Lynn McCormick
Hunter College/CUNY
Introduction
Immigrants have grown steadily as a proportion of New York City’s
health care workforce since 1970, when they comprised over one-quarter
of all health care jobs. At the last census, in 1990, immigrants
held 36% of all health care jobs; today, they could hold one-half of all
such jobs locally. Immigrant entrance into health care jobs coincided
with the start of this industry’s expansion phase in the mid-1960s after
enactment of the Medicare and Medicaid programs. It was also stimulated
by passage of the Cellar-Hart Immigration Reform Act, which increased immigration
to the United States from a set of new sending countries.
In this paper, I track the entrance of immigrants into the nurse
aide occupation in New York City’s health care industry since 1970 to shed
light on the immigrant incorporation and skills mismatch debates.
I find that the “ladder” notion of an ethnic economy—which hypothesizes
that native-born workers hold “better” jobs at the top of an occupational
hierarchy—is helpful as an initial organizing framework for understanding
the early distributions of natives and immigrants within the city’s health
care industry. Over time, however, this ladder fell apart.
Key institutional players—like government and private payers of health
care, employers, and unions—played a major role in breaking up and redefining
its rungs, or occupational niches, to deal with “bottom-line” issues.
At times, this allowed certain newcomers to “jump the queue” into good
jobs without waiting their turn, invalidating the thick co-ethnic hiring
networks of former jobholders.
This occupational case study is informed by the immigrant incorporation
debate.1 Recent immigration flows have prompted scholars and
others to argue over whether immigrants take jobs away from the native-born.
Do immigrants take jobs from natives because they offer employers a better
deal due to their willingness to accept lower wages, more limited job security,
and poorer working conditions than the native-born? Or, do immigrants
merely take the “bad” jobs—those that are poorly paid and requiring few
skills—that natives, given their other possibilities, would never consider?
Waldinger (1992) offers a concise and sophisticated answer to these
questions. In expansionary periods, when there are plenty of jobs
to go around, immigrants enter the economy at the “bottom” and replace
natives, who—with greater knowledge of and power within the labor market—move
up into better job opportunities. Hence, white, native-born workers
are at the top of this occupational ladder (in jobs that pay the most and
offer good opportunities for advancement); they are followed by black,
Hispanic, and other native born workers; the most recent immigrants enter
the economy at the bottom on the last rung. Individuals create “ethnic
niches” in the occupations and industries in which they are over-represented,
allowing ethnic peers to continue to be hired there through communal relationships,
or “networks.” But during recessionary times, when jobs are less available,
native workers fight to keep their existing jobs, and immigrants compete
with and may even displace them.
That the number of health care jobs in New York City has been consistently
increasing over the last several decades would suggest that immigrants
have been replacing natives in this industry all along. But, this
interpretation, by itself, underplays the serious efforts of health care
employers and “payers” to downgrade lower skilled jobs—like nurse aide—to
deal with increasingly important “bottom-line” pressures. They have
done this, in part, by moving aide jobs into non-unionized settings.
Job downgrading may push native workers out, without necessarily giving
them better jobs to move into up the occupational hierarchy.
At the same time that aide jobs have been downgraded, employers have
been expecting better quality care and higher skills from aide jobholders.
This lends support to scholars who hold that low-skilled, entry-level jobs
in the American economy are all “upskilling.” This point-of-view
argues that low-skilled jobs are disappearing as employers increase their
use of computer-based technology to remain competitive.2 Low-skilled
natives are displaced from entry-level jobs because they lack sufficient
experience or credentials for these new, higher-skilled jobs. Instead,
they try to get the remaining low-skilled jobs, which are in dwindling
supply, and driving wages down.
Others in this skills-mismatch debate argue that that entry-level jobs
may, in fact, be “upskilling,” but at a pace not significantly different
from technological upgrades to jobs in the past. These scholars contend
that a significant amount of lower-skilled, entry-level jobs remain in
our economy, but they are deteriorating in wages and benefits because of
a widespread erosion in “postwar” labor market institutions, such as unions,
that protected low-wage workers from excessive competition in the past.
Upskilling among nurse aides in New York City is occurring. But,
although this occupation shows continual upskilling—in terms of educational
levels—throughout the last three decades, increased skills in the past
were accompanied by “job upgrading” because of unionization, whereas they
have coincided with “job downgrading” since the mid-1980s, due to significant
employer and payer pressure on health care costs and union demands.
Because of this, few natives would want to take such jobs. This constitutes
immigrant replacement of natives to the extent that the latter move on
to better paying lower- or higher-skilled jobs; it represents displacement
to the extent that natives are pushed out because they are unwilling to
invest in upgrading their skills for stagnating compensation. Thus,
immigrants have helped the health care industry in its efforts at restructuring
and containing costs. To the extent the immigrant incorporation and skills-mismatch
debates underplay employer, payer, and union efforts to reshape occupational
ladders, along with the skill and remuneration content of related jobs,
they miss a significant part of the explanation for why and how immigrant
versus natives—and “oldtimer” versus “newcomer” immigrants—compete on the
job.
I explain this argument by following African-Americans, and Jamaican,
Dominican, and Filipino immigrants, holding nurse aide jobs in New York
City. The paper first covers the environment that led to expansion
of the health care industry in New York City from the mid-1960s.
The paper then presents the industry’s early ethnic job ladder among nurse
aides and discusses the key factors that have reconstructed this ladder
over time—unionization, expansion of a bottom rung of low-paid jobs in
home care, and the current pressures for both upskilling and downgrading
among aide jobs across the board.
Case Study Data
Information for this case study was gathered from interviews held with
a dozen key institutional actors, from published and unpublished sources,
and from the Public Use Microdata Sample (PUMS) of the U.S. Census.
The PUMS data was drawn from the ipums site at the University of Minnesota
to facilitate comparison of the data historically. For each of the
three years utilized—1970, 1980, and 1990—a file of health care employment
was created by place-of-work and limited to the New York City area.
This allows the city’s health care industry to be studied as to its occupational
composition and changes to its labor supply needs over time.
However, due to differences in how the data were collected each year,
aggregation of this place-of-work file also differed for each year.3
Therefore, between-year analyses—such as growth rates over time—should
be subject to the greatest scrutiny. Given its flaws, PUMS still
remains one of the most accurate data sources on immigrants by occupation.
The Environment
Hospitals and many other health care facilities receive payment for
their services from “third party” payers. Hence, the generosity of
these payer systems helps determine the rate at which health services grow
in a society. In the United States, a key factor in the expansion
of the health care industry—starting in the mid-1960s—was the Great Society
programs of Medicare and Medicaid, funding health services for the elderly
and indigent. Furthermore, growing unionization nationally in the
1950s and 1960s encouraged employers to provide private health insurance
coverage to their workers through group insurance plans—like Blue Cross/Blue
Shield. All three of these payer sources initially reimbursed hospitals
and other health care providers for their services on a full-cost, per-day-of-stay,
“fee-for-service” basis. This fueled consumption of medical services,
as well as investments in the new medical technologies of the time (e.g.,
coronary artery bypass surgery) and in hospital construction (Sultz and
Young 1999).
Hospital employment in New York City rose from about 120,000 in 1970
to 175,000 in 1980 and over 230,000 in 1990 (Table 1). Nursing home
employment also rose sharply in the 1970s—going from about 8,500 to almost
36,000 workers then—with state and federal encouragement. This included
new state support for construction of nursing home facilities. Would-be
nursing home entrepreneurs flooded the market in this decade. In
contrast to the city’s hospital sector, which contains public, private,
and nonprofit facilities, most nursing homes then and today are privately
operated facilities.
The rapid rise in health care costs in this period started a trend
toward increasing scrutiny of all health care institutions and practices
as hospital profit margins swelled.4 However, little was done to
curb costs until the following decade. Instead, hospitals increased
in size and complexity, becoming important community employers, the center
of much medical research and training—especially in New York, renowned
for its academic medical centers—and principle site of most health care
provision (Berliner et.al. 1994, Berliner 1995, Sultz and Young 1999).
Nursing homes also expanded in the 1970s; home health care grew later—after
1980 (SEIU 1999).
At First Glance—A Hierarchical Ethnic Job Ladder
In 1970, after five years of tremendous growth in health care employment,
immigrants held 33% of all hospital jobs and 35% of nursing home jobs.
Immigrant entrance into health care jobs continued throughout this decade,
expanding especially into these two largest subsectors. At first
glance, both their initial positions and subsequent mobility patterns seem
to be structured much as Waldinger’s (1996) ethnic queue framework would
suggest. Firstcomers to the industry, like Jamaican immigrants, captured
the “better” jobs in hospitals versus nursing homes. Latecomers—Haitians
and Dominicans—funneled into the worse paying nursing home and home care
jobs. Black native-born aide workers also began to move up this ladder
beyond immigrant aides into “better” positions offered in government hospitals
and doctors’ clinics. This section summarizes the structure of the
aide occupational ladder and key mobility paths.
In 1970, most health care workers (69%) worked in hospitals.
On the whole, private hospitals paid their workers less than government
hospitals. For this reason, 70% of all immigrant hospital workers
found themselves in private hospital facilities. Private hospitals
also offered less secure employment conditions. These features are
illustrated by looking at the hospital aide occupation.
In 1970, aides in private hospitals received a lower annual wage (on
average, 79% of the average annual wage paid to all health care workers
in New York City, compared with 98% paid to government hospital aides,
respectively) (Table 2). Fewer aides in private hospitals worked
on a full-day, full-year basis compared with aides in government settings
(Table 3). About 87% or more of the aides in public sector hospitals worked
48-52 weeks a year in 1970, compared with only 72% of aides in private
hospitals. Whereas 75% of the native-born in private hospitals worked
a full year, only 67% of immigrant aides did so. Furthermore, 96%
of aides in public hospitals worked 35 or more hours a week, compared with
83% of aides in private hospitals.
Immigrants as a whole, but especially those who had just come since
1965, were more concentrated in private hospital aide jobs compared with
natives. Whereas only 43% of all native-born aides worked in private
hospitals in 1970, 51% of earlier arriving immigrant aides and 65% of newcomers
did (Table 4). By contrast, in the more stable and higher paying government
hospital jobs, natives dominated. Forty-two percent of all native-born
aides worked in such settings, compared with only 32% of earlier arriving
immigrants and 19% of the newcomers. Hence, a ladder of good and
not-so-good hospital aide jobs existed with government hospital jobs at
the top—and filled with natives—and private hospital jobs at the bottom
and increasingly filled by newly arrived immigrants.5
In the good government hospital jobs, black native-born workers dominated;
they comprised 57% of all such aides in 1970 (Table 5). Island-born
Puerto-Rican natives also clustered there; half of all Puerto Rican aides
then worked in government hospital settings (or four percent of all government
hospital aides). White native aides were less concentrated here—perhaps
because they had already moved upward and onward prior to 1970. Instead,
they concentrated in doctors’ offices and clinics—where they filled 86%
of such jobs in this time period. (White foreign-born workers—Poles—filled
the remaining 14% there.) Although office and clinic aides worked
fewer hours per week (an average of 31 hours to 39 hours worked in government
hospital positions), their hourly wage was a close second to that in government
hospitals ($2.66 versus $2.83, respectively) (Table 2).
Whereas aide jobs in doctors’ offices offered greater status, high
pay and relatively easier working conditions than work in private hospital
settings, nursing home aide jobs were situated at the other end.
On average, nursing home aides in 1970 made 67% of the average annual wage
income for all the city’s health care workers (versus 79% and 98% for private
and government hospital aides, respectively). Nursing home aides
were also more likely to work shorter workweeks than aides in private hospital
settings and face greater turnover or insecurity in the annual length of
employment. For instance, in 1970, 35% of all nursing home aides
worked less than a 48-to-52-week year, compared with only 28% of private
hospital aides; 21% of nursing home aides worked less than 35 hours a week
versus 17% of private hospital aides (Table 3).
Immigrants were even more likely to be concentrated in nursing home
settings. Roughly 45% of all aides in nursing homes were immigrants
in 1970, compared with only 39% in private hospitals, 26% in public hospitals,
and 14% in doctors’ offices and clinics (Table 5). Given the choice
of work settings available, native-born aides were more likely to eschew
nursing home settings in favor of better settings. Only nine percent
of native-born aides worked in nursing homes then, compared with 15% of
newly arrived immigrants and 14% of those who had come earlier (Table 4).
Although nursing homes had also begun to grow in 1970, they still employed
a relatively small number of health care workers in total. Compared
with the hospitals—at over 120,000 workers—nursing homes only employed
about 8,500 workers in total. Among the 26,554 aides working in the
health care industry that year, 47% worked in private hospitals, 37% in
public hospitals, and 11%--or about 2,900—worked in nursing homes (Table
1).
The positions of specific immigrant groups also conform to the
ladder notion. Jamaicans, for example, who comprised the largest
sending-country group of workers throughout this period, entered health
care relatively early. Because of this they gained an important early
foothold in hospitals before many other immigrant groups that are employed
in health care today. Among the third of health aides that were immigrants
in 1970, Jamaicans represented the largest group (at eight percent) of
all aides in the industry), followed largely by other Caribbean islanders
(Table 5). The next largest groups (in order by size) were those
from the “Other West Indies” (3.4%), Haiti (2.6%), Trinidad and Tobago
( 2.3%), and the British West Indies and Panama (each at 1.5%) (see Table
4). Jamaicans were also among the most recent arrivals; slightly
more than half (52%) of those who were from Jamaica had entered the country
recently (since 1965),6 compared with 29% of immigrant aides in general.
Jamaicans made up 41% of all such “newcomers.” The next largest group
consisted of aides from Trinidad and Tobago, at 19% of the newcoming aides.
Carrying the framework of the ethnic ladder further, we see that some
mobility occurred upward along the rungs just established between nursing
aide jobs in different settings. So, for example, starting in 1980
and increasing significantly in 1990, black native-born aides moved into
jobs in doctors’ offices and clinics—once the sole province of white aides.
The growth rate in their share of such jobs in the 1980s occurred at a
phenomenal 1063%, increasing from zero to 541 aides by 1990 and almost
replacing the 600 white native-born aides that were employed there in 1970
(Table 6).7 As black native aides moved into these jobs, Jamaican
aides increased their foothold in government hospitals—initially the stronghold
of black native workers. Their share of government hospital jobs
increased 200% in the 1970s, compared with an increase of 28% in their
share of private hospital jobs. New immigrants—from the Dominican
Republic, the Philippines, and India, for instance—began to replace Jamaican
aides in private hospitals, showing higher rates of growth. Others—like
Haitians—moved increasingly into nursing homes. Thus, at first glance,
Waldinger’s ethnic ladder works well as a framework for organizing the
flows of various groups of workers in nursing aide jobs in New York City’s
health care sector.
A Second Glance—Constant Reshuffling of the Rungs of the Ethnic Ladder
On second glance, however, this framework becomes problematic when
one looks at the details. First of all, the neat ladder of good to
bad aide jobs available in 1970 shifts by 1980, and again by 1990.
For instance, whereas public hospitals paid their aides the most in 1970,
in the next two decades, private hospitals reached parity, nursing home
pay improved, but home care pay deteriorated significantly. Because
of these changes, incumbents’ understanding of what is up versus down on
this ladder must also shift continually. Therefore, it becomes as
important to look at the forces producing these shifts as at relative ethnic
distribution among these different health care settings. Here, the
efforts of unions, employers, and payers in regard to health care costs
become critical.
A second problem with the framework is that even given these shifts,
ethnic groups do not always flow sequentially into various health care
settings. For example, although Jamaicans moved up into government
hospital jobs in the 1970s, they declined in their share of all hospital
jobs later on and instead increasingly concentrated in the poorer paying
nursing home jobs. At the same time, other groups—like Filipinos
and Indians—leapfrogged into private hospital jobs in the 1980s ahead of
other waiting immigrants. Again, a closer look at employers and payer
actions help to understand this. Each of these forces—union, payer,
and employer actions—modifies the shape and direction of the aide occupational
ladder and extent of job competition among groups.
Unionization in the Health Care Industry
The expansion of hospitals into big business in the 1960s and 1970s
encouraged attention by the labor movement. Hospitals were organized
first, followed by nursing homes and, later still, a portion of the home
health field. Unionization has been a key tool for improving compensation
and working conditions for nurse aides, along with other lower-skilled
workers in the health care industry. Because of that, it has helped
create the rungs of better jobs in the aide occupation overall. Unionization
has also prompted some of the cost-consciousness among health care payers
and an expansion of new lower-cost, lower-rung jobs for immigrant aides,
as discussed in the following section. Unionization patterns are
briefly discussed here.
Several unions have historically represented health care workers in
New York City—especially Local 1199, initially of the Retail Drug Employees
Union. Local 1199, started a campaign to organize New York City’s
private and nonprofit hospital sector. Initially successful at Montefiore
Hospital in the Bronx in the late 1950s, Local 1199 made major inroads
into the rest of this industry through its agreement with the League of
Voluntary Hospitals in 1968. The union achieved major gains in pay,
benefits, job security, and job training for hospital workers in the 1970s
through constant negotiations with employers and government payers. Today,
all but one of the city’s hospitals is unionized (Fink and Greenberg 1989,
SEIU 1998).
Nursing homes were unionized along with hospitals. Nursing homes
have been represented mostly by Local 1199 or Local 144 of the Hotel, Hospital,
Nursing Homes and Allied Services Union; wages of service workers in nursing
homes were bargained for along with those of similar workers in the hospital
industry (for example, see Mooney and Jamieson, 1996). As Foner (1994;
17) found in her ethnographic study of nursing home workers in a New York
home, unionization made these relatively bad jobs better by the late 1980s
than other entry level jobs for immigrants:
Aides stay put in New York City facilities because their wages and
benefits are relatively good compared to those for other low-skilled jobs
available to women in the city. Nursing aide jobs at unionized hospitals
and nursing homes in New York City—the vast majority are unionized—are
not easy to obtain. In fact, aides in the replacement pool at Crescent
were willing to endure a two-year wait as part-timers to get on staff.
Clearly, this situation is not the case in most parts of the country where nursing homes are less likely to be unionized and wages and working conditions are much worse. A 1985 Bureau of Labor Statistics study of full-time nursing home aides in twenty-two metropolitan areas showed New York City ranking first in terms of average hourly wages (at $8.87). This far exceeded, by more than $2 an hour, the average wage in the second-ranking city, and it was over $5 an hour more than the worst-paid city … When I conducted my research [in 1988-89], aides at the Crescent Nursing Home received $10.30 an hour for a 36 1/4-hour week…
Hence, unionization pushed up aide wages in certain settings; the lack
of it has kept wages low elsewhere. The bottom of the aide wage scale
is currently paid in the half of the home care field that has not been
unionized. Here, more skilled home health aides make less than homemaker
aides8 employed in the unionized segment. The latter segment was
organized in the late 1980s. At that time, Local 1199 with District
Council 1707, AFSCME, and eventually the Home Care Council of New York—an
employers association—instigated a successful union bargaining campaign
among New York City’s home care organizations that utilize Medicaid funding
(Donovan 1989, Donovan et.al. 1993). They were successful in that
all Medicaid-funded organizations contract with the City; hence, the City
could be bargained with as a single employer. Much outsourcing occurs
in the remainder of the home care field (that which is Medicare dependent),
which makes unionization efforts extremely difficult given the large number
of small employers.
In sum, what had been lower-paid jobs in private hospitals and nursing
homes in 1970, became much better paid jobs after a decade of organizing.
By 1990, the average hourly wage for aides in these settings became roughly
comparable—at $10.74, $10.45, and $10.30, on average, in public and private
hospitals, and nursing homes, respectively (Table 2). Given these
wage rates, Jamaicans shifting between private to public to nursing home
settings over the time period studied makes less difference than in 1970.
However, the fact they have also shifted into the low-paying home care
field requires more explanation. How exactly has the relationship
among these sectors changed over time?
Expansion of the Bottom Rung
National concern about health care costs started as early as 1970 and
escalated recently. This concern increasingly led state and federal
policymakers to encourage the movement of short and long-term care out
of the more costly hospital setting. Nursing homes were the cheaper
alternative in the 1970s. By 1980, home care was. By advocating
these lower cost care alternatives, government health care payers and insurance
companies have significantly added new bottom rungs to the aide occupational
ladder. These new bottom rungs became magnets for immigrant workers
since the native-born were, by 1970, already concentrated in higher paying
hospitals. And, although new-arriving immigrants were not formally
“displacing” natives from their jobs in hospitals, these bottom rung jobs
in nursing homes and home care facilities are where the major portion of
nurse aide opportunities have been. Hence, expansion in the lower
rung has come simultaneously with the relative stagnation of aide opportunities
at the top of the ladder.
For example, although black native-born aides have moved up into opportunities
in doctors’ offices, the sheer size of this rung (about 2,700 jobs in 1990)
pales in comparison to the size of the new bottom rungs—roughly 20,000
aide jobs each in 1990 (Table 2). Furthermore, the large and high
rung jobs in hospitals have stagnated in the last several decades.
So, whereas aide jobs as a whole grew by 192% from 1970 to 1990, hospital
aide jobs increased by only 54%. By contrast, aide jobs in nursing
homes during this time period increased by 533%--most growth occurred in
the 1970s. Home care jobs jumped a whopping 3932%--mostly since 1980
(Table 1).
One-third of all newly arriving immigrants in 1990—those who had emigrated
within the prior five years—went to work as aides in health services,9
which includes home care, compared with none of the newcomers in 1970 (Table
4). Two-thirds of Dominican newcomers and almost half of Haitian
newcomers went into home care in 1990. Among new immigrant groups,
they have begun to specialize, as it were, in these lowest rung jobs.
But even Jamaicans—the group with the longest and most sizeable presence
in health care in New York City—showed a higher than average influx into
home care in 1990 (37%), compared with all newly arriving immigrants (34%).
What are the forces that have produced the phenomenal expansion of
this bottom rung of jobs in the 1970s and 1980s? Chief among these
have been payer efforts to find ways to cut the escalating costs of health
care. These costs have risen due to increasing consumption of health
care services and increasing unionization of the industry in New York City.
Combined with the increasing reluctance of the state government to finance
these growing costs, new low-cost care settings have proliferated.
For instance, New York State policymakers urged construction of nursing
home facilities in the 1970s to relieve higher-cost hospitals of patients
needing longer-term care. Since states finance half the Medicaid budget,
they have a direct incentive for wanting to lower health care costs.
This has led, over the years, to a seesaw effect between journalistic exposés
of abuses in the “low cost” nursing home setting and subsequent state efforts
to clean up nursing homes and assure citizens of quality care there.
So, for example, in 1970, the first nursing home “scandal” hit New York.
Investigative reports in the newspapers pushed the governor to set up a
study commission, which especially targeted New York City facilities. After
the Moreland Commission’s report, New York State passed laws to upgrade
the standards and reimbursement rates in these homes (Hess 1974, Prial
1975). Renewed deterioration of nursing home wages and conditions
occurred in the 1980s, after President Reagan’s deregulatory policies.
This prompted Congressional action in the late 1980s, because of renewed
reports of nursing home abuses.
Initial state action in cleaning up nursing home conditions, plus unionization
in this subsector—pushed wage income up for aides in this sector to become
close to that in hospitals by 1980. Because of the scandal and rising
costs in nursing homes, the state put a moratorium on new nursing home
construction in the 1980s and encouraged development of home care options
instead. Residents in New York City now utilize home care much more
than elsewhere in the country. In 1990, when nursing home and hospital
aides made, on average, over $10.00 per hour, home care aides (in health
services) made only $7.04. Clearly, home care has offered an important
cost advantage to health care payers since 1980.10
In the 1980s and 1990s, continued rapid expansion of Medicare and Medicaid
resulted in Congressional actions to contain costs and encourage expansion
of home care services. Congress enacted the Omnibus Budget Reconciliation
Acts of 1980, 1981, and 1989, which aimed to decrease the overall amount
of hospitalization, reduce lengths-of-stay, and cap physicians’ and hospital
fees through prospective payment systems. The Balanced Budget Act
of 1997 mandated significant cuts in overall Medicare and Medicaid funding
until 2002 and pushed providers to adopt “managed care” practices.11
New York State officials also increased their efforts at cost control,
first placing hospitals under a regulatory framework from 1983 to 1996—the
New York Prospective Hospital Reimbursement Methodology (NYPHRM) program—and
later deregulating them to foster greater competition (under the Health
Care Reform Act of 1996) (Berliner 1994, Sparer 1996, Bovbjerg and Marsteller
1998, GNYHA 1999, Sultz and Young 1999).
This increasing cost-consciousness resulted in worsening job conditions
for aides in hospitals and nursing homes, along with a growing inability
of health care unions to pass increased wage demands along to the state
and other industry payers.12 Cost-consciousness has stimulated the expansion
of lower-cost care alternatives, such as home health care today.
Current hospital deregulation has led not only to layoffs (e.g., see Steinhauer
2000), but also to highly individual solutions among hospitals in the refashioning
of the job content of their non-licensed staff—such as aides. They
have sought higher skilled, yet lower paid nursing capacity through immigrant
recruitment, as discussed next.
Upskilling and Job Downgrading Since the Mid-1980s
A final feature that has characterized aide jobs most recently has
been increased demands for aides to upgrade their training. However,
whereas upskilling of aides in the past resulted in increased compensation,
due to the efforts of unions, upskilling today occurs concurrently with
job downgrading, and strong downward pressure on wages. Today’s upskilling
has also produced a shifting in the positions of some groups of immigrants.
From 1970 to 1990, the educational profile of the nurse aide occupation
has continually been upgraded. For instance, whereas 28% of all aides
in 1970 had only an eighth grade education or less, by 1990 this share
was 11% (Table 7). Similarly, the share of aides with college increased
from nine percent to 29% between these decades. The most significant
jump in aide educational levels occurred in the 1970s when the share with
college jumped to 24% by 1980 and those with elementary educations dropped
to 15%.
Three forces in the 1970s could stimulate this upskilling. This
decade was characterized by the relatively unfettered national expansion
of the health care industry and its costs, along with successful unionization
and union pay gains in the New York City area. To the extent that
unions made these better jobs, and employers were willing to agree to wage
gains, aide positions would attract more competitive individuals.
Upskilling took place among both native and immigrant aides. However,
another trend that also could explain the significant upskilling of aides
then was the institution of state licensing exams for foreign-trained nurses.
Hospitals—aided by special legislation facilitating immigration by
nurses13—have been directly recruiting immigrant nurses since the mid-1960s
as a way to deal with this country’s ongoing nursing shortage. In
1970, when Jamaica was the leading supplier of immigrant nurses (Jamaicans
comprised 23% of all foreign-born nurses then), immigrants could assume
nursing jobs solely on an endorsement that they had completed the appropriate
training and licensure in their countries of origin. A few years
later, however, states began requiring licensing exams before foreign-trained
nurses could be admitted to practice (Ong and Azores 1994).
Many such immigrants failed to pass licensing exams once in the United
States, so they became licensed practical nurses or nurse aides instead.
Ong and Azores (1994)—citing an American Journal of Nursing study—report
that in 1975, 84% of foreign nursing graduates initially failed their state
licensing exams; some continued to fail on repeated tries. This situation
benefited hospitals and other health care employers, which obtained nursing
skills at the cost of a nurse aide.
Charges of hospital exploitation of immigrant nurses led to the creation
of the Commission on Graduates of Foreign Nursing Schools (CGFNS) in 1977,
which introduced screening exams—held in a potential immigrant’s home country.
This improved the situation—such that 89% of those taking licensing exams
now pass and obtain nursing jobs in the U.S., but some still do not pass
once they come here. Brown (1997) cites figures throughout the 1980s
showing a constant excess in the number of Jamaican nurses admitted into
the United States over those who pass the CGFNS exams.14
Upskilling of aides has also caused a reshuffling of the niches of
specific immigrant groups in this occupation, as well as an increasingly
differentiated division of labor between aides in different health care
sectors. For instance, coming from a dominant position of all immigrant
aides in hospitals in 1980, Jamaicans found their opportunities shift in
the 1980s. In 1990, two-thirds of Jamaican newcomers settled mostly
into aide jobs in nursing homes or home care organizations—regardless of
their strong hiring networks in hospitals. On the other hand, almost half
of Filipino newcomers went to work as aides in private hospitals versus
only eight percent of Jamaicans. Yet, Filipinos represented only
a tiny share of all aides in 1980 (less than one percent), so their initial
ties to this sector were much weaker than those of Jamaicans (at 12% of
all aides). Why did Jamaicans get bumped off the ladder of good jobs
in hospitals?
Jamaican newcomers into the aide occupation in 1990 started to represent
a “middle case” in skill level compared with aides from other countries—say
those from the Dominican Republic and the Philippines. Whereas in 1970,
Jamaican newcomers into the aide occupation were among the more highly
trained then, by 1990, they were no longer so. For instance, newcoming
Jamaicans in 1970 had completed, on average, more than ten years of formal
schooling, compared with only nine years of schooling for all other recently
arrived immigrants. Newly arrived Jamaicans looked more like black
natives who also had completed, on average, about ten years of schooling.
Aides from all of the largest sending countries of new arrivals showed
considerably higher education then. These included those from Jamaica
(42% of all recent immigrant aides), Trinidad and Tobago (19%), and the
British West Indies (eight percent). In the case of Jamaica, 55%
of its aides had been high school graduates or college enrollees; this
gave them a competitive edge—even in aide occupations—over other recent
immigrants.
By 1990, however, fewer Jamaican aides had gone on to college compared
with other immigrants (24% versus 28%, respectively). Filipinos,
especially, represent among the most educated of aides then. Eighty-four
percent of Filipino aides had some college training. Furthermore,
by 1990, Filipinos had supplanted Jamaicans as the leading supply of immigrant
nurses (representing 25% versus 14% of all immigrant nurses, respectively).
That Filipinos exhibit greater difficulty passing state license exams and
are more likely to have come on visas targeted to their continuing employment
in nursing, suggests that those trained as nurses but failing the exams
would more likely stay on as aides.15 Recent Jamaican immigrants
were more likely to have come under the family reunification provisions
in the immigration law (New York City 1996). Any who were nurses
who had failed licensing exams repeatedly could more easily move on to
better non-nursing occupations, given their education.
Hence, the pool of Jamaican aides in 1990 ceased being the most competitive
for the good hospital jobs, and flowed instead into nursing home employment.
These jobs began to represent a “middle case” of aide jobs; they require
better-educated workers and also offer some on-the-job training, supervision,
better wages, and better working conditions. Dominicans, on the other
hand, came with much lower educational levels—almost 40% of Dominican aides
had only an eighth grade education or less compared with 16% of all immigrant
aides. Therefore, two-thirds of Dominican newcomers moved into home
care settings, which can require less training. Home care aides are
also paid much worse16 and offered less employment security, benefits,
on-the-job-training, and workplace safety (Donovan 1989, Donovan et.al.
1993, Burbridge 1993, SEIU 1999). These comprise the bottom rung
of aide jobs today. As aide jobs have become increasingly differentiated—according
to educational levels—groups are getting reslotted into various health
care settings.
In any event, recruitment of Filipino and other foreign-trained nurses
seems to have helped increase the skill levels of nurse aides in New York
City hospitals over the time period studied (Table 7). Some hospitals
are now upgrading their aide jobs—into “personal care attendants” who are
able to assume some of the duties of nurses.17 The skills of nurse
aides have been increasing in other settings as well. Since the early 1990s
after Congressional action to upgrade standards, nursing home aides are
now mandated to receive a set training regimen, pass a state competency
test, and register as Certified Nurses Aides on a state registry, which
tracks aide misbehavior such as patient abuse (Tolchin 1988, Eisler 1996).
Some home care attendants are also under pressure to upgrade their skills
so they are qualified to take both home attendant and home health cases.
In an increasingly competitive market, this makes their agencies more successful
at attracting work. But, the incentive to seek more training is negligible
since the more skilled home health care work pays less (it comes from the
nonunion portion of the market).
Hence, today upskilling is occurring among aides across the board—but
it is not necessarily accompanied by higher pay as it was in the past.
Wage increments among aides result from unionization more than educational
enhancement. As discussed earlier, aide wages increased, as a share
of all health care wages, in private hospitals and nursing homes during
the 1970s—where Local 1199 had been especially active—but decreased again
in the 1980s when the union was under turmoil (Table 2). Aide wages
fell again then, even though aide educational levels continued rising.
Therefore, although upskilling is, and has been, occurring among aides,
the downgrading of job conditions is now more likely accompanying it, especially
under today’s extreme cost-competitiveness among all health care providers.
Conclusion: Immigrant Aides In Health Care
What this case study of nurse aides in New York City’s health
care industry shows is that there has been ongoing competition among unions,
health care payers, and health care employers to reshape the occupational
ladder facing nurse aides in the last several decades. Following
closely upon an industry expansion phase—kicked off by the enactment of
Medicare and Medicaid legislation in the mid-1960s—health care payers started
expressing concerns over escalating health care costs with an ever stronger
voice. Acting on this concern, they have pressured the industry to
develop new low-cost care alternatives to the hospital setting. They
have also increasingly pushed specific employers to cut the cost of service
delivery, while ensuring quality provision.
Immigrants have facilitated these developments. First,
they helped in the initial expansion phase. Firstcomers under the
new immigration law of 1965, like Jamaicans, helped hospitals to grow,
especially flowing into private hospital settings. Initially, a ladder
of good to bad nurse aide jobs was quickly established—with immigrants
in poorer-paying private hospitals and native in higher-paying government
facilities. However, the rungs of this ladder have been constantly
reordered. I have argued that to understand the logic of this ethnic
nurse aide ladder over time, we must look closely at the activities of
unions, health care payers, and health care employers.
Unions, generally, have been able to create better jobs for lower-skilled
health care workers in the setting in which they have been active.
Union efforts have had more to do with raising aide wages than has increased
educational attainment. Health care payers and employers have increasingly
focused on the bottom line. This has led them to expand the lower-cost,
bottom-rung of the aide occupational ladder through first nursing home
and later home care facility development. Employers—most confronted
with the trade-off between quality and low cost—have benefited from recruiting
foreign nurses, a portion of whom carry out nursing functions while being
employed at an aide wage rate. On the whole, the educational levels
of aides have been constantly rising over the past several decades, yet
their wages have not always simultaneously improved—as measured against
all health care wages.
To the extent that employment in the health care industry has
been experiencing a long-term expansionary phase, immigrants can be seen
as replacing natives in jobs at the bottom rung. However, to the
extent to which some aide jobs are stagnating in wages but demanding increased
education and skill, immigrants supply a package—higher skills at lower
cost—that employers find more attractive. Hence, in this sense displacement
is occurring—immigrants of natives, newer immigrants of older immigrant
groups.
Sources
Bibliography
Berliner, Howard S., et.al. 1994. The Supply and Demand
for Health Workers in New York City: 1995-97, Report, New York State Department
of Health, Bureau of Health Resources Development.
Berliner, Howard S. 1995. The Impact of Hospital Downsizing
on Employment in Minority Communities in New York City, New School for
Social Research, May.
Berman, Eli, John Bound, and Zvi Griliches. 1993. “Changes in
the Demand for Skilled Labor Within U.S. Manufacturing Industries: Evidence
from the Annual Survey of Manufacturing,” N.B.E.R. Working Paper, No. 4255,
Cambridge, Mass.
Bernstein, Jared. 1997. The American Workforce: Skill Deficit
or Wage Deficit? Testimony before the U.S. House of Representatives Committee
on Education and the Workforce, Subcommittee on Oversight and Investigations,
The American Worker at a Crossroads Project, http://edworkforce.house.
gov/hearings/105th/oi/awp102997/Bernstein.htm, 9/14/00), October 29.
Bovbjerg, Randall R. and Jill A. Marsteller. 1998. Health Care
Market Competition in Six States: Implications for the Poor (Washington:
The Urban Institute, www.urban.org/, 10/30/2000).
Brown, Dennis A. 1997. “Workforce Losses and Return Migration
to the Caribbean: A Case Study of Jamaican Nurses,” in Caribbean Circuits:
New Directions in the Study of Caribbean Migration, Patricia Pessar, ed.
(New York: Center for Migration Studies), 197-223.
Burbridge, Lynn C. 1993. “The Labor Market for Home Care
Workers: Demand, Supply, and Institutional Barriers,” in The Gerontologist,
vol. 33, no. 1, 41-46.
Capelli, Peter and K.C. O’Shaughnessey. 1993. “Are Skill
Requirements Rising? Evidence from Production and Clerical Jobs,” Industrial
Labor Relations Review, 46: 515-530.
Capelli, Peter, Laurie Bassi, Harry Katz, David Knoke, Paul Osterman,
and Michael Useem. 1997. “Chapter 5: Implications for Policy:
A ‘Skills Gap’?” in Change at Work (New York: Oxford University Press),
154-172.
Donovan, Rebecca. 1989. “Work Stress and Job Satisfaction:
A Study of Home Care Workers in New York City,” in Home Health Care Services
Quarterly, 10, 1-2: 97-114.
Donovan, Rebecca, Paul A. Kurzman, and Carol Rotman. 1993.
“Improving the Lives of Home Care Workers: A Partnership of Social Work
and Labor,” in Social Work, 38, 5: 579-585, September.
Eisler, Peter. 1996. “New Home-Care Rules Considered Proposal
Would Adopt Nursing-Home Standards,” New York Times, 20A, November 18.
Fink, Leon and Brian Greenberg. 1989. Upheaval in the Quiet
Zone: A History of Hospital Workers’ Union, Local 1199 (Urbana: University
of Illinois Press).
Foner, Nancy. 1994. The Caregiving Dilemma: Work in An American
Nursing Home (Berkeley: University of California Press).
GNYHA (Greater New York Hospital Association). 1999. The
New York Health Care Economy: 1999 Environmental Assessment—A Briefing
Document for Policymakers (www.gnyha.org, 8/10/00), Spring.
Greenwood, Michael J. and John M. McDowell. 1986. “The Labor Market
Consequences of U.S. Immigration, Journal of Economic Literature, v. 24.
Handel, Michael and Maury Gittleman. (November) 1999. Is
there a Wage Payoff to Innovative Work Practices? Jerome Levy Economics
Institute, Working Paper No. 288.
Harrison, Bennett. 1994. “Chapter 9: The Dark Side of Flexible
Production,” in Lean and Mean (New York: Basic Books).
Hess, John L. 1974. New York Times Abstracts, October 9: 85.
Howell, David. 1994. "The Skills Myth," The American Prospect,
no. 18, Summer.
Hudson Institute. 1986. Workforce 2000 (Washington, D.C.).
Kasinitz, Philip. 1992. Caribbean New York: Black Immigrants
and the Politics of Race (Ithaca: Cornell University Press).
Killingsworth, Mark. 1986. “Effects of Immigration into the United
States on the U.S. Labor Market: Analytical and Policy Issues,” in U.S.
Immigration and Refugee Policy: Global and Domestic Issues, Mary M. Kritz,
ed. (Lexington: Lexington Books, D.C. Heath and Co.).
Mooney, Mark and Wendell Jamieson. 1996. “Hospital &
Nursing Homes Aides on Strike,” New York Times, 7, June 25.
New York City, Department of City Planning. 1996. The Newest
New Yorkers, 1990-1994.
Ong, Paul and Tania Azores. 1994. “The Migration and Incorporation
of Filipino Nurses,” in The New Asian Immigration in Los Angeles and Global
Restructuring, Paul Ong, et.al., ed. (Philadelphia: Temple University Press),
wysiwyg://7/http://userpage.fu-berlin.de/~mayer/Ca/ong.htm, 5/8/01.
Ong, Paul and Abel Valenzuela, Jr. 1996. “The Labor Market:
Immigrant Effects and Racial Disparities,” in Ethnic Los Angeles, Roger
Waldinger and Mehdi Bozorgmehr, eds. (New York: Russell Sage Foundation).
Prial, Frank J. New York Times Abstracts, January 17, 1975: 1.
SEIU (Service Employees International Union). 1999. Home
Care Workers: A Briefing Paper, submitted to the U.S. Department of Labor
and U.S. Department of Health and Human Services (website, 9/5/00), May.
Sparer, Michael S. 1996. “Medicaid Managed Care: Lessons
from New York and California,” …
Steinhauer, Jennifer. (June 17) 2000. Workers Cut As Hospitals
Tighten Belts—Looking to Save Money As Medicine Changes, The New York Times.
Sultz, Harry A. and Kristina M. Young. 1999. Health Care
USA—Understanding Its Organization and Delivery (Gaithersburg, MD: Aspen
Publishers).
Tolchin, Martin. 1988. “U.S. Fails to Carry Out Law To
Improve Nursing Homes,” New York Times, December 9: Section A: 1.
Waldinger, Roger. 1996. Still the Promised City? African-Americans
and New Immigrants in Postindustrial New York (Cambridge: Harvard University
Press).
Interviews
Howard Berliner, New School
Anne Brosnan, Community Liaison, Home Care Service Manager, St. Luke’s
Roosevelt Continuum Health Partners, Inc.
Joseph Campenella, Home Care Council of New York City
Diane Lindsor Cohen, New York State Department of Health
Robert Dougherty, New York State Department of Health
Mary Ellen Evans, Health Program Administrator, NYS Dept. of Health,
Hospitals section
Amy Gladstein, SEIU 1199
Debra King, SEIU 1199
Nedelka McClean, SEIU 1199
Laura Nejira, SEIU 1199
Carol Rodat, Home Care Association of New York State, Inc.