Home health care workers are demanding better pay. Cuts to Medicaid could stand in their way.

“You sacrifice your life so someone else can have one,” Moshier said. “I’ve done that for the last three years without a full day off, no matter how I’ve felt, no matter how sick I was, or how much physical pain I’ve been in due to my own physical ailments.”

Moshier makes $21 an hour for a 40-hour week, or less than $44,000 annually — a rate that cannot contend with rising housing prices or other cost of living increases. She is not eligible for overtime, though she typically works 14-hour days, or more.

It’s a system that is not sustainable and deeply broken, advocates say. Now Moshier and thousands of other home health care workers who care for some of the state’s frailest residents are fighting for change.

In March, Moshier and nearly 2,000 fellow home health care workers in Rhode Island overwhelmingly voted to unionize, marking the largest election of state workers since the 1980s. They’ll join the SEIU 1199NE union.

“This is the lowest wage health care job in the state of Rhode Island,” said Jesse Martin, SEIU 1199’s executive vice president. “They are working in apocalyptic conditions.”

These Rhode Island workers are part of a broader effort by home health care workers and the unions trying to organize them nationally to demand better wages and benefits. But they may face an uphill battle, due to uncertainty around federal funding – including Medicaid – under the Trump administration.

Proposed changes in federal funding and policy “are likely to have wide-ranging impacts on health and human services programs and resource availability moving forward,” said Kerri White, a spokesperson for the Executive Office of Health and Human Services, the state agency that runs the home care programs.

White said any federal changes “may require us to make difficult decisions to preserve the progress we have made” while also reallocating investments elsewhere.

US House Republicans have proposed cutting Medicaid spending by $2.3 trillion over the next decade. That would force states to raise new revenues or reduce Medicaid spending — which would be difficult in a state like Rhode Island, where 311,444 residents get full Medicaid benefits. Cuts of this size could be acutely felt in home health care, 70 percent of which is paid for by Medicaid.

Home health care workers, who call themselves the “invisible workforce,” help seniors and people with disabilities who live at home with daily needs including bathing, feeding, dressing, toileting, getting to doctor appointments, grocery shopping, picking up prescriptions, and medication reminders.

Cuts to Medicaid would have profound effects on the 4.5 million home-based patients nationally for whom these health care workers are a lifeline, and could lead to hospitalizations, emergency room visits, or death.

David J. Meyers, a health economist at Brown University, said any cuts to Medicaid could have a “massive, qualitative impact on people’s lives” and lead to “additional health care spending down the road because they aren’t getting their needs met at home.”

Across the country, a “silver tsunami” is coming. Nearly 80 percent of older Americans want to age in their own homes, according to a 2021 AARP survey. Despite the critical need for home health aides, which is expected to increase, they are typically paid less than other entry-level jobs, according to a 2023 report from the US Department of Health and Human Services.

In 2023, legislation made thousands more home care workers in Massachusetts eligible to organize and join a union. At the time, 58,000 personal care attendants paid by MassHealth were already unionized and represented by SEIU. This spring in Nevada, home care workers are demanding their second wage increase in two years to reach $20 an hour. In New York, home aides are in the middle of a fight to end 24-hour shifts.

Workers in Rhode Island are expected to request higher wages, benefits, time off, and training in their negotiations with the state. They will also seek a functional registry to connect consumers with workers, create more stability and flexibility in the system, and give workers the ability to take time off.

“If there was a registry, I could take a full day off to go to the doctor’s while someone else cares for Holly,” said Moshier, who currently must complete daily errands for herself and Allen within two hours, the amount of time Allen can be left on her own.

Overwhelmingly, home health workers are typically family member caregivers or close friends of their patients.

That includes Emanuel Rodriguez, 25, who cares for his brother Jorge, 26, who was born developmentally delayed.

His brother, Rodriguez said, can’t be left alone for long. “He’ll start cooking, and he’ll forget he’s cooking and move on to something else, and there’s a fire. That’s happened on one or two occasions already,” he said.

His brother was also a victim of a recent text message scam. His disability “makes him more prone to be gullible because he doesn’t think too deeply about things,” Rodriguez said.

Rodriguez went to school for one year to study mechanical engineering but left to care for his brother. Doing so has earned him just $15 an hour for the last five years. It forced him to take a second job as a paraprofessional for children with special needs in the Coventry Public School District.

Home health care workers “care for the most vulnerable. … We make sure they are not just left to their own devices,” he said.

States, including Rhode Island, could raise taxes to cover federal cuts to Medicaid. Meyers said it’s more likely that states will cut back on services.

“In Rhode Island, it’s a really constrained environment that’s only going to be pushed further to the brink,” Meyers said.

Moshier, who made a promise to her friend’s elderly mother years ago to care for her daughter, gets frustrated when home care workers are characterized as “glorified babysitters.” She sees no difference between what she does and those who work in a facility, such as a group home for adults.

“We’re caring for people who have nowhere else to go. And people don’t realize how many caregivers are struggling just to make ends meet and don’t have a safety net,” Moshier said.

“Being in the position I’m in, you have to make it work. You have no choice,” Moshier said. “You do it out of love for another human being. But comes at a cost.”

Alexa Gagosz can be reached at [email protected]. Follow her @alexagagosz and on Instagram @AlexaGagosz.