By Ashley Johnson, ACLU Legal Fellow, Women's Rights Project.

At the onset of the pandemic, as most of the country shuttered themselves inside to avoid COVID-19 infection, home health aides remained on the front lines, taking care of our loved ones and risking their lives in the process. These caregivers — the majority of whom are Black and Brown immigrant women — face considerable risks on the job.

Home care workers help people with disabilities and seniors with intimate and vital tasks like bathing, dressing, and eating, making social distancing impossible. Yet, many states’ emergency COVID-19 measures excluded home health aides from their definition of “essential workers,” failing to assure them access to adequate PPE, prompt COVID-19 testing, and vaccines.

And home health aides, like many essential workers, are prone to pandemic-related emotional burnout because they often work alone, isolated from supportive colleagues. Now in the pandemic’s third year, we must urge both federal and state action to ensure that those who care for our loved ones and neighbors are able to stay healthy and safe.

More than 8.6 million older adults and people with disabilities rely on home health aides, and home care remains one of the nation’s fastest growing sectors. But home health aides are among the lowest paid workers, with a median wage of $13.02 per hour, or $27,080 annually for a full time aide. Unsurprisingly, in a survey of home health aides’ experiences during the pandemic, 76 percent of personal care attendants and 64 percent of agency-employed home health aides said they could not afford to stay home if they or a family member got sick, or quarantine if they were exposed to COVID-19. It’s no wonder why 1 in 6 of these workers lives below the federal poverty line.

The safety and dignity of home health aides is inextricably linked with the safety and dignity of those they care for. Assuring higher pay and safer conditions for home health care workers is essential to attracting and retaining high quality caregivers. Government-mandated pay increases can, however, have the unintended consequence of hurting the very communities served by home health aides, because state and federal Medicaid reimbursements are inadequate to cover these higher costs. As a result, an increase in caregivers’ pay can often lead to a decrease in caregivers’ hours — and thus, a decrease in needed support for people with disabilities.

We can and must avoid pitting these communities against one another. Instead, we must consistently couple our advocacy on behalf of home health aides with calls for increased Medicaid funding to ensure in-home care remains affordable.

The Build Back Better legislation introduced in Congress last year would have invested $150 billion into the home care workforce and in home and community-based services for people with disabilities. Though far less than the $400 billion originally proposed by President Biden, this funding would have presented a transformative, vital investment in home health aides’ dignity and their clients’ well-being. Now, as the White House and Congress negotiate new legislation, it is crucial that any new budget package expands access to home-based care. The bill should incentivize states to improve coverage under Medicaid, the primary source of funding for such services, and increase funding to allow states to expand home-based services.

If federal legislation is enacted, it will only be a long-overdue first step, and it must not be the last. States can and should take action. Some already are:

• In March 2021, the New Jersey legislature passed a budget that included a home and community-based service worker rate-setting provision, increasing wages.
• In September 2021, Colorado passed a measure that will increase pay for home care workers using federal pandemic relief money.
• In Maine, the governor recently announced that $126 million in MaineCare funds will be allocated as bonuses for home care and community-based workers.
• In New York, the state budget raised home care workers’ pay $3 an hour, but the Fair Pay for Home Care Act would establish even greater protections: a base pay for home health aides of at least 150 percent of the regional minimum wage.

In addition to the immediate dangers of COVID-19, home health aides’ safety and health concerns are distinct and dire.

The physically-strenuous intimate care these workers provide results in on-the-job injuries at often higher rates than in other industries. Nearly half of home health aides have reported being physically and sexually harassed on the job, and they also must contend with the family members of those they care for. And despite reporting higher rates of violence than people in more traditional work settings, home health aides are less able to vindicate their legal rights when violations occur because they are disproportionately non-unionized.

Workplace laws themselves must be reformed to protect this especially vulnerable group. Federal anti-discrimination laws, for instance, apply only to employers with 15 or more employees, while the Fair Labor Standards Act — which provides minimum wage and overtime protections — has loopholes that exclude some home health aides outright, or are open to misinterpretation and abuse. Rep. Pramila Jayapal, along with Sens. Kirsten Gillibrand and Ben Ray Lujan, sought to correct this injustice by reintroducing the National Domestic Workers Bill of Rights Act in July 2021, which would expand paid sick leave and anti-discrimination protections to home health aides. But the legislation has not progressed in this Congress.

It has never been more crucial to invest in the people who care for us and our loved ones. By increasing wages and pushing states to make home care services affordable, Congress would take a significant step forward in improving home health aides’ financial stability while attracting new workers, remedying a critical shortage in this sector. But we must take even more dramatic action to shore up our caregiving infrastructure — during the pandemic and beyond.

There is, of course, the obvious answer: women. Cisgender women have abortions more than any other group of people. There is plenty of data to back this up. Abortion among women who can become pregnant is extremely common and nearly one in four women will have an abortion in their lifetime. The vast majority of data available about abortions and abortion access surveys women. That data tells us that the average person who gets an abortion is a woman of color who is already a mother and who lives at or below the federal poverty level.

The more expansive and more accurate answer is anyone who can become pregnant needs to be able to get an abortion if they need or want one, including many cisgender women, some non-binary people, some intersex people, some Two Spirit people, and some trans men.

As a bisexual transgender non-binary person, I can become pregnant. I am not a woman — and yet, I could need access to abortion care. I also know that I never want to be pregnant. For me, access to abortion would be a matter of lifesaving health care. When trans people articulate the need for access to abortion services, or that we have accessed abortion care in the past, these experiences are often dismissed by those who want to deny that more people than just cisgender women need abortion. But we’re here, we’ve been here, and we’re not going anywhere.

The fight for abortion rights and LGBTQ+ rights go hand in hand because they are both ultimately about protecting our bodily autonomy. But they’re also intertwined because lesbians, bisexuals, trans people, queer people and yes, some trans gay men, can experience pregnancy and deserve control over if, when, and how we become pregnant, and whether or not we stay pregnant.

Photo by Zach D Roberts/NurPhoto via AP

When conversations about abortion reduce it to a “women’s issue” or an issue only for people who can carry pregnancies, we exclude a wide swath of people.

There is a tendency to exclude men, without an acknowledgment that some trans men can become pregnant and despite the fact that cisgender men are not the only people who can’t become pregnant. Trans women, cisgender women who struggle with infertilty, some intersex people, some trans men, some non-binary people, and some Two Spirit people all cannot become pregnant.

Protest signs and messages often use the framing of “no uterus, no opinion,” ignoring that there are many cisgender women who have and have not carried pregnancies who have had hysterectomies and no longer have a uterus. Hysterectomies are, in fact, the second most common surgery for cisgender women.

Centering who gets to have opinions about abortion around whether or not people are currently able to become pregnant excludes people from our understanding of abortion rights, rather than expanding it.

In the same breath, we must acknowledge that the systems and structures involved in banning abortion are focused on restricting the rights of women and the rights of trans people. Over 300 anti-trans and anti-LGBTQ bills have been proposed in state legislatures just in 2022, and over 20 new anti-trans bills have become law over the past three years. In the same period of time, 541 of restrictions aimed at pushing abortion out of reach have been proposed and 38 have become law.

Nearly all of these bills politicize our bodily autonomy and access to essential, life-saving health care. Trans affirming health care and abortion are both already hugely expensive medical procedures, often not covered by health insurance. Both are often prohibited from being covered by insurance under state laws.

For trans people, laws in some states prohibit access to gender affirming care, particularly for youth, or worse, criminalize parents who allow their children to access this care. For people who need abortion care, there are legal restrictions that prohibit insurance coverage, enforce long waiting periods for time-sensitive care, and other medically unnecessary barriers.

Any way you slice it, diving into the politics of both abortion access and trans rights requries people who may need an abortion and trans people to be ready to debate why we need access safe, common medical procedures that will save our lives. It is, quite frankly, exhausting to repeatedly ask for acknowledgment of a shared experience, especially one that can be so medically life-altering.

Our bodies are our own. Our health care choices are ours to make. And abortion and gender-affirming care are our right.