Walking the Line: Navigating Market and Gift Economies of Care in a Consumer-Directed Home-Based Care Program for Older Adults.

Abstract

CONTEXT Paid caregivers of low-income older adults navigate their role at what Hochschild calls the "market frontier": the fuzzy line between the "world of the market," in which services are exchanged for monetary compensation, and the "world of the gift," in which caregiving is uncompensated and motivated by emotional attachment. We examine how political and economic forces, including the reduction of long-term services and supports, shape the practice of "walking the line" among caregivers of older adults. METHODS We used data from a longitudinal qualitative study with related and nonrelated caregivers (n = 33) paid through California's In-Home Supportive Services (IHSS) program and consumers of IHSS care (n = 49). We analyzed the semistructured interviews (n = 330), completed between 2010 and 2014, using a constructivist grounded theory approach. FINDINGS Related and nonrelated caregivers are often expected to "gift" hours of care above and beyond what is compensated by formal services. Cuts in formal services and lapses in pay push caregivers to further "walk the line" between market and gift economies of care. Both related and nonrelated caregivers who choose to stay on and provide more care without pay often face adverse economic and health consequences. Some, including related caregivers, opt out of caregiving altogether. While some consumers expect that caregivers would be willing to "walk the line" in order to meet their needs, most expressed sympathy for them and tried to alter their schedules or go without care in order to limit the caregivers' burden. CONCLUSIONS Given economic and health constraints, caregivers cannot always compensate for cuts in formal supports by providing uncompensated time and resources. Similarly, low-income older adults are not competitive in the caregiving marketplace and, given the inadequacy of compensated hours, often depend on unpaid care. Policies that restrict formal long-term services and supports thus leave the needs of both caregivers and consumers unmet.