The “Gray Market” in US Home Care: Complexities and Contradictions

Home health and personal care are among the fastest-growing occupations in the United States. Public funds (primarily Medicaid) often cover home care workers’ wages, but many care recipients are not eligible for such support, and instead pay out of pocket. Many privately-paid home care workers are formally employed – hired through specialized employment agencies or on-line matching services, but a substantial (though unknown) number are hired informally, typically paid in cash and outside of governmental regulation. This is the “gray market,” for which data is almost nonexistent. To understand this gap, the paper presents the findings drawn from original data generated using an innovative methodology (based on Facebook’s targeted advertising) to survey privately-paid home care workers compared to agency workers in four large U.S. areas: New York City; Los Angeles and surrounding counties, and a selection of metro areas in the Southwest and the Southeast. We also interviewed a subsample of survey respondents to both help interpret the survey results and collect workers’ own insights on the past and future of home care. On the basis of these data, we compare three types of home care: formal employment in the Medicaid-funded segment of the home care market, formal employment in the privately-paid segment, and the understudied 'gray market.” Our analysis complicates the conventional narrative about this rapidly growing occupation by highlighting the structural segmentation of the home care labor market as well as its geographical variations.

We seek to inform efforts to strengthen labor standards enforcement, which is especially vital for undocumented and vulnerable immigrant workers employed by private households, and support the broader effort to secure equitable and sustainable long-term care, for care providers and recipients alike. In this presentation, we will describe the challenges and rewards of our methodology and present preliminary findings from the project.