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The Dignifying Solution to America’s Care Crisis

Employee ownership turns care work jobs into good jobs—and leads to better patient outcomes.

When she was 33 years old, Clara Calvo came to New York City from the Dominican Republic. Alone and looking for a foothold in her new country, she took a job at a garment factory sewing cotton T-shirts. Her mother, a skilled seamstress who had raised 12 children, had passed on her sewing skills to Clara—skills that would help her earn more than the base salary of just over $4 an hour.

When Clara went to collect her pay after her first two weeks on the job, the floor boss told her she was owed for only one week. She remembers staring him down across the table that separated them. Her fellow workers had told her that the company owed them money too, but they were afraid to press the issue. Many of them were undocumented—what if the boss reported them to immigration officials? “Mantén la cabeza baja,” they told her. Just keep your head down.

From her mother, Clara had also inherited a lack of tolerance for bullshit. When the boss continued to insist that she had miscalculated, she pushed the table into his belly and said, “I want my money today or I’m going to call 911.”

She left with what she was owed and vowed to never come back. But finding better work proved difficult. Stints dyeing women’s hair at a salon on Staten Island—where the sharp smell of ammonia made her feel sick—and working in the unbearably hot confines of a food truck weren’t long-lived. Things at home were eroding too; she and her new husband fought a lot. One night, he hit her in the face and became violent with her young daughter. Clara was determined to leave him, so she needed a dependable job. But how?

In 2001, a friend recommended that she check out Cooperative Home Care Associates (CHCA) in Manhattan’s Washington Heights neighborhood. “You could be a home attendant,” the friend told her.

Clara was hired and took to the work at CHCA immediately. She loved talking with her clients—seniors and people with disabilities—cooking them nourishing food, keeping their bodies fresh and clean, coming to understand where they ached and how to soothe it, who and what mattered to them most. But it wasn’t just the work itself that felt different. At CHCA, a worker-owned cooperative, she wasn’t just a body on the factory floor but a whole person. She learned that a worker-owned co-op is a business that is owned, controlled, and operated by the people who work there; the worker-owners share in the decision-making and in the profits. Soon, Clara was elected to the board of directors and was contributing ideas for the management of the co-op, including what should be done with surplus money at the end of the fiscal year. (She thought investing it in their insurance pool, rather than distributing it as year-end bonuses, made the most sense.)

There are more than 3 million people in home-healthcare jobs like Clara’s in the United States, taking care of the elderly and people with long-term disabilities in their homes. (More than 680,000 additional caregivers work in residential settings like nursing homes and memory-care facilities.) This sector is expected to grow massively as the American population ages. During the past decade, the share of the population over 65 grew by nearly 40 percent. By 2030, there will be 59 million baby boomers, all of them over 65.

Family members—adult daughters, wives, husbands, and other loved ones—will, of course, take on much of the caregiving work; according to a recent AARP/National Alliance for Caregiving report, there are 63 million family caregivers in the US. But the burden on unpaid family caregivers can be heavy. If they lack the support they need, family caregivers inevitably burn out; 18 percent of caregivers caring for a spouse with dementia died before their loved one did because of the stress. And family caregivers often drop out of the workforce when the strain of juggling all the demands gets to be too much. According to AARP, about two-thirds of working caregivers report difficulty balancing work and caregiving responsibilities, and more than a quarter have reduced their work hours or shifted to part-time work in order to meet their caregiving responsibilities.

The direct-care sector, which includes home-care providers like certified nursing assistants, home health aides, and personal-care aides, is expected to add around 860,000 new jobs from 2022 to 2032—more than any other single occupation in the country. But, by and large, these are not good jobs. The annual turnover rate is a whopping 75 percent. Low wages combined with unpredictable hours make it challenging for direct-care workers to financially support themselves and their families. The median annual earnings for direct-care workers are just under $26,000—which forces nearly half of them to rely on public food and cash assistance.

In the 1990s, when today’s boomers were coordinating care for their “Greatest Generation” parents, the majority of home-care agencies were locally owned and operated nonprofits. Boomers’ kids, however, face a radically different landscape: The Centers for Disease Control and Prevention reports that 83 percent of home-care agencies are now for-profit, largely because private-equity firms have discovered that this growing industry can generate handsome returns. According to Fortune Business Insights, the home-care market now has a value of more than $432 billion.

This increased privatization hasn’t benefited the recipients of home healthcare. According to some studies, for-profit home-care agencies are costlier for Medicare than nonprofit ones, and the quality of care is worse, with more patients requiring repeat hospitalizations.

There is, however, a growing trend in home healthcare that cuts against the spread of for-profit care provision. Worker-owned home-care agencies like CHCA differ from both for-profit and nonprofit agencies in a number of meaningful ways. In worker-owned home-care agencies—most often structured as worker co-ops—professional caregivers earn an hourly wage but also shape the training protocols, cultural expectations, and financial management of the company. Home-care workers in these agencies make, on average, $2 more per hour and have a 38 percent annual turnover rate. These care workers stick with their jobs not only because the pay is better but also because the jobs themselves are structured in ways that make them feel more respected and effective.

Clara’s current client is Sam, 47, who lives in a one-bedroom apartment on the 13th floor of St. Margaret’s House, a large building in Manhattan’s financial district that houses tenants who pay rent with Section 8 vouchers. Sam has cerebral palsy and uses an electric wheelchair. He dreams of running his own after-school program someday, but for now he spends most of his days with Clara gazing out at the South Street Seaport and talking about everything under the sun. At night, after Clara has headed back up to Washington Heights, he can hear the concerts at the nearby Rooftop at Pier 17; last summer, he even caught one of his favorite bands, Green Day.

Medicaid has been funding Clara’s work supporting Sam four days a week since 2023. She helps him with his laundry, goes to the supermarket or medical appointments with him, cleans his sparse apartment, helps him shower, and cooks meals for him—including his favorite of her dishes, baked salmon in coconut milk.

When I spoke with them in Sam’s apartment, Clara had just returned from a visit to the Dominican Republic. (CHCA has provided paid vacation time since it was founded, which is not the industry standard.) While Clara was gone, Sam........

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