Health care and health-care policies have a long history in the United States. Obama's recent victory in the Patient Protection and Affordable Care Act (often called Obamacare) is only one example of the complicated and contentious relationship between health care and politics in the world's leading market economy. Whenever health-care reforms in the US are discussed, attention is directed mostly towards the recipients of health-care services, and especially the funding of curative health-care services. The fact that a large part of the American population has no health insurance and therefore runs great risks in the event of health emergencies is an issue of concern to many. Yet, in the debate on the American health-care system, much less attention is paid to health-care providers, and in particular to the large numbers of women (and in some cases men) providing home-care services to the elderly, the chronically ill, and the disabled.

Home health workers are a particular segment of the health-care sector that is working “in the shadow of the welfare state”. They assist people at home in such day-to-day tasks as bathing, getting dressed, cooking, and cleaning. They are neither nurses nor cleaners, yet they are America's front-line care-givers, as Boris and Klein state in their impressive book Caring for America: Home Health Workers in the Shadow of the Welfare State. While a burgeoning number of academic studies have been published on the increased employment of domestic workers (often migrants) in welfare states, home health workers have remained largely invisible. Yet, according to Boris and Klein, home care is one of the fastest growing occupations in the US, and at the centre of the economy (p. 6). The restructuring of the welfare state, and in particular of the health-care system, coupled with the changes that have taken place in white middle-class families, where women have taken up paid employment, have led to a structural demand for home care. In the absence of public policies providing and protecting long-term care at home for those in need, a large variety of workers, such as personal attendants, in-home support workers, homemaker-housekeepers, and home health aides, are employed. These care workers are part of the growing group of “intimate labourers”: people who take care of the intimate needs of others.Footnote ¹

In their preface Boris and Klein refer to the feminist motto of the 1970s, that the personal is political. Their interest in the topic is not only intellectually inspired but also linked to their personal experiences. Confronted with the caring needs of their parents and grandparents, they experienced how difficult it was to obtain good home care, even for people with financial resources. To understand why this is so difficult, and in particular why this form of care is so undervalued, underpaid, and invisible, the authors hope to show how such a health-care system developed. Their book provides a much needed history of home-care workers in the United States, and in doing so it unravels the intimate relationship between home care, the politics of public health care, and the many struggles experienced by workers and unions to secure recognition for their essential work.

Whereas home care has long been treated as a private issue, Boris and Klein show that it has become the core of the new care economy. Unlike other sectors of the US economy, care work cannot be “offshored” (p. 6). Instead, cheap and flexible labour is found at home among African-American and immigrant women. The fact that, like domestic work, home health care is greatly gendered and racialized perpetuates its invisibility, marginality, and lack of recognition. For a long time the labour movement in the US neglected care work at home. Labour unions did not regard home-care workers as real “workers” because they lacked formal status as an employee. In addition, home care was heavily dependent on state funding, workers were dispersed over a multitude of private homes, and employers were individuals in need of care instead of private companies in search of profit. Yet, despite these challenges, home health workers were able to organize themselves in such a way as to affect the membership, goals, and strategies of the labour movement. How they succeeded in doing so is described in detail in this book.

In their first three chapters Boris and Klein describe and analyse the history of home care since the 1930s in the light of government policies and programmes, both at the national and the federal level. They show how home care as a profession developed in political periods such as the New Deal (1930s), the postwar years (1950s), the War on Poverty (1960s), and the Reagan era (1980s). They pay special attention to the states of New York, California, Illinois, and Oregon, where home-care workers and recipients of care were actively involved in the development of social programmes. While these chapters could be read as a history of a hitherto fairly unknown part of the health-care workforce, they also show the importance of individuals in the development of home health care and related policies. In addition, these chapters show the intricate, and increasingly close, link between the public and the private sectors in the United States; right from the start, public welfare programmes were dependent on a wide range of private organizations, such as charities, non-profit organizations, and vendor agencies. Yet the balance between public and private changed drastically with the privatization of the health-care sector in the 1970s and 1980s, a trend that has intensified in the past two decades. Flexible labour policies, increased outsourcing, and the continuous search for profit have turned home-care workers into casual employees excluded from legal protection.

The last four chapters focus on the struggle for the recognition and rights of home-health workers. In 1968 the Service Employees International Union (SEIU) became the main organization defending the rights of home-care workers in the United States and Canada. Developed out of a union for janitors and window cleaners, the SEIU nowadays represents 2.2 million cleaners, care workers, nurses, and other service professionals, many of them immigrants and women. The authors describe the history of protests, the wide variety of strategies, and the importance of individuals both within and outside the home-care movement. They argue that state policies enabled workers, recipients of care, and political constituencies to demand better wages and better care. The home-care movement experimented with new structures of representation and used different strategies at different levels – state level, community level, and labour-union level. In doing so, it was able to change the focus of the US labour movement to such an extent that the service sector is now one of its most vibrant parts.

In this part of the book the voices of home-care workers themselves are louder, as the authors have been able to include more interview material. The women speak with passion about their work, underlining its great emotional and social value for themselves and for those they take care of, but also emphasizing the fact that it is “real work”. It is precisely this thin line between care and work that has hampered the recognition of home-care workers as workers. The large number of people and organizations involved in the unionization of home-care workers across the United States is impressive, and so are the results. Despite the enormous challenges, the home-care movement has shown that professional long-term care can be guaranteed only when care providers are paid adequately, are protected by the law, and are recognized and respected.

This book is not only an excellent contribution to labour history, but also a tribute to home-care workers in the United States. For non-Americans, the complicated US landscape of politics and health care becomes clearer, although the many different authorities, organizations, and programmes involved, and the corresponding abbreviations, are at times confusing. The list of abbreviations at the beginning of the book is therefore very useful. In addition to its academic importance, this book is of great social relevance as it outlines in clear terms the urgent need to rethink and re-evaluate care work in the United States and beyond.