the work that it is funding across the state, as well as other issues related to economic security. Previously, Rachel led the foundation’s initiatives to integrate primary care with mental health and substance use treatment, specialty care, and public health systems. Thanks for joining us today, Rachel.

Rachel Wick

Thank you, Van. It’s fun to be here.

Van

Well, let’s start with the topic of economic security. Can you tell us, Rachel, about the foundation and why it is interested in economic security, which might strike people as odd given that you are connected to a health insurer?

Rachel

Yeah. Well, Blue Shield of California Foundation’s mission is to build lasting and equitable solutions that make California the healthiest state and end domestic violence. And to do that, we have to work to together to remove the barriers to health and wellbeing, especially for Californians of color who are most affected by health inequities. We believe if we do that, we can create a more just and equitable future.

So, when you think about barriers to health and wellbeing — and as we listen to families and communities across California — what they told us is that health and wellbeing and family safety and stability is just not possible when you are caught in a relentless daily struggle for survival. We know from the data that California has one of the highest poverty rates in the country when you control for the cost of living and we haven’t seen the growth in wages keep pace with the cost of living.

We also know that the majority of people living at or near poverty in California are working, and many of them are working multiple jobs. They are disproportionately people of color, women, immigrants, many undocumented, and those are the communities that also experience the greatest inequities in health. So, for a health foundation, focusing on economic security is critical.  I’m a public health person by training, and there’s lots of public health research that demonstrates the connection between income, wealth, race, ethnicity, gender, and health.

Van

Well, that’s a tall list of health, wellbeing, safety, security, poverty, wages, multiple jobs…these are all very difficult interconnected topics. I’m wondering what can be done? What are you seeing as possibilities? I could imagine that a policymaker looking at all these issues wouldn’t know even where to start.

Rachel

Yes, addressing poverty is a complex problem. As a health foundation, where we started was to look at strategies that had a strong connection and strong evidence between economic security and health and domestic violence. And so for us, there were three core areas of work that we decided to focus on. One is how do we expand access to income supports and benefits that put more time and money into low income people’s hands? We’ve seen how powerful unrestricted cash support to families can be through programs like tax credits and guaranteed income pilot programs. We also see how critical benefits like paid family and medical leave are where people can take time off to care for their loved ones and not sacrifice significant earnings and wages in the process of doing that. The second area we decided to focus on, and I hope we talk more about today, is how do we increase wages, benefits and job quality for care workers? The last strategy is unique to our focus on survivors of domestic violence, and there we want to address and prevent homelessness and the impact of financial abuse on survivors.

Van

So, let’s dive into the second of those three areas of your focus. Talk to us about your objective of increasing job quality in the care workforce since this is of course a topic close to home for Futuro Health.

Rachel

I came to care work and focused on care workers through participating and actually funding the California Commission on the Future of Wo and what we learned in that process is that care is one of three sectors with the highest concentration of low wage workers in California. When I talk about care work, I’m referring to childcare work and direct care or home care work, which is assisting older adults and people with disabilities with the activities of daily living.  I’ve done work in healthcare, and I know you do deep work in healthcare workforce, and what we know is that  care workers are a critical prevention workforce when it comes to health. So, childcare workers take care of children and families in the earliest years at a time of rapid intellectual, social and emotional development, laying the foundation for a healthy future. Direct care and home care workers take care of people and allow those who are aging and disabled to live independently and remain in their homes and communities.

But in terms of job quality, we know it’s very low paid care. The work is complex work. It’s human work that’s physically and emotionally taxing and it’s just deeply undervalued and that’s because it has roots in our country’s history of slavery and excluding certain workers from labor protections dating back to the 1930s. It’s also the work that makes all other work possible. I’m here with you today because my son is at a wonderful family childcare provider home, and my mother is taking care of my father. She’s his 24-hour caregiver. So, we know how critical care workers are to all workers and to the economy.

They allow many of us to be in the workplace and for women to succeed in the economy, having access to care and caregiving is a top challenge, especially for single mothers. So, the jobs are critically important. We could make them better paid. We could make them better quality. I think that we’re going to have to do it with the aging of the population. We won’t have a choice. I feel like we’re kind of standing on this precipice of major change that could have a real impact on work and workforce.

Van

Both the childcare and the direct home care workforce is largely women and a lot of that caretaking falls on women and, as you mentioned, they tend to be low wage. You’ve done a lot of thinking about raising the wage floor. Tell us about that approach.

Rachel

Yeah, I mean the work is the work and so what we have to do is value the work, and that means raising the wage floor. What’s unique about the sector is it’s very tied to our public investments in care. We know we have a K to 12 education system that’s a public investment that we’ve made. We have a healthcare system that we’ve invested in, and when we do that, we are able to offer jobs with living wages and benefits to workers. And so that’s the kind of public investment that we need right now in childcare and direct care. We came very close to getting a major federal investment in Build Back Better, but we did not succeed.

I think what we’ve seen since then is a lot of focus turn back to the states and here in California, in the childcare sector, one of the policy levers that folks are focusing in on is rate reform or really changing the way childcare providers are paid in California to cover the true cost of care and to value all aspects of the work, not just the time in which you’re directly working with a child or a client, but all the work that goes around that to prepare for that work. Things in childcare, like cleaning your home and your facility and all that…that’s all work that needs to be compensated and valued and so that’s the big push right now on the childcare front.

In direct care and home care, there are policy efforts underway specifically for In Home Supportive Service (IHSS) workers to push for statewide collective bargaining. We’ve seen how powerful the statewide bargain process has been for childcare workers who are unionized. IHSS workers are also unionized and they are seeking a statewide collective bargaining process. Right now, they have to go county by county to fight for better wages.

I think another policy lever is how do we tackle some of the challenges with benefits? So 30% to 40% of the care workforce is relying on public benefits, and when you get a wage increase, you risk losing access to public benefits. So, I think some policy attention is needed, some new solutions, to figuring out how do we either increase access to benefits in the jobs through new systems and structures, or at least protect people so when they experience wage growth, they aren’t at risk for losing what they have. I think it’s a big challenge.

Van

Can I dive a little bit into the topic of rate reform? You talked about rate reform for childcare providers… making sure that their prep time and adjacent time is compensated. How would you know that the wage gain would actually go to the worker?

Rachel

I think that’s a critical piece of the policy puzzle when it comes to care, because again, when you say we need more public investment in care, what we have to do is make sure that those public investments translate and the worker is key in that and that their wages do grow and are protected as we increase public investment.

One of the things that’s really important in terms of a change strategy is to make sure that not only are workers organized, but they’re partnering with families so that in all of our policy change, we align workers and families so that we have a balanced system. In that way, increases in access to care don’t come at the expense of worker wages or worker wages don’t come at the expense of affordable care for families. That’s a real tension and I think we need to build that into policy design. They’re trying to do that a little bit in the Medicaid program when it comes to direct care. They’re looking at things like how do you ensure that Medicaid funding — some percentage, proportions, some ratios — are directed toward worker wages so that they get a bigger share of the pie?

Van

Rachel, some of the policy levers that you’re advocating…is it highly contextualized for the state of California or would it work also in other states? And what kind of states would have a more conducive environment for those types of policy leavers?

Rachel

Well, some policy levers are tied to federal programs like the Medicaid program and so there is this relationship between federal action and state action and what kind of changes can we get federally that then would go down to California. Some of the federal work is actually offering states incentives and options to focus on this. It does take state leadership to say, ‘we want to be in a pool of states that want to try something different or want to lean in on testing some of these policies.’ The complexity in California, of course, is our size. I’ve seen in other states that they used ARPA funds, for example, to increase worker wages, but those were one-time funds. A gamble like that in a smaller state is really different than in a state like California where we’re such a large state. The dollar implications are much, much higher than they are in smaller states. But I think across the board, state leadership is key.

We have great federal leadership within the bounds of what the federal government can change. We have an executive order on care — the first time we’ve ever had something like that — where we’re activating all federal agencies that touch care to do whatever they can to create a glide path for states in particular. That was a key piece of how California’s rate reform efforts were smoothed and enabled was through federal support. So you need both. We need both federal and state leadership in California.

People look to California because even despite all the challenges I mentioned, we’re an innovative state. We’re a state people look to for a sense of possibility when it comes to policy change. I think we do have incredible momentum here and a really strong foundation to build on…strong advocates, really excellent leadership at the agency level in California, we have master plans on early care and education and aging that are really moving the needle. I think workers are named in both of those plans, but we need really meaningful focus and action on the worker piece if that is what undergirds successful transformation of those systems.

Van

And with the big shifts that are ahead for the future of care, like value-based care or more care shifting to the home, do you see any of those creating policy windows for some of the changes that you’re advocating?

Rachel

I think value-based care is exciting because it might actually be a way for those who are in most direct contact with patients to be part of a care team and be rewarded through that kind of model. But systems are systems and we have a lot of work to do to value that care. There’s been a push to say direct care is not low-skilled care. It’s actually very high skill work, working so closely with patients and honestly with families, too. So we need some cognitive shift and mindset shifts in healthcare where those who are having that really deep and frequent touch with patients are valued in those new schemes for keeping people safe, keeping them in their homes and out of institutions. So I think there’s potential there, but we also just have to contend with the perception of that work.

Van

So, I mentioned in my opening that you have a report that is out called Forging a Sustainable Future for California’s Direct Care Workforce. I was wondering if you’d like to do any more call out of key points or anything you would like to spotlight further?

Rachel

When I started working on care worker work and care workers, the first thing I had to do was educate myself. This has not been my twenty-year career. So what’s been fascinating, and that I had to learn, was there are many names, many settings, and many payers when it comes to care work. The implication of that is it’s really hard to get good data on both the number of care workers, good data on wages, and there’s a lot of gray market activity and private pay activity, which just isn’t going to be captured in a lot of our workforce systems and data systems.

I did that initial workforce on childcare workers, and then we did this report on the direct care workforce to just continue to educate people about who are these workers, where are they working, and what are the public financing strains that touch them.  There’s also a lot of private pay, but we had to understand all that to sort of bridge people who are interested in workforce with people who do healthcare financing in this case, and the complexities of the way we finance healthcare in this country that connects then to the way workers are paid and where they work and all of that.

So the primer was like a level set for our foundation, but also other foundations, workforce advocates, workforce development people. If we really want to understand the levers of change, if we really want to commit to supporting the direct care workforce, we have to have a shared understanding of who the workers are and the policies and systems that are impacting their pay, and so that’s where we started.

I think one of the things that’s been really interesting looking at the report is some of the history of where we’ve been in California and at some moments we made some progress and then we let something that had promise go and moved on to the next thing.  So I hope that the primer also gives us a sense of what’s possible…that we’ve tried some things before that worked. We also have some new opportunities that are coming through federal change and how do we really work together in new ways to focus on direct care to get ready for the future, to have the workforce that we need and really to make these jobs, quality jobs, valued jobs, jobs that pay well?

Van

Rachel, how do our listeners get a hold of this primer?

Rachel

The primer is posted on our foundation’s website and I can share a link with you. We’re really excited to have conversations with people about the primer. The primer is a tool for us to be in dialogue with other advocates and with state agencies. One of the recommendations in the primer is that we support a solutions table in California. Again, we’ve had the Master Plan on Aging and even the report on the future of the healthcare workforce, but we haven’t felt like there’s just been a consistent, dedicated leadership and team that’s focused on really driving change in this space. So, that’s we’re hoping the primer will catalyze that kind of energy and conversation and leadership.

Van
Well, thank you for sharing that resource. Why don’t we close out by asking you a future of care question. Are there any innovations you’re excited about that support health and economic security for direct care workers?

Rachel

Yes, there’s actually quite a few of ’em. One that I’m really excited about is the Home Care Cooperative Initiative. There was a home care cooperative established down in Los Angeles County by the Pilipino Workers Center. It’s called Courage Cooperative and it is a model for the direct care workforce and the home care workforce to have good wages and good working conditions.  I think we’ve seen a lot of abuse of workers in the home care industry, and there are examples of workers who were being paid $5 an hour, working twenty-four shifts. Getting into this cooperative gave them dignity and respect in their work. It gave them control over the hours that they work, better control over the wages that they made. For those who employ home care workers, it is a way to be a high road employer. So, that’s been really exciting.

There’s also a group of partners that have come together to think about how to scale home care cooperatives in California. So, what’s the infrastructure that we could create that would allow small groups of workers to form worker-owned cooperatives, and how do we give those cooperatives kind of a backbone of support — marketing systems, technology systems and things like that to plug into make the model efficient and effective?  I’m really excited about the potential of that. It also just models what is a high road employer in this industry, and if we can show that that’s possible, it can be a tool for regulation and pushing policy that enforces worker justice and equity in this sector.

The other innovation I’m excited about, and this also comes out of the domestic worker movement, is a portable benefits pilot that’s being stood up in San Francisco. When you work for many different employers as domestic workers do, it’s really hard to have access to paid sick time because you’re being paid by many different people. This project proposes to use an app based system where multiple employers could pay in for home care workers, nannies, and house cleaners so that they could use that benefit for paid sick time. They would be able to collect paid sick leave essentially from multiple employers and do it through an app. That’s getting going in San Francisco, and I’m excited to see what that looks like because there’s just many workers who are shut out of any access to benefits, like paid sick time, because of employment arrangements that challenge our typical model of employer-based benefits. So, that’s pretty exciting.

Van

So, the app is not tied to the payroll service between the employer and the direct care worker?

Rachel

Well, domestic workers are often in private pay arrangements with individuals in their homes and so the app is really a way for those employers to contribute to the individual worker, like a fund to the individual worker.

Van

And you were about to give a third example.

Rachel

Well, I think the other thing I’m seeing is some of the ‘earn and learn’ models are coming to childcare and to home care and direct care. I know through the Cal Grows initiative, there were some really great programs that were looking at that model in childcare. We’ve seen apprenticeships for childcare providers get going. I think the hard part is we need public investment in the ‘earn’ part of the model. There’s lots of great providers out there to offer the learn, but we need a funding source for the earn part of those models.

Van

Well, those three examples are excellent — home care cooperative, portable benefits pilot on an app, and earn and learn models. Well, thank you for leaving us on an inspiring note. Rachel,

Rachel

Thank you so much. It’s been a pleasure to talk about this workforce. They’re really an invisible workforce, and again, like I said, they are the workers that make all other work possible. So, I’m excited to work on economic and racial justice on their behalf.

Van

I appreciate you being with us today. I am Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you’ll join us again as we continue to explore how to create a future-focused workforce in America.