Every day, in millions of homes around America, homecare workers integrate into their clients’ daily routines, helping them move from bed to wheelchair in the morning, or make dinner in the evening. Homecare enables seniors and people with disabilities to live in the community. Despite steep and growing demand for homecare services and low wages in the industry, Medicaid workers and care recipients are subject to constant scrutiny by a government intent on reining in Medicaid costs. The latest chapter in this story has given rise to Electronic Visit Verification (EVV) that imposes rigid and invasive time and location tracking requirements on workers.

The specter of “fraud, waste, and abuse” in the welfare system has always been politicized to justify austerity. The homecare industry is increasingly dominated by women of color, many of whom are immigrants, making them targets of racialized suspicion, while clients face the stigma that often attaches to poverty and disability. In contrast with oversight programs that focus on institutional accountability, like auditing home healthcare billing practices, EVV scrutinizes Medicaid-funded homecare workers and clients themselves, further straining a workforce that already struggles to hire and retain workers.

What is EVV?

In late 2016, Congress passed the 21st Century CURES Act, a broad piece of legislation that included a provision requiring all Medicaid-funded personal care services (PCS) and home health care services to implement an EVV system. This requirement arose in response a 2016 Investigative Advisory recommending that the Centers for Medicare and Medicaid (CMS) improve oversight and monitoring of PCS programs. EVV answers this call by imposing time and location tracking requirements on workers.  

Most states struggled to implement EVV, but over the past year, states have begun to implement EVV systems in earnest, affecting an estimated 4.8 million low-income children, adults, and older people with disabilities. Specifics vary, but EVV programs typically require homecare workers to use a smartphone app to verify their activity by clocking in and out of shifts and verifying the service provided. States contract with private vendors, prominently including management software company Sandata, to provide EVV technology. Federal legislation mandates that EVV systems remain “minimally invasive,” but offers no specific guidance on how to do so. In practice, homecare providers and care recipients have found the rollout of EVV both burdensome and confusing, throwing a wrench into working relationships that are essential but often precariously maintained.

New Responsibility Shifted to Workers

In the wake of EVV implementation, some caregivers noticed paychecks coming up short. As reported in the Guardian, one homecare worker in Arkansas found that glitches in the state’s new Authenticare system left her paycheck missing $900. Her client found himself digging into emergency savings to cover the shortfall.

Before the EVV requirement, most workers logged their hours asynchronously on a timesheet or web portal, with both worker and care recipient signing off on documentation. EVV requires recording in real time. If a worker forgets to clock in through the app at the beginning of a shift, or lapsed internet connectivity or a (reportedly common) glitch in the app prevents them from doing so, they won’t get paid for the unrecorded time. It is the worker’s responsibility to resolve these issues. Many find themselves facing an impersonal bureaucracy to correct the record. Government and technology companies tout EVV as an efficient way to manage a large and dispersed workforce, but it would be more accurate to say that the burden of management and accountability has been shifted onto workers themselves.

One 2021 impact assessment of EVV found that, overall, the system tends to reduce the quality and quantity of care by making caregivers spend care time logging their activity, and by preventing them from attending to time-sensitive needs like helping clients use the bathroom at the beginning or end of visits.

Privacy Concerns

Perhaps the most contentious part of EVV is the use of GPS tracking and geofencing.  EVV apps incorporate GPS to verify home care workers’ location. Some set a geofenced zone around the homes of recipients, requiring that workers be within that zone when they clock in or out. This effectively limits the movement of care recipients, making it difficult or impossible for homecare workers to meet or accompany clients outside the home. One 2020 survey found that homecare recipients reported leaving home less often out of fear of geofencing restrictions. Geofencing claws back some of the autonomy that homecare can provide for clients. As documented by Data & Society, States differ in how restrictive GPS tracking is, with some flagging all locations outside the home as noncompliant, and others allowing caregivers or recipients to enter outside locations that they plan to visit ahead of time. Even in those cases, however, location tracking effectively creates a map of a clients’ entire social network. This poses a particular concern for workers and clients whose networks include people who are undocumented.

Straining Relationships

EVV’s model of accountability has hampered many of the informal adjustments that caregivers and recipients make to sustain their relationships. This is especially true for the many people who register as homecare workers for their own relatives or friends through self-directed care programs. Data & Society highlights the story of Rafaela, who cares for her mother, Ana, as a registered caretaker, while also raising two young children. Sometimes the demands of the day mean that Rafaela brings Ana to her own house. Those instances get flagged by her EVV app. Rafaela’s struggle to juggle caring for her mother and her own kids between their respective homes reflects the reality of the way that friends and family of those who need care manage to integrate caretaking into their shared lives. Realtime, location-tracked, timekeeping makes such flexibility difficult if not impossible.

Pushback from Care Workers and Clients

Both disability activists and labor activists have spoken out against EVV. “Stop EVV,” a grassroots campaign led by disabled people and care workers sees EVV as a civil liberties issue, violating the Fourth Amendment right to privacy. Others have argued that EVV runs afoul of the Supreme Court’s decision in Olmstead v. L.C., which that held that under the Americans with Disabilities Act (ADA), public entities must provide community-based services to people with disabilities when they are appropriate and wanted. Advocates point out that EVV restricts the autonomy of people receiving community-based care, and also makes such care generally less available by eroding the homecare workforce and creating technical barriers to entry.

In 2018, two unions representing California homecare workers, issued a joint statement warning that EVV “would make receiving services in the home and community more difficult and restrictive” and would exacerbate the shortage of workers in the field by making jobs harder and pay less reliable. Unions have also expressed a fear that the data collected through EVV monitoring will ultimately be marshalled to justify reducing the public provision of care.

While the goals of reducing fraud, waste, and abuse in the home-based personal care system may be reasonable on their face, it seems that EVV is designed to police compliance with its regulations more than to ensure quality care. At the end of the day, quality care demands more resources, not more scrutiny directed towards an already strained workforce.