Of all the looming crises facing America today, it's the one that could well have the greatest effect on your life and the lives of your loved ones: the ballooning of the nation's elderly population, and the dire shortage of home-care workers needed to care for them.
But making an action-packed film about it? That's not so easy.
"A lot of care is sort of anti-drama," said Deirdre Fishel, director of Care. The new documentary produced by Fairmount resident Tony Heriza will have its Philadelphia premiere screening Thursday. It also will be broadcast on WHYY TV12 on Sept. 7, and will be available for free streaming on the America ReFramed website from Sept. 7 to Oct. 6.
Care provides an unusually close-up vantage of the home-care industry, and of the people who — whether because of disability, disease, or advanced age — rely on it. Tracking caregivers and their clients over two years, Care depicts a system of home care that is impossibly costly for middle-class Americans, even as the wages are unsustainably low for workers, pushing them into poverty or even homelessness.
And, it warns, things are about to get worse: By 2040, the number of older Americans will double, and the system is unprepared. It's projected the country will need a million more home-care workers by 2022.
"The question is: What's our societal commitment to caring for those who have become vulnerable? We have to have a public dialogue," Heriza said. "Somewhere along the way, we decided sanitation workers deserved a living wage. But we didn't decide that about people who take care of other individuals."
What was, for decades, unpaid women's work is now more often outsourced. It's covered only by Medicaid, so recent proposals to cut Medicaid have made the problem still more urgent.
When work on the film began, Heriza said, "We thought we would be in a place of trying to build a better system, recognizing the current system is inadequate. Instead, people were in a defensive posture, just trying to hold on to the existing system."
Fishel became interested in the topic after her own mother, who was in her 80s, began to need help. Fishel enlisted Heriza, and together they sought grant funding and ran a successful $50,000 Kickstarter campaign.
The filming begins in 2013, and continues long enough to watch a flimsy safety net fraying before our eyes.
Fishel shot many of the scenes herself, with no crew, so as not to disrupt the intimate portraits of caregivers and the clients who rely on them for help exercising, bathing, cleaning, shopping, and other basics of daily life.
She followed Vilma Rozen, a caregiver on Staten Island who was eligible for a green card but who deferred applying for years because she couldn't afford the administrative costs. Rozen's client, who was 92, had not retired until age 90 but was already running through her savings and was close to losing her home.
Fishel also traveled to McClure, in central Pennsylvania, where Laurie Bahajak was making $302 per week caring for a man named Larry Dobson, who was dying of lung disease. That income wasn't enough to support her family, she said. After Dobson's death, she went to work hauling blacktop — making $5 more per hour than she had as a home-care worker and, for the first time, getting health benefits.
And she filmed Delores McCrae, a home health aide in the Bronx who loved her work but who could not make a living doing it. By the time filming wrapped in 2015, she was living in a homeless shelter.
In Pennsylvania, which has the nation's fourth-largest population of seniors, the shortage of home-care workers is already upon us, according to Karen Kulp, president of Home Care Associates, a worker-owned cooperative.
"I've been doing this work for 16 years, and it's harder and harder to recruit people who want to do the work and want to stick with it," she said. "The people who end up doing the job are people who have a real heart for it."
Nationwide, the typical home-care worker makes just $13,000 a year, according to the filmmakers, and the annual turnover rate is estimated to exceed 40 percent.
At Home Care Associates, pay depends on state Medicaid-reimbursement levels, which have been flat for several years. The state reimburses $19.52 per hour. But after administrative costs — including perks most other home-care workers don't get, such as training, health insurance, and paid time off — starting wages are often just $8 or $9 per hour, Kulp said.
Kulp finds she can't pay enough to stay competitive, even as she needs to be recruiting more. Seniors composed 15 percent of Pennsylvanians in 2015; that's projected to rise to 25 percent by 2030.
United Home Care Workers of Pennsylvania, a union, negotiates collective bargaining agreements for some workers who are employed by agencies or independent living centers, but it can't negotiate on behalf of the far larger population of 20,000 home-care workers around the state. For those workers, future compensation and working conditions depend in large part on the state legislature.
Antonio Bowser, 45, of Tioga, a home-care worker since 2000, is one of the worker-organizers. For Bowser, caregiving is a calling. But between his $13.96 hourly wage and his unpredictable schedule, he said the work was not sustainable and not enough to provide for his family.
"We need to be recognized as a job, first and foremost. A lot of people that leave the hospital want to go home, not to a center or a recovery home. So we need to be recognized, as home-care workers, as a job — a real job, not as a babysitter."
Care aims to start a conversation about solutions.
"Do we want to be a society that's going to take care of people when they become frail? If we do, then we need to be talking about how," Fishel said.
And, in its quieter moments, it presents an image of what's possible.
"Vilma was putting this woman, Dee, to bed and she started to pray over her. I knew it had meaning for Dee, too," Fishel said. "It was so beautiful and so loving, and I just thought, 'Wow, everyone should be taken care of that way at the end of their life.' If they have that kind of frailty, they should be met with that kind of humanity."