The “careworkers” at the heart of the story that Eileen Boris and Jennifer Klein tell in Caring for America have been both the instruments and the objects of welfare policy in the United States over the course of the twentieth century. That, and the fact that these workers have been overwhelmingly female and largely minority, account for the persistent struggle to attain decent pay and working conditions either through regulation or through unionization. The intimate labor provided by these workers, helping care for people in their homes, has emerged as a vital social service over the past hundred years, but the needs of the workers themselves have often remained in the shadows, as the book's subtitle suggests.

One of the primary obstacles facing such workers in the home is how their work was defined, and at times even the struggle to have it recognized as legitimate “work.” Carework, the term Boris and Klein settle on to describe the labor whose history they trace, emerged in the United States in the 1930s out of “visiting homemaker” programs sponsored by private charities and, on a larger scale, by New Deal-era employment programs; poor women were employed to go into the home, usually of mothers who were incapacitated for some reason, to replace the labor of the mother. While occasionally the programs attempted to dignify the work with a professional aura, the workers, then and in similar programs in the following years, ran up against the fuzzy boundary between their work and that of poorly paid domestic servants, or that which was done for free by female family members. Neither would bode well for attempts to make the work a path out of poverty for women often drawn from or near the welfare rolls themselves.

One strand of carework would remain rooted in these welfare-oriented institutions, both public and voluntary, but an ultimately more significant source of employment came through the health-care sector in the post-World War II period, where hospitals, seeking to reduce crowding and costs, sought to shift patients out of costly long-term care and back into their homes. Funding for carework for elderly and disabled clients was supported piecemeal through the Social Security program, and substantially expanded through Medicare and Medicaid in the 1960s and 1970s, but primarily linked to the elements of the welfare state where states, counties, and localities were liable for substantial portions of funding (unlike in Britain, where it was made an element of the National Health Service). Thus the revenue streams were unreliable, particularly during times of recession and budget cuts, and programs like home care that consisted of largely labor costs were particularly vulnerable.

The women who worked in these jobs were in the shadows in many ways. For one, these programs typified the fragmented, public–private structure of the welfare state. Though ultimately most of the money came from public sources, the actual employer was often obscured; as more jobs were contracted out to nonprofits or proprietary companies as a way to reduce labor costs, the workers were often held to be “independent contractors” and thus outside the coverage of labor laws (which offered little to home care workers anyway; the Fair Labor Standards Act, which regulated wages and hours since the 1930s, specifically excluded this sort of labor). Those who sought to organize these workers – who labored out of the public eye, by themselves, in homes, with the employer role divided between client, funding institution, and contracting agency – had to rethink organizing strategies designed for industrial workplaces. By the late twentieth century, such unions as the Service Employees International Union had developed a model of “political” unionism that sought to build a movement culture among workers to substitute for a common worksite, and to recruit allies among clients and contractors to lobby for adequate funding for the programs that underlay the home care system. But the economic crisis that started in 2007, the slashing of public budgets, and the increasing attacks on public-sector unionism have all eroded what initially seemed to be one of the few bright spots in an otherwise depressing history.

Telling a story about workers in the fragmented American welfare regime required Boris and Klein to weave together a national narrative with case studies rooted in several states and cities, and the work they have done (and conveyed in only two hundred pages) is impressive. Occasionally, the voices of the workers themselves get lost in the need to explain the political and organizational forces shaping their work lives. I might have sacrificed some of the discussion of the internal union politics from the latter half of the book in order to include more anecdotal first-person evidence on the day-to-day nature of the work to remind readers of how difficult, and necessary, these women's work is. But that aside, the authors have skillfully and forcefully demonstrated that if a society actually values caring, then we need to attend to those who care as much as to those who are cared for.