Long-term care workers (those who are paid to provide custodial care for long-term patients in nursing homes or at home) must care for a growing number of increasingly disabled or dependent persons. They are working for agencies and institutions under growing pressure to increase productivity. They face new training and competency requirements, and most work for low wages and few benefits, a situation that is unlikely to change soon. This crisis is real and will only get worse. The burdens of cost containment cannot be borne largely by an exploited female work force. As comprehensive long-term care programs are debated, questions of financing and reimbursement are not the only issues. Service delivery is a central issue. Who will provide daily care? How will providers be recruited, trained, and retained? The solutions will require a new model of care. Nursing aides and home health aides are oppressed by the acute medical model that still dominates long-term care services, as "skilled" and "custodial" categories of care created by Medicare lock them into underclass status. Are these workers truly "unskilled," is the real issue the disdain in which caregiving and nurturing is held? Since the general perception is that anyone can do it, and those who do are nearly all women, the work is not truly valued. Long-term care workers and their advocates are responding to these pressures by organizing to ensure both the quality of long-term care and the quality of worklife for paid long-term care workers. (Includes 37 reference notes.) (KC)