They prepare the meals, do the bathing and the shopping for about 12,000 poor and disabled Missourians. Many people probably don't give much thought to the services provided by these home-care workers -- until some of them stage a protest over wages or vote to form a union.

Most earn $7.50 an hour, low pay that has been blamed for a high turnover in an industry where training is poor and no-shows are plentiful. This may explain why more than 75 percent of Missouri voters approved the Quality Home Care Act, or Proposition B, in November 2008. One goal of this ballot initiative was to set up a structure for recruiting, training and building a capable work force of in-care attendants. These functions will eventually be carried out by an 11-member body, the Missouri Quality Home Care Council, which also will help to set wage rates and benefits for attendants. (Click here to read a Beacon story about Prop B.)

But now there's a new force to contend with. Last week, about 60 percent of attendants in Missouri voted to form a union. Attendants favoring the union believe it's a good move both for themselves and the disabled. In the Missouri Home Care Union, they will have an advocate representing them as they seek better wages and working conditions that could lead to improved home care.

But not everyone thinks so. While attendants were celebrating the birth of their union, the muted response among some in-home vendors spoke volumes about their uncertainty and disappointment. Vendors receive state contracts to help run the in-home program. While not opposed to higher wages for workers, some vendors say the attendants might discover to their disappointment that unionization will make no difference in their pay and benefits in light of Missouri's budget situation.

HOW THE SYSTEM WORKS

Save for vendors, attendants, and Missourians with disabled relatives, most people probably know little about the in-home program. It is part of what's known as consumer-directed care, meaning disabled people who use the service also have the power to hire or fire attendants.

To make sure the employer-employee system works well, the state contracts with vendors to do background checks on prospective attendants and handle most other employer functions, including bookkeeping and payroll matters, once an attendant is hired. Vendors get a $14.75 hourly rate to cover services for each attendant, including the minimum $7.50 hourly wage rate. Attendants who remain on the job for a long time can expect a higher wage, but most are said to earn the minimum.

There is disagreement over whether a union will make this system better.

Some vendors, such as Paraquad, were neutral on the union issue but have been sympathetic to the idea of higher reimbursement rates to boost pay for attendants and for services. Kirsten Dunham, associate policy director for Paraquad, praises the in-home program, saying it empowers the disabled by putting them in control of who gets hired and who is coming into their homes. That gives them the option of putting a trusted neighbor on the payroll rather than a stranger from across town. It also let them make the tough decisions on the spot. If an attendant fails to show up, a disabled person doesn't have to go through an agency to complain. He or she can simply tell the attendant "you're not doing your job, you're fired."

ARGUMENTS FOR AND AGAINST UNIONS

But others, like Jeannine Brannum, don't think unions have a place in health care. She argues that voters may have been misled on Proposition B, not realizing that it would pave the way for attendants to unionize. She is director of Medicaid home health care for Algonquin Nurses Inc., one of the vendors for the in-home program.

"They are already making a low wage and for a union to take money from these individual salaries is, I think, ludicrous," she says. "This is a state program, a low-reimbursement program. They know what their wage is and anymore money coming out would be a bad situation for them."

Critics like Brannum are right when arguing that Proposition B's ballot language made no reference to a union. Instead, voters were asked whether they favored amending Missouri law to "enable the elderly and Missourians with disabilities to continue living independently in their homes" by setting up the council to shore up the in-home care work force.

But a fuller version of Proposition B, also available to voters, called for the Missouri Office of Administration to represent the council in sessions with those representing the attendants on wage and benefit issues. The agreement that the two sides reach is then presented to the council for adoption. The General Assembly also must act on the wage and benefit recommendations. Attendants are forbidden to strike.

The Quality Care Council's chair, Bruce Lynch of Poplar Bluff, wouldn't talk much about wages and the union issue during an interview, saying his only wish at this point is for the council to bring stability to the home-care work force. The 11-member council will have to sort out these and other others. Members serve three-year terms; they receive no pay but can be reimbursed for expenses.

Some attendants believe the union will act in the best interest of the disabled as well as workers. They point to an incident last winter when some lawmakers proposed to cut spending by reducing the hours, and by extension, the wages, of in-home attendants. Many of them went to Jefferson City on Feb. 18 and joined other protesters who succeeded in beating back the cut. At that time and after the union vote as well, attendants framed the issue as a move to protect the interests of the needy and disabled. Even so, each incident also involved protecting a pocketbook issue for those who provide care.

The vote to form the union was a victory in general for organized labor in Missouri, where union membership peaked at nearly 16 percent in 1989 and had fallen below 10 percent by last year. The Missouri Home Care Union is affiliated with the Service Employees International Union. The group described the vote as one of the nation's largest union elections in recent years. Along with Missouri, the 10 states where the union has organized in-home workers include Illinois, Iowa and Michigan.

Whether Missouri voters knew or didn't know that Proposition B might lead to a union for attendants, the voters clearly expected the ballot measure to bring some improvements to the care for the disabled.

Among other things, the Home Care Council is charged with expanding the size of the home-care work force, setting standards and minimum qualifications for attendants, boosting training, recommending wage rates and benefits, and working with other agencies on ways to prevent abuse and neglect of disabled people needing in-home services.

Algonquin's Brannum says vendors already work closely with the Department of Health and Senior Services in performing many of these duties. While she might dislike unions in health care, Brannum agrees that that the in-home program saves the state and taxpayers money because it allows the disabled to remain in their homes instead of moving to nursing homes.

In addition to the program's benefits to the disabled, some like Paraquad's Dunham say the issue of pay for attendants remains important.

She says, "Some people feel it's a shame that you can work at McDonald's and make more money than you can make being an attendant."