By Cati Coe, PhD

The United States has historically depended on employers providing health insurance to their employees, which resulted in many low-wage workers going without. Earning enough to disqualify them for Medicaid and too young for Medicare, this flexible workforce faced unaffordable medical bills or avoided medical care altogether when they got sick. When those with health insurance through their employer became very sick, they were unable to keep working and lost their jobs and health insurance simultaneously. The Affordable Care Act attempted to address these issues, but did so inadequately.

This situation became clear to me through my research with African immigrant home health workers who provide care and companionship to America’s growing population of seniors. When I began this research, before the Affordable Care Act, most care workers I met did not have health insurance. One said, “The people who designed this system have no soul,” because she had no health insurance despite providing health care to others. Another told me, “You don’t feel part of society here as a result. Even at McDonalds, you get benefits.” The lack of health insurance was particularly poignant given the high rates of injury among direct-care workers, as reported by the Institute of Medicine, four times the rate of non-fatal occupational injury than all occupations and higher than that of either construction workers or truck drivers. Most of the injuries were to backs and knees because of the physical effort of lifting and transferring patients.

Many direct-care workers did obtain health insurance through the Affordable Care Act, as found in my research and nationally by the Paraprofessional Health Institute, although 26 percent remain uncovered. The reasons why a quarter of low-wage health workers do not have health insurance reveals why health insurance should not be linked to work.

Like other workers in today’s flexible labor market, home care workers have little job security. The home care worker loses her job when her patient enters the hospital, passes away, or runs out of money for care. The Affordable Care Act, on the other hand, assumes that workers have stable, full-time work. It requires businesses with more than 50 employees to provide health insurance to its employees who work full time, or 32 hours a week. One agency owner told me, “Our caregivers work full time one week, part time another, and then six to eight weeks full time.” One care worker in her fifties was working 24 hours regularly for a nursing home and she would occasionally substitute for an additional eight hours. If she worked 32 hours for four weeks, she was eligible for her employer’s health insurance. She was going on and off health insurance constantly, depending on how many hours she had worked. Sometimes, when she went to the hospital for her diabetes and heart condition, she had to pay out of pocket and at other times, she would be covered. She was eager to work full time because she so desperately needed health insurance for her multiple health problems.

The Affordable Care Act’s Medicaid subsidy is meant to allow a low-wage workforce to buy affordable health insurance, independently of their employer’s coverage. However, the fluctuations in care workers’ incomes mean that they sometimes qualify for a subsidy and sometimes do not. When I called a care worker one day in March 2016 to see how she was doing, she told me that she was on her way to her public health department “to see about Obamacare.” She had complained to the health department previously: she never knew how much she was going to be earning, because her patient could die or go to the emergency room. Then, she loses her job or she only gets four hours of work a day on the next case. Now that she had just lost a patient, she was going to see if she could again afford health insurance.

One of the reasons that the New Deal’s substantial expansion of labor protections failed African-Americans was because it only considered industrial production to be real work, excluding the agricultural and domestic work in which African-Americans were concentrated at the time. Tying health insurance today to employment, and particularly to full-time employment, similarly excludes certain kinds of workers, leaving those with precarious jobs and schedules not well covered by the Affordable Care Act.

The great thing about Medicare for All is that it would de-couple health insurance from employment, ensuring that a low-wage, flexible workforce, including home care workers needed to provide care for aging baby boomers, are cared for and can continue to care for others.

Cati Coe is a professor of anthropology at Rutgers University, and the author of a forthcoming book called “Exclusion through Care: The Complex Dynamics of Belonging among African Care Workers in the United States.”