In a state where barbers, manicurists, and massage therapists must be licensed, home care agencies providing nonmedical support are subject to shockingly little oversight, despite the profound vulnerability of the people who rely on them.

Massachusetts is one of only four states without a licensing process for private, nonmedical home care agencies, said Harrison Collins, director of legislative affairs for the Home Care Alliance of Massachusetts, an industry group representing about 200 agencies that provide help with the tasks of daily living, including bathing and toileting, household chores, and basic companionship.

“In many respects, it’s easier to open a home care agency than a pizza shop in the Commonwealth,” he wrote in a letter endorsing the legislation.

That may soon change.

Earlier this month, the Massachusetts House passed a bill that would create a licensing requirement and establish standards and oversight for nonmedical home care agencies. The legislation focuses on home care businesses, not individuals who work in the field, such as through the state’s personal care attendant program. It proposes worker background checks, mandatory training on skills including infection control and dementia care, transparency around the services that agencies provide and their costs, and protections for workers.

“The industry is asking for regulation,” said state Representative Thomas Stanley, a Waltham Democrat and sponsor of the bill that passed the House earlier this month. “We want to get higher quality people to take care of our loved ones.”

If passed by the Senate, the legislation would become the latest in a series of health care-related laws to address Massachusetts’ aging population and the shortage of people to care for them, including two that increased oversight for long-term care facilities and hospitals.

Well over 100,000 people work as home health or personal care aides in Massachusetts, according to 2024 data from the Bureau of Labor Statistics, many of them giving extraordinary care that’s both emotionally and physically taxing for modest pay. Their mean annual income nationally was shy of $17 an hour, the bureau reported.

Because of the lack of oversight in Massachusetts, it’s not clear how many people rely on these services. The state runs 24 regional senior services offices that provide home care to 70,000 individuals, but that doesn’t include the many thousands who get care through private agencies. A lack of oversight of those private agencies leaves the door open for unscrupulous or inexperienced operators, and families adrift in their search for competent help at home.

“Right now anybody could roll into town and they could put a shingle out and they could start hiring people and offering home care,” said Paul Lanzikos, a coordinator for the disability advocacy group Dignity Alliance Massachusetts.

Before her illness, which was diagnosed five years ago, Kirsten Hano had a thriving career as an advertising account executive and raised three sons. She started the first girls high school hockey team in Vermont, her husband said, and contributed to an inner-city girls mentoring program.

“She was always giving back,” Doug Hano said.

He works from home most of the time but relies on home care aides to help between 11 a.m. and 3 p.m.

Agency workers’ quality of care varies wildly, Doug Hano said. One worker listened to an online class on her earbuds while helping his wife eat lunch. Another left her staring at a television while the worker stared at her phone.

“If there’s somebody who’s not so great, who’s not so engaging, who doesn’t know how to keep the energy up and stay positive, she can sink into a really tough spot,” Doug Hano said of his wife.

Under the proposed legislation, agencies would need a three-year license through the state Executive Office of Health and Human Services to operate. HHS could inspect and investigate agencies, and would have the power to suspend, revoke, or refuse to renew licenses. Penalties would include a $500 daily fine until the violation is resolved.

Anyone with a 5 percent or greater ownership stake in an agency would have to be identified and provide background information, including criminal and civil findings.

An April letter from the union representing about 60,000 home care workers statewide, SEIU 1199, noted private equity has made inroads in the home care industry.

If passed, the legislation’s requirements for home care agencies would go into effect within a year.

Collins, of the Home Care Alliance, said many agencies already meet the proposed standards. But with virtually no bar to entry, a glut of businesses leaves those that spend the money on training and quality control at a disadvantage.

“They’re being undercut by agencies that skirt the rules,” Collins said. “In the end, it creates subpar care.”

There are as many as 1,500 home care agencies operating in the state, according to Representative Stanley’s office.

The legislation benefits workers, too, said Rebecca Gutman, SEIU 1199’s vice president of home care. Along with protections to ensure fair payroll practices and workers’ compensation and liability insurance, it proposes creating a reporting and tracking system for mistreatment complaints from both clients and workers.

“If there are employers out there consistently harassing the workers that come into their home, there needs to be a process for protecting that worker,” Gutman said.

While the licensing requirements would apply only to agencies, the abuse protections would benefit anyone doing home care work.

This year, Doug Hano found a home care worker whom he ranked as an 11 on a scale of one to 10.

“She knew all the ins and outs of dealing with someone with Alzheimer’s,” he said.

Then, about two months ago, her car failed. She hasn’t been able to get it fixed and is now only available for overnight care when he goes on business trips.

The agency’s replacement is good, he said, but his wife’s condition is declining, and he is concerned he may soon need more hours of daily home care support. If his current care worker isn’t able to fill those hours, he may be forced once again to search for someone he can trust with Kirsten’s wellbeing.

“It seems mind-boggling that Massachusetts, pretty progressive, wouldn’t have something…” he said, “to just make sure that there is more training, there is more vetting, there is more accountability.”

Jason Laughlin can be reached at jason.laughlin@globe.com. Follow him @jasmlaughlin.

Yet, the full 10-person panel has not gathered in a meeting since, nor has the commission held a series of legally mandated hearings to gather public input ahead of a Dec. 15 deadline to produce its recommendations.

It appears unlikely the panel actually will do so. A commission spokesperson told the Globe that the panel intends to seek a second extension, and is “aiming” to have its next full commission meeting at some point in December.

“The Seal, Flag and Motto Advisory Commission has been hard at work engaging experts and the public about what they want to see in our state’s symbols,” Alana Davidson, the commission spokesperson, said in a statement. “We believe that more time is needed to ensure robust community engagement.”

Davidson did not respond to a question about how much more time the commission would seek from the Legislature, which wrapped up formal sessions for the year earlier this month.

The panel, similar to the one before it, has been trying to navigate a fraught debate about representation and potential erasure in the iconography the state assigns itself.

The effort to replace the flag dates back decades, but it gained traction in 2020, when the murder of George Floyd sparked a nationwide reexamination of race and historical emblems, including the Massachusetts seal.

Members of the state’s Indigenous community are themselves split on how to replace the state’s current 19th-century emblem, which sits on the state flag and depicts a colonist’s arm holding a sword above the image of a Native American. The image is draped by a Latin motto that roughly translates to: “By the sword we seek peace, but peace only under liberty.”

The design draws on the original seal of the Massachusetts Bay Colony, which featured a Native American man, naked but for some shrubbery around his groin, saying, “Come over and help us.” And the sword depicted once belonged to Myles Standish, a 17th-century military commander for the Plymouth Colony known for his brutality toward the Indigenous population.

When the panel released a set of new designs in August it had culled from public submissions, commission members cautioned that the proposals — which rated the highest during a round of internal scoring — were not the finalists from which a final recommendation would emerge.

In the months since, a group of commissioners have met in subcommittee meetings, during which members lamented moving too quickly to ask for ideas without better educating the public — and commission appointees themselves — about the problematic history of the state’s official emblem.

The commission’s work is also unfolding during a different time than in 2020. Over the last five years, the racial reckoning that helped spur the first commission has largely receded from the public view.

The debate over changing the flag has also since migrated onto the campaign trail, where some of Governor Maura Healey’s Republican opponents — both past appointees of former governor Charlie Baker, who signed the initial measure in January 2021— have cast the state’s effort as an attempt to erase the state’s own history.

“There’s a public misunderstanding about why the current flag is not appropriate,” Kate Fox, the executive director of the state’s Office of Travel and Tourism and the commission’s co-chair, said during a Sept. 9 meeting.

Critics have long said that the placement of a broadsword above the Native American figure is racist imagery and symbolizes the violence inflicted on Native American populations. Still others, both on and off the commission, have warned against eliminating Massachusetts’ Indigenous communities from the seal entirely.

The first iteration of the commission voted unanimously in 2022 for replacing the state’s motto and seal, but it disbanded the next year without offering specific substitutes for either.

Summer Confuorto, a current commission member, said in a late September subcommittee meeting that she’s heard pushback casting the panel’s effort to rethink the flag as a “liberal state that wants to make this change” and that Native Americans themselves aren’t driving it. In fact, she said, Indigenous leaders have been talking for decades about why the imagery needs to change.

“It’s not to waste people’s time and . . . there’s a purpose and intent” behind the commission’s work, said Confuorto, who has Gros Ventre, Cree, Mi’kmaq heritage, according to her employer, the Mass Cultural Council.

In a late October meeting, Rhonda Anderson, an Iñupiaq – Athabascan commission member who also is the Western Massachusetts Commissioner on Indian Affairs, said the advisory panel needs to both educate and reframe its work, including to other Native Americans, that “we’re actually providing something better” with a new emblem.

“When people believe that we’re taking something away, they just really clutch tighter,” Anderson said. “I don’t want to take anything away from anyone, but I do want to do better.”

Efforts to reach Confuorto, Anderson, and other members of the advisory commission for this story were not successful.

John “Jim” Peters, the executive director of the Commission on Indian Affairs and a state seal advisory commission member, said in a phone interview that the panel is tackling a “difficult question” and he himself is at odds with others on a path forward.

He said he’s made his preference clear: The “most effective” option, he said, is to simply remove the disembodied arm and sword from the state, and change the state motto.

Actually changing the seal and flag, however, is “something that the citizens of the state need to be on the same page [for],” he said.

Whenever the panel does submit its recommendations, the governor is required to submit legislation “to codify the new state motto and designs for the seal and flag,” though the law does not dictate when it must be submitted. The Legislature ultimately would then have to approve any changes.

Peters is not among the commission members who’ve sat in on subcommittee meetings in recent months, the last of which fell shortly before Halloween. But told the Globe he was aware that the advisory panel planned to seek an extension.

“Another holdup,” he said.

Matt Stout can be reached at matt.stout@globe.com. Follow him @mattpstout.

Massachusetts lawmakers will be taking up a bill this session that seeks to establish a permanent commission on the status of transgender people.

The legislation (S. 2725) An Act Establishing a Commission on the Status of Transgender People, would task the commission with conducting an ongoing study of all matters concerning transgender people.

The commission would also report its findings to the public, serve as a liaison between government and private interest groups concerned with issues affecting transgender people; assess programs and practices in all state agencies that may affect transgender people, and identify and recommend qualified transgender people for appointive positions at all levels of government, including boards and commissions.

An original draft was filed in February by state Senators Joanne Comerford (D-Northampton), Patricia Jehlen (D-2nd Middlesex), Jamie Eldrige (D-Marlboro) and state Rep. Lindsay Sabadosa (D-Northampton). The group has since completed a second draft, which was reported favorably by the committee on Rules of the two branches and referred to the Committee on the Rules of the Two Branches, on Monday.

In a February 25th Facebook post announcing the filing of the original draft, Sen. Jehlen pointed to what she calls an “attack” by the Trump Administration on the “rights of minority communities across the country” as a motivator for her support.

“We have seen the federal administration attack the rights of minority communities across the country. One of the many affected groups whose rights are being stripped and jeopardized is the LGBTQIA+ community. Thanks to the hard work of incredible advocates over the last several years we have been able to codify and strengthen protections for many but not all,” Sen. Jehlen wrote.

“Part of ensuring everyone in our community is protected is making sure we know what changes could improve the lives of our neighbors who are vulnerable. Establishing a permanent commission on the status of transgender people that will focus on improving their lives can bring us one step closer towards equitable protections for all,” she said.

The commission would be made up of 21 unpaid members who each would serve three-year terms. Six members would be appointed by transgender-led organizations of groups that directly serve, support or advocate for transgender people in Massachusetts. Two members would be appointed by transgender-focused health programs at Massachusetts-based health centers, with another two members each appointed by an organization that supports LGBTQ+ students and by a group that supports homeless LGBTQ+ individuals with housing. The remaining nine members would be appointed by groups that LGBTQ+ people facing domestic violence, are incarcerated, and who are sex workers; as well as LGBTQ+ veterans and with disabilities.

The legislation calls for the commission to be made up of at least 11 transgender persons in total, two of which are between the ages of 18 and 24, with two more members aged 60 or older and another two being representatives of mental health professionals.

The development in this legislation comes a week after news broke of Gov. Maura Healey’s appointment of trans woman Giselle Byrd to the Massachusetts Commission on the Status of Women in August. Healey has defended her appointment of Byrd, who says she’s been receiving death threats since she joined the commission.

Gov. Healey received widespread criticism for the decision, with many opposed to the move stating how they feel it would have been more appropriate and deserving for a biological female to have been appointed.

The Herald has reached out to state Rep. Sabadosa and state Senators Comeford, Eldridge and Jehlen for comment.