The American Prospect #316

Special Report on Building Universal Family Care

I D E A S, P O L I T I C S & P O W E R

CAREGIVING IN

CRISIS AND HOW TO FIX IT

David Dayen | Janelle Jones | Kimberly J. Morgan | Bryce Covert Marcia Brown | Rhacel Salazar Parreñas | Sarah Jaffe Alexander Sammon | Maureen Tkacik | Sara Luterman Tasmiha Khan | Ai-jen Poo | William E. Spriggs Cassandra Lyn Robertson | Darrick Hamilton | Rachel M. Cohen Robert Kuttner | Brittany Gibson | Gabrielle Gurley Dorian T. Warren | Seth Borgos | Sen. Elizabeth Warren BONUS ISSUE, 2020 THE AMERICAN PROSPECT 35

Everyone deserves safe drinking water.

Infrastructure isn’t just about roads or bridges.

It also includes the systems that bring clean, affordable water into our homes, and those systems are in desperate need of repair.

It’s time to Rebuild America.

americanmanufacturing.org

FAMILY CARE A SPECIAL ISSUE

INTRODUCTION

2 Why Universal Family Care Belongs Atop the Progressive Agenda

By David Dayen

PART I: CAREGIVING IN CRISIS

6 The Failed Economics of Care Work By Janelle Jones 10 Missed Opportunities, Partial Solutions By Kimberly J. Morgan 14 Running on Empty By Bryce Covert 18 Care Workers Organizing for Dignity By Marcia Brown 22 The Aging of Migrant Domestic Workers By Rhacel Salazar Parreñas 25 Caregiving in the U.K. By Brittany Gibson 28 Why Americans Need Paid Sick Leave By Sarah Jaffe 33 The Collapse of Long-Term Care Insurance By Alexander Sammon 35 The Corporatization of Nursing Homes By Maureen Tkacik 42 The Neglect of Disability Care By Sara Luterman 46 How the Pandemic Disrupted Care By Tasmiha Khan

PART II: THE SOCIAL INSURANCE SOLUTION

52 An Interview With Ai-jen Poo By David Dayen 56 Building Back the Care Economy By William E. Spriggs 59 Economic Rights as Industrial Policy By Cassandra Lyn Robertson and Darrick Hamilton 62 Family Care: Good Policy, Good Politics By Rachel M. Cohen 65 How to Finance Universal Family Care By Robert Kuttner 69 What the U.S. Can Learn About Caregiving From the World By Brittany Gibson 72 Washington: The Caregiving State By Gabrielle Gurley 76 Building Movements Around the Care Economy By Dorian T. Warren and Seth Borgos

PARTING SHOT

80 An Interview With Sen. Elizabeth Warren By Robert Kuttner

Illustrations by John Hersey

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 1

THE FAMILY CARE ISSUE

Why Universal Family Care Belongs Atop the Progressıve Agenda An introduction to our special issue on how to solve the family care crisis

By David Dayen My grandmother spent months con-

fined to a hospital bed, weak and unable to swallow, before she miraculously recovered enough to return home. But once there, she needed assistance to accomplish the basics of her life: preparing meals, cleaning the apartment, bathing. Such support was so expensive that it would quickly bankrupt her.

She wasn’t alone. What my grandmother faced was precisely what our current care system requires before it steps in to help.

Medicaid will pay for long-term nursing care in the home, but only if applicants can show that they carry

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no more than $2,000 in assets. That includes cash, savings accounts, investments, or property other than a primary residence, the equity of which cannot exceed a certain limit.

Elderly Medicaid recipients can still have a car, but most 90-year-olds like my grandmother don’t have much use for one. They are also allowed to put some money aside in a burial fund so they won’t be interred in a pine box.

Every check my grandmother had written and every withdrawal she had made for the previous five years was scrutinized to ensure she was truly poor and not hiding her financial condition. Eventually, she got that vital in-home care paid for

through Medicaid, but at a cost.

Many of the elderly on Medicaid can no longer afford independent living; many survive on food stamps; many seek charity, or the support of family, to subsist. Their ability to choose how to live out their final days becomes constricted, and their anxiety in retirement heightened.

The other option for those who don’t want to see their loved ones forced into this penury is to care for them themselves. But had it fallen to me at that time, I would have faced an insoluble dilemma. For close to 20 years before I took over at the Prospect, I was a freelance employee. Taking off weeks or even months to care for a loved one would have brought

my income to a sudden stop. Unless you have a job with generous benefits, a forgiving boss, or the technical ability and determination to be able to juggle caregiving and full-time work from home, you’re probably in this situation too.

I don’t have a child care story of my own to draw from because I don’t have children. But just a couple of weeks ago, I was speaking with Migreldi Lara of Reading, Pennsylvania, a hair stylist and single mother of three. She told me through an interpreter that her salon had closed almost immediately after the COVID19 pandemic began, but reopened several months later. She hasn’t been back, however, because her children didn’t have in-person schooling to attend, and they were too small to be left alone. She was months behind on rent, and at the time that we talked, on the verge of homelessness.

I’d be willing to bet that there isn’t a family in America that doesn’t have one of these stories. Virtually everyone can tell you about a time in their life when a parent or grandparent or uncle or aunt or child or grandchild needed care, and the struggles and sacrifices the family had to make to secure it. Mine are relatively benign. My grandmother was fortunate to have a family willing to support her and allow her to complete her life with a modicum of dignity. The family or medical leave moment never happened for me. My mother-in-law and her sister, both of whom suffered with dementia in their final years, had accumulated enough savings through their lives to afford strong support.

I’m the lucky one; not every story

ends this way. And American public policy doesn’t seem to care. Every four years, Republicans and Democrats spar over which party will do more for working families. But then they discuss tax credits and apprenticeships and ladders of opportunity. When it comes to helping people care for family members, though, the country is failing.

In the years when a single income could produce a middle-class lifestyle, we pushed these burdens onto uncompensated mothers, who may or may not have wanted to stay home as caregivers. Today, the majority of children grow up in a home where all the parents caring for them work.

Removing a breadwinner from the workforce to care for someone is unthinkable to most families. And we have not adapted public policy to account for these changes.

Family life today involves a perpetual strategizing to figure out how to incorporate care work into busy lives and strapped budgets. When a child is born, the family must fig-

ure out who can raise them; when a parent grows ill, their care must be worked out. Often these things can happen simultaneously, squeezing sandwiched families to the breaking point. Families with children are typically in the earliest part of their career cycle, while seniors are beyond their working life and often on fixed incomes; in both cases, the care needs occur at the worst possible financial moment. And an unexpected illness or disability creates an even bigger shock.

These almost universal situations receive virtually no support. State and federal child care coverage is simply inadequate, with fewer than one in six eligible children receiving coverage under the main federal program. In-home and center-based child care is somehow simultaneously prohibitively expensive for parents and pervasively unremunerative— paying poverty wages—for workers.

And often it cannot be found at all in the child care deserts that blot the American landscape.

Family life today involves a perpetual strategizing to figure out how to incorporate care work into busy lives and strapped budgets.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 3

THE FAMILY CARE ISSUE Only three countries in the world supply no paid parental leave, and just 13 provide no mandatory sick days; Americans live in the one and only country that lacks both. Only 7 percent of adults over age 50 have the kind of insurance policy that can cover long-term care needs, the average cost of which in the U.S. is $266,000. We have institutionalized long-term care in nursing homes that are often substandard and have increasingly become means for private equity vultures to extract the final bits of wealth from their customers. Direct care services for the elderly, either in nursing homes or in the home, is one of the fastestgrowing jobs in the economy, but as low-wage a career choice as child care. Meanwhile, the small businesses that handle child care, many of them minority-owned, verge on bankruptcy or closure as a fact of life.

And while the pandemic has shone a bright light on these inadequacies, the care economy was in crisis before we ever heard of the novel coronavirus.

The effects of these dilapidated frameworks touch every corner of our lives. When someone must leave the workforce to care for a child or

elderly loved one, more often than not it’s a woman, stalling her lifetime earning potential. Yet, this stunting of financial growth is often seen as preferable to going into debt to pay for outside care. Forced to choose between giving care and keeping a job, workers’ morale suffers, as does worker retention. Child development, elderly vitality, and personal health outcomes all suffer from how difficult America makes it to care for our families. And the creation and growth of a low-wage workforce, even though it’s in a critically valuable profession, is intolerable and contributes to the runaway inequality that hovers over the entire economy.

These burdens fall most heavily on women of color—the primary group in the care workforce and the cohort most likely to have to leave their jobs to perform uncompensated care.

Historically, the care work of Black and Latina women has been undervalued and neglected in terms of its contribution to society. Our broken care infrastructure reinforces this lingering discrimination.

Liberal advocates have a host of recommendations to fix the care economy, but they remain troublingly segregated from one another. There

are plans for universal child care that do nothing for long-term care; there are plans for parental leave that offer nothing for medical leave; there are plans to solve the problems of seniors and people with disabilities that keep the problem of caring for small children unsolved.

Yet we’re all part of families that can include children, parents, grandparents, siblings, even those outside the immediate family who might need help. We don’t have one stable or static care need over the course of our family lives. And the problems families face with care are integrated. A family that must suddenly care for a parent may also need assistance for their child; a caregiver who falls ill must be cared for and replaced in caregiving. These waves of care needs rise and fall in unpredictable ways, and just one part of a safety net won’t cover them all.

About a year ago, the National Academy of Social Insurance issued a long report identifying options for a Universal Family Care system, a social-insurance fund paid for through worker payrolls along with other special assessments. Universal Family Care would cover, with one point of access, universal child care

WHAT IS FAMILY CARE?

• Early-childhood care and education: preschool and daycare services • Paid family and medical leave: time off work to deal with medical issues or care for family members • Long-term services and supports: medical and non-medical caregiving for seniors or people with disabilities

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and early learning, paid family and medical leave, and long-term services and supports. This would fill a distressing gap in American life that has grown into an absolute crisis.

More than anything, it would allow families to exhale.

Even relatively affluent families worry about a sudden shock that requires extra caregiving, or the management of child care costs that continue to escalate. Universal Family Care would offer peace of mind to these and other families across America. It would give them the freedom to choose to work outside the home, or be gratified rather than stressed with care work. It would give them the security to have children, without the financial burden becoming too big a hurdle to clear. It would give seniors the option of staying connected to their communities and loved ones by aging in place. It would make life in America a little more pleasant and connected. We would all have more of a stake in each other, and in the success of each other’s families.

This special issue, in partnership with our friends at the National Domestic Workers Alliance and Caring Across Generations, is about family care: how it works right now, and the universal solution that can make it better. Family care has too often been placed on the peripheries of the top issues in American politics. In this election season, we want to stress the basic inhumanity of how hard public policy makes it to create and maintain a family, and provide ideas about how we can change it so that families thrive.

We do it through on-the-ground reporting that documents the stress that caregiving causes right now with scant federal support.

We provide evidence for how a universal social-insurance system can work to alleviate the care burden

by sharing the cost burden. And we highlight the grassroots movements for improvements in caregiving that have already paid dividends. Most of all, we talk to people, mostly women of color, in the caregiving industry and at the forefront of decisions within families on care, whose testimony explains why and how this system is crying out for an overhaul.

Time and again, opportunities to transform aspects of family care have fallen short in Washington. But the worm may be turning. Four years ago, Hillary Clinton called for 12 weeks of paid family leave and a cap on family child care costs. This year, Joe Biden has made caregiving one of the four pillars of his “Build Back Better” agenda, with $775 billion in investment focused on expanded access to in-home support for long-term needs, universal pre-K, improvements to care facilities, and increased pay and union representation for caregivers. The progression from Clinton’s plan to Biden’s, to bigger and better promises of intervention, shows the growing importance of the caregiving crisis. Dealing with family care can no longer be confined to a swiftly forgotten position paper; it’s now a policy imperative.

Today, we bury families in worry, game-planning, and paperwork. We punish them for having too much money and fail to fully support them if they don’t have enough. We’ve failed to remove a key obstacle to families’ quality of life. In 1935, when the situation of elderly poverty was intolerable, we created Social Security, devoting the resources of the nation to ensuring dignity for senior citizens. That investment in each other, spread across workers and employers, made an enormous difference.

This issue tries to make the case that we all must pitch in again. Because at one point or another, we all need to be cared for. n

EXECUTIVE EDITOR DAVID DAYEN FOUNDING CO-EDITORS ROBERT KUTTNER, PAUL STARR CO-FOUNDER ROBERT B. REICH EDITOR AT LARGE HAROLD MEYERSON DEPUTY EDITOR GABRIELLE GURLEY ART DIRECTOR JANDOS ROTHSTEIN MANAGING EDITOR JONATHAN GUYER ASSOCIATE EDITOR SUSANNA BEISER STAFF WRITER ALEXANDER SAMMON WRITING FELLOWS MARCIA BROWN, BRITTANY GIBSON EDITORIAL INTERNS SHERA AVI-YONAH, BLAISE MALLEY, ALEX ROUHANDEH CONTRIBUTING EDITORS MARCIA ANGELL, GABRIEL ARANA, DAVID BACON, JAMELLE BOUIE, HEATHER BOUSHEY, JONATHAN COHN, ANN CRITTENDEN, GARRETT EPPS, JEFF FAUX, MICHELLE GOLDBERG, GERSHOM GORENBERG, E.J. GRAFF, BOB HERBERT, ARLIE HOCHSCHILD, CHRISTOPHER JENCKS, JOHN B. JUDIS, RANDALL KENNEDY, BOB MOSER, KAREN PAGET, SARAH POSNER, JEDEDIAH PURDY, ROBERT D. PUTNAM, RICHARD ROTHSTEIN, ADELE M. STAN, DEBORAH A. STONE, MICHAEL TOMASKY, PAUL WALDMAN, SAM WANG, WILLIAM JULIUS WILSON, MATTHEW YGLESIAS, JULIAN ZELIZER PUBLISHER ELLEN J. MEANY CONTROLLER SALLY FREEMAN COMMUNICATIONS SPECIALIST STEPHEN WHITESIDE BOARD OF DIRECTORS MEHRSA BARADARAN, DAAIYAH BILAL-THREATS, CHUCK COLLINS, DAVID DAYEN, STANLEY B. GREENBERG, JACOB S. HACKER, AMY HANAUER, DERRICK JACKSON, ROBERT KUTTNER, ELLEN J. MEANY, MILES RAPOPORT, JANET SHENK, ADELE SIMMONS, GANESH SITARAMAN, WILLIAM SPRIGGS, PAUL STARR, MICHAEL STERN SUBSCRIPTION CUSTOMER SERVICE STEPHEN WHITESIDE, 202-753-0937, INFO@PROSPECT. ORG PRINT SUBSCRIPTION RATES $36 (U.S.), $42 (CANADA), AND $48 (OTHER INTERNATIONAL) REPRINTS PROSPECT.ORG/PERMISSIONS VOL . 31, NO. 6. The American Prospect (ISSN 1049-7285) is published bimonthly by The American Prospect, Inc., 1225 Eye Street NW, Ste. 600, Washington, DC 20005. Periodicals-class postage paid at Washington, DC, and additional mailing offices.

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BONUS ISSUE, 2020 THE AMERICAN PROSPECT 5

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

The Failed Economics of Care Work The care market is high-value but offers little reward to providers.

Economists don’t know how to explain this.

BUILDING UNIVERSAL FAMILY CARE CAREGIVING IN CRISIS

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By Janelle Jones What is something “worth” in the

marketplace? Who gets to decide that? If you ask someone steeped in classical economic theory, they will tell you that something is worth exactly what someone else is willing to pay for it. They will say that the “market” decides, through the laws of supply and demand. And they will say that all of these individual market transactions come together to make up “the economy.”

It should be clear to most of us by now, but classical economic theory doesn’t actually explain how the economy works, at least not in a way that is meaningful to those who actually live in it.

Care work is a perfect example.

Classical economic theorists would tell us that care work simply isn’t very valuable, and neither are the workers who conduct it. If the best way to determine something’s worth is how much people receive in payment for it, then this would be exactly

right. More than one in six domestic workers, including house cleaners, nannies, home health care aides, and child care providers in their own home, are in poverty. For house cleaners, the number is even higher, with one in four not meeting the poverty threshold. There is a 40 percent wage gap between domestic workers and other workers ($12.01 per hour compared to $19.97 per hour).

But imagine a world without domestic workers. Imagine there is nobody to take care of children while parents go off to their jobs.

Nobody to clean, cook meals, or take care of sick or elderly people. In a world where that was the case, the economy as we know it today simply couldn’t function.

You don’t have to think too hard to imagine a world bereft of care; the COVID-19 pandemic has created a natural experiment in this devastating reality. As child care options closed, and social distancing kept care workers home and off the job, families found themselves in a state of crisis. People with careers of their own were pulled into time-consuming domestic work, caring for children who weren’t going to school, or sick or elderly relatives without support. These people saw their productivity at work collapse. This new burden of care work fell disproportionately on women, and even more so on women of color, who are the ones most often called upon to make that difficult choice between caregiving responsibilities and employment.

In the ensuing months of lockdowns, the care infrastructure and the people it employs were seen more than ever to be absolutely essential.

So if a form of work is so important that its elimination would make all other work difficult or impossible, and if it adds so much value to an economy that its removal causes massive productivity declines, does

it truly make sense to say that domestic workers aren’t “worth” very much?

Clearly not. So how does this make sense from an economic perspective?

What is happening here is that we have a system where there is high demand for a highly valuable service, but in which the financial benefits flow not to the ones providing the service, but rather to the ones purchasing it. And as usual, the failure of this relationship between wages and values falls disproportionately on women of color, the main caregivers and service providers, who are systemically devalued.

Let’s dig a bit deeper into this.

The relationship between wages and value is often measured through productivity, or value of output, and this is extremely hard to measure in care work. The measure of productivity does not capture the positive benefits for the purchasers and the broader economy. A day care provider does more than babysit children. She provides a service and also allows for a parent to go to work. She also, through providing learning activi-

ties and social experiences, supports critical early development, benefiting a child’s future academic achievement, lifetime earnings, and even their ability to stay out of the criminal justice system. None of this is included in the dollar value of care work. An AARP report in 2019 found that family caregivers provided unpaid care worth $470 billion in economic value.

Another major challenge to a traditional economic view of domestic work is that while individual worker wages are very low, the actual work can be prohibitively expensive to provide. That’s because of the high ratios between caregivers and those who receive care. While there are 16 students in an average K-12 classroom, federal recommendations and state mandates require as high a ratio as one adult for every three infants in child care, and for every three to six toddlers and preschoolers. In-home support service for the elderly is often a one-on-one experience.

That means that consumers of family care must spend far more per

If the work is so important that its elimination would make all other work difficult or impossible, how can we say that domestic workers aren’t “worth” very much?

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 7

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS staff member than with traditional K-12 education. It has created the anomaly of prices that are unaffordable to the median family, and wages too penurious for workers to live on.

Subsidies exist that could help both families and caregivers cope, but they are too few and far between.

Only one in six eligible children benefit from federal child care block grants, according to 2015 estimates, and to become eligible for government long-term care support, elderly individuals must spend down all of their savings to qualify for Medicaid.

The demand for care will only grow, straining families and caregivers alike. More than 41 million workers have children under 18. In a few years, nearly 70 million people will be between the ages of 60 and 78.

In economic terms, this is simply

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not a stable market.

But that’s not all. As noted earlier, traditional economic assumptions state that the price of a product or service is equal to how much the consumer is willing to pay. But this doesn’t tell the whole story. Very often, domestic care isn’t a luxury, it’s a necessity—whether that’s to care for a sick or elderly family member, or to allow both parents to keep their jobs and keep their heads above water. In economic terms, this means that the price is “inelastic,” meaning that the price doesn’t change much in response to demand.

For example, consumers of health care will typically spend whatever it takes, assuming they have the resources, to be treated. Other types

of care are similar. Thus, prices might not be a particularly good or useful “signal” in the care economy.

Consumers of care are not likely to be willing to sacrifice quality for savings, if they can afford it. Who would willingly select substandard care for their children or grandparents? So when it comes to domestic work and the care economy, like we see in health care, we can’t really rely on the “market” to work its magic by counting on consumers to comparison-shop and drive prices down through competition.

41 million: workers with children under 18 40 percent: the wage gap between domestic workers and the average worker 12 percent: decrease of mothers in the workforce in areas without adequate child care 1 in 6: number of domestic workers in poverty Similarly, classical economics assumes that people are making choices with perfect information, comparing costs and benefits to maximize their self-interest. Each piece of this assumption fails under the reality of our current care system. Patchwork systems of providers for both in-home and center-based care services include government, small-business owners, private companies, and family members. Families face different leave policies from employers, and different allowances depending on their city or state, which leads to incomplete and everchanging information. The cost of care is often too high for low- and middle-income workers. And the ultimate “low-cost” option, providing in-home care to loved ones, is often impossible to do while maintaining a full-time job, making it the most expensive option of all.

This crisis is magnif ied for women, and especially for women of color, who must face the dual discrimination of sexism and racism, which is often larger than the sum of its parts. There is a long history of Black women as domestic workers who are not given protections in

the workplace and lack supports to care for their families at home. This continues today. More than half of domestic workers are Black, Latina, or Asian American/Pacific Islander women. At the same time, a large majority of Black and Latina mothers are contributing significantly to keeping their households afloat.

Women of color are more likely to be single parents than white women, meaning the decision between caregiving in the home and entering the labor market is more likely to fall on them. Women of color are disproportionately represented as workers and business owners in the child care market.

Another way this market fails is highlighted by the existence of family care deserts, those areas of the country where supply of care is low even though consumers are willing to pay for it. A 2018 report found that more than half of Americans are living in child care deserts, where there is an insufficient supply of licensed child care. There is no state or federal government mechanism to spread around caregivers to all the areas of the country that need it. In areas where day care is scarce, there’s a measurable 12-percentage-point drop of mothers in the workforce, which affects not only personal finances but overall economic vitality.

As schools implement remote classes during the pandemic and day care facilities remain closed, policymakers pushing to reopen the economy are ignoring the care constraints faced by millions of workers.

Even for those parents and caretakers returning to work remotely, there will be decreased performance as they juggle caregiving responsibilities at home. A recent survey found that parents are losing on average one full day a week due to child care needs. Workers returning to brick-

and-mortar jobs will have to cut hours, resign, or try to find another solution. In a survey of parents over the summer, one in eight had to reduce hours or leave jobs due to child care needs.

How this is playing out is no surprise. The wealthy can afford babysitters, nannies, and home learning “pods” with professional support, but low- and middle-income households are increasingly choosing burdening themselves with care work as facilities remain closed, and bearing the economic impact of that decision.

So if only the rich and upper class can afford quality care, and in the process, providers don’t have quality jobs and can’t afford to pay their own bills or advance up the economic ladder, is that truly a functioning market? The answer is clearly no.

Oscar Wilde famously quipped that “the cynic knows the price of everything and the value of nothing.”

Today he might say the same about classical economists.

Caregiving infrastructure is a perfect example of something that is being failed by a classical economic view of value, and it needs to be taken out of a market that will continue to view it through that prism. Actual people value domestic work. Actual people value the care economy. The economy is made up of these actual people, not the models that classical economists use to try to predict what actual people “should” value. Treating caregiving as a public good, and making sure that the actual caregivers receive their fair share, could help us assign value to this work where it belongs. n Janelle Jones is the managing director for policy and research at Groundwork Collaborative. Previously, she was a researcher at the Economic Policy Institute, the Center for Economic Policy Research, and the Bureau of Economic Analysis.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 9

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

Missed Opportunities, Partial Solutions Why America doesn’t have a system of family care

By Kimberly J. Morgan The United States is an outlier in

family care policies. It is one of the few wealthy democracies without national provision of paid parental or sick leave. It devotes fewer public resources than its international peers to early-childhood education and care. And it has failed to join a growing number of countries with broad-based programs for care in old age.

A long history of missed opportunities lies behind this pattern. At critical moments of choice over the past century, the United States could have adopted family care policies of the kind that are now well established in Europe and other parts of the world. Part of the explanation for those missed opportunities lies in the difficulty of moving social legislation through America’s governing institutions, with their multiple “veto points.” When advocates for reform have succeeded in putting change on the political agenda, they have

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also often been outmatched by wellfunded antagonists, who have told Americans that family care policies are a threat to free enterprise and a step on the road to socialism. With each moment of frustrated change, a hodgepodge of public and private arrangements has partially filled the void. As a result, instead of universal policies, Americans today confront a confusing array of means-tested programs, employer-provided supports (for some), and private services that are often prohibitively expensive for people with moderate incomes.

The history of America’s missed opportunities begins in the early 20th century. Between 1915 and 1919, Progressive reformers campaigned in the major industrial states for publicly financed health insurance plans that included compulsory maternity benefits and sickness pay.

Indeed, their proposals were intended as much to cover the cost of lost wages during illness as they were to pay for medical bills. No private health insurance business existed at that time, but insurers nonetheless didn’t want government intruding in their industry (and the proposals did include a funeral benefit that threatened part of their life insurance business). Business groups objected to sick pay on the ground that it would encourage malingering, and although the American Medical Association initially favored the proposals, it turned sharply against them as the legislation came up in the states and physicians worried about government regulating their incomes. By the 1930s, New Deal reformers left out health insurance and sick pay from the Social Security Act for fear of arousing the insurers, employers, and physicians and endangering the entire legislation.

Other attempts to expand federal supports for children and families proved short-lived. The 1921 Shep-

pard Towner Act directed federal funds to state governments for programs intended to help combat the country’s comparatively high rates of infant and maternal mortality. Although opposed by the AMA and conservative groups who decried the bill as Bolshevism, the act squeezed through the legislative gauntlet because members of Congress feared newly enfranchised female voters would throw them out of office if they voted against it. By the late 1920s, however, politicians decided they had more to fear from an enraged AMA than female voters, and they repealed the law. In the 1930s, the FDR administration used federal funds for nursery schools that could create employment for teachers, nurses, janitors, and others thrown out of work during the Great Depression. The 1940 Lanham Act then spent the equivalent today of $1 billion to support these and other child care programs that helped women work in support of the wartime economy. Yet, the centers were quickly shut down as men returned from the war and women were expected to retreat back to the domestic sphere.

Another opening came at the start of the 1970s, spurred by rising rates of employment among women with young children and growing attention to early child development. The 1971 Child Development Act (CDA) sought to create a network of federally funded child care centers that would be free to parents with low incomes but available to others on a sliding fee scale. Sponsored by two Democrats, Rep. John Brademas and Sen. Walter Mondale, the bill began with wide bipartisan support as many in Congress agreed that working women needed help and that children would benefit from enriching early-education programs. Yet, as the bill wended its way through the

Advocates for reform often have been outmatched by wellfunded antagonists, such as business groups and other private interests. legislative process, it became caught up in racially inflected struggles over who would run the centers. By the time the bill passed both chambers of Congress, many Republican backers reversed course and voted against it.

Waning Republican suppor t enabled President Richard Nixon to veto the bill. He did so with a vitriolic message, authored by White House staffer Pat Buchanan, which claimed the law “would commit the vast moral authority of the National Government to the side of communal approaches to child-rearing over the family-centered approach.” The veto message’s sharp rhetoric reflected Nixon’s sympathy with right-wing critics who claimed the bill was socialistic overreach. Nixon’s and future administrations would, however, support means-tested funds for programs aimed at those on public assistance, as well as tax breaks for families’ child care costs. The day after Nixon vetoed the CDA, in fact, he signed a bill expanding middleclass access to child care tax breaks.

But the United States has never again come so close to enacting a universal

federal child care initiative.

Such reforms have been off the table largely as a result of a conservative mobilization that took shape in the 1970s combining free-market opposition to expanded public programs with social conservatives’ antipathy toward policies that encourage mothers’ employment.

These forces helped obstruct campaigns for federally mandated paid parental leave, which Phyllis Schlafly famously derided as a “windfall for yuppies” that was of little use for traditional families. Business opposition to paid leave was particularly fierce, especially given expectations that employers should not only allow their employees relief from work but also help pay for those days off.

After a decade-long effort, a broad coalition of advocates finally got the Family and Medical Leave Act through Congress in 1993; Bill Clinton signed it only two weeks after taking office. The legislation was a compromise measure, however, that guarantees up to 12 weeks of unpaid leave and, due to various limitations, covers only 60 percent of workers.

Cathy Belair, grandmother of two young children, Fletcher, NC

I am a teacher and my husband works early shifts, so the first challenge was to find a place that would take the kids at 7:30 in the morning.

When we did find centers that had the hours, the programs were not as robust as I would want. There was nothing affordable that had the hours and the capacity to teach to the depth that we wanted. It’s unaffordable for most people, and we were just lucky that we had some savings to dip into.

Even once we found the place that we wanted, we had to get on a wait list. I put the first child in at six months old, and I barely made it. And this was for when she turned three. If I hadn’t heard about it at the right time, there’s no way I could have gotten into that program. The second child, even before she was born, I had her on that list.

We basically paid oodles and oodles of money to put them in a good place that had the right hours.

We were sacrificing our retirement so that they could have a good early education, because as a teacher, I know how important the first few years are.

—Blaise Malley

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

For instance, those who have worked for less than a year or are employed in establishments with fewer than 50 employees are ineligible for the leave the law is supposed to guarantee. Decades of painstaking advocacy work since 1993 have thus far managed to get paid leave on the books in eight states and the District of Columbia, as well as a new measure giving federal employees paid leave rights as of October 2020.

Democrats and Republicans in Congress also have sponsored recent paid leave measures: Rep. Rosa DeLauro and Sen. Kirsten Gillibrand, both Democrats, have sponsored the FAMILY Act, which would use a new pay-

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roll tax to pay workers 66 percent of wages during their 12 weeks of family and medical leave, while Republican Sens. Marco Rubio and Mitt Romney have advocated a voluntary system allowing employees to draw on future Social Security benefits to pay for family and medical leave.

The financing of long-term services

and supports—care for older adults and people with disabilities—has come chief ly from two sources: Medicaid and private long-term care insurance. Both are limited, especially from the standpoint of middle-class Americans. Since Medicaid covers only individuals in poverty,

people have to spend down nearly all of their personal resources before they can gain access to it. Private long-term care insurance is expensive, and the market suffers from “adverse selection”: The main people willing to buy coverage tend to have health problems and anticipate needing to use the policy. Not only does the high cost deter the healthy from buying a policy; the higher that cost rises over time, the fewer healthy people buy it, until the insurer abandons the market altogether, the result of a relentless “death spiral.”

Social insurance alone can create a large enough pool of participants to share the risks and costs of long-term

AP PHOTO

Richard Nixon vetoed a national child care system in 1971, condemning “communal approaches to child-rearing.”

care. In recognition of that reality, some countries have added longterm care to their systems of social insurance, but such efforts have been stymied in the United States. During the 1980s, Sen. Claude Pepper led one such effort, only to see it fail for lack of public support for the necessary taxes. Policymakers have instead sought to subsidize private long-term care insurance policies, but subsidies for voluntary purchases of coverage do not overcome adverse selection, as illustrated by the experience of the CLASS Act. Enacted as part of the Affordable Care Act in 2010, the CLASS Act sought to create a long-term care insurance program that beneficiaries could use to help cover institutional and home-based care and support.

Yet the benefit was to be purely voluntary and financed entirely by beneficiary premiums, with no federal subsidies to support it. Soon after the bill was passed, however, the Obama administration concluded that the program was unsustainable, and in 2011 it was repealed.

This history of non-reform has left

a void in family care that has been filled by an array of partial solutions marked by unequal access.

Employer-provided paid sick leave is a clear case in point. As of 2019, only 51 percent of workers in the lowest-paid 25 percent have paid sick leave, compared to 92 percent of those whose earnings put them in the top 25 percent. Thirteen states plus the District of Columbia also now require that employers provide paid sick leave, but the specific mandates vary considerably.

The situation with parental leave is far worse. Access to paid parental leave in 2019 was limited to a mere 9 percent of those in the lowest 25 percent of wages, compared to 30 percent in the top 25 percent. In the past

year, Congress enacted a temporary measure that has allowed people in firms with fewer than 500 employees up to two weeks of paid sick leave (or ten more weeks paid at two-thirds pay). To qualify, workers must have reasons related to the pandemic, such as the closure of schools or child care centers. This mandate, however, is set to expire at the end of 2020.

Child care takes a big bite out of the annual income of parents with small children, and it is especially tough on moderate-income families.

Taking into account tax breaks and other subsidies, middle-income and low-income two-earner and singleparent families in 2018 had to pay 30 percent of their earnings to keep two children in full-time centers, compared to an average of 17 percent for two-earner middle-income families and 11 percent for low-income single-parent households in 35 member countries of the Organisation for Economic Co-operation and Development.

Why do Americans appear to tolerate this situation? In fact, publicopinion surveys show that majorities favor expanded federal spending on child care, mandated family leave, and long-term care. But public sen-

timent has not easily translated into political change. Not only do the proposals face the usual conservative and business opposition; the current patchwork of provisions fragments constituencies for reform. Many people find a way to muddle through during times of need, and Americans with higher incomes (and thus likely more political power) tend also to have employer-provided benefits and the means to pay for care services.

The pandemic may create an opening for change, as many people have become aware of how much our economy depends on the provision of child care and how little we have done to protect seniors in nursing homes. The pandemic has also made clear that paid sick leave serves the interest of the whole community by enabling workers who are ill to stay home. We have had enough missed chances in the past to address the needs for family care. The lessons of the pandemic give us another opportunity, and we ought to seize it. n Kimberly J. Morgan is a professor of political science and international affairs at George Washington University, where she directs the European and Eurasian studies program.

Public-opinion surveys show that majorities favor family care.

But public sentiment has not easily translated into political change.

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

Running on Empty

Small-business owners providing child care struggled to survive with low pay and long hours before the pandemic. Now they’re verging on collapse.

By Bryce Covert Ask nearly anyone who runs a child

care service why they decided to open their business, and the word you’ll almost certainly hear is “passion.”

The word you won’t hear is “money.”

Despite the fact that parents spend on average nearly $12,000 a year to put an infant in a day care center, the average child care provider makes less than $24,000 a year. Even the top earners in the industry make less than $33,000.

How can it be that child care is expensive for parents, but not lucrative for providers? One reason is that business owners cannot create efficiencies of scale to rack up profits. The costs are more or less fixed: rent and utilities to maintain a physical space, compensation for enough staff to give individualized care to children and meet state-mandated adult-to-child ratios in facilities, plus all the toys and food that children require. There are no corners to cut.

But parents can only be squeezed for so much, and the United States devotes a smaller share of our GDP

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to early childhood than all developed countries except Ireland and Turkey.

As a result, America has entrusted a critical cog of our economic engine, which allows parents to work and young children to thrive, to a throng of dedicated small-businesspeople, disproportionately Black, Latino, Asian, and female, engaged in an arduous labor of love.

The drive to be a caregiver was

ingrained in Donna Mason early.

She’s the second-oldest child of six children born to teenage parents, and her oldest and youngest siblings both have special needs. “I probably was nurtured to be a caregiver,” she said. She started early, running a thriving babysitting business in her neighborhood as a teenager, but she never intended to go into earlychildhood education as a career. In college, Mason enrolled in premed.

But then as a young single mother, she started pricing out child care and realized that she couldn’t afford it. So she got a job at a center, allowing her to enroll her son for free. This experience is common: Half of the child care providers in the country are mothers themselves. Mason eventually became the director of a center, and then an administrator of the St. Albans Early Childhood Center, a large organization in Washington, D.C., that runs three different day care sites for 225 kids. “I made lemonade. I made it work,” she said.

BriTanya Bays of Stamford, Texas, also felt innately drawn to care work after working at a child care center straight out of high school. Armed with a degree in child communication disorders, she started crafting a business plan to open a child care center of her own, “in response to a lack of high-quality, affordable child care in Texas,” she said. Across the country, there are far more infants and toddlers in each state than the

available number of licensed child care spots, and half of American families live in a place where they can’t get care at all. Those who can find a spot, meanwhile, often aren’t guaranteed high quality; in 2006, fewer than 10 percent of day care centers provided high-quality care, according to the National Institutes of Health.

Bays was working as the director of an existing center while pregnant with twins and realized she couldn’t even afford to enroll her own children part time, so she started her own in-home program. “The work is hard,” she said, with long hours to go along with the low pay. But “to provide daily care for children who are not your own is virtuous.”

Sylvia Hernandez fell into the industry by accident. Her mother ran a day care in California, and when she got injured, she asked Hernandez to take over while she recovered.

Hernandez agreed, “not knowing I was going to be doing this for the rest of my life.” She stayed, like many in this line of work, because she wanted to improve children’s lives. Hernandez told me about caring for children who grew up, graduated college, and came back to thank her. “It’s very rewarding, because you are making a better person.”

Her in-home center in the San Fernando Valley offers care around the clock, accommodating parents who work odd or long hours. This comes at a personal sacrifice. She only sleeps about two or three hours a night. “I don’t get to rest until the last child leaves,” she said. And then she gets up again, to greet the one who arrives at 4 a.m. “By 7 [a.m.], I already have 10 to 12 kids,” she said.

She takes a one-hour nap at the same time the kids do.

But she feels called to serve her parents. “We are practically the only person they can count on. I don’t

Child care facilities are schools in miniature, with directors serving as teachers, principals, school administrators, and business owners all at once. want them to not go to work because of me,” she said. “So I have extended my hours.”

Makisha Binns decided to open up a licensed in-home day care in Belleville, Illinois, when her daughter, who is now eight, was one year old.

Binns has always had a passion for teaching, and for years she worked in a number of school positions: teaching assistant, teacher’s aide, afterschool program instructor, preschool teacher. But she sustained an injury while in a violent domestic relationship so severe that she was told she would never walk again, let alone work in a school. Child care was a way for her to keep her love of teaching going while still being able to rest and be comfortable in her own home.

Binns takes pride in what she does, interacting with her kids on an individual level. Nap time started while we were speaking, and each child came to give her a hug before they lay down. “It makes me so excited to know I can make a difference in a child,” she said. “The first three to five years in a child’s life [are] the most important. So if I can set the foundation for those children, it’s the beginning of their life, the rest of their life.” Starting to tear up, she

told me, “That’s what motivates me.”

Practically all of the providers I talked to called out the stereotypes people have about working in day care, that they do nothing but sit kids in front of a TV and wipe their bottoms. They described instead how they each create detailed curricula and schedules full of activities, designed to keep children intellectually and socially stimulated during some of the most formative years of their lives. These are schools in miniature, with directors serving as teachers, principals, school administrators, and business owners all at once.

About half of these child care businesses are minority-owned, and an incredible 93 percent of the workforce is female, according to Labor Department data. And child care providers share something else in common: The finances are tenuous, because parents can only be asked to pay so much.

“The work put into a quality child

care program is definitely not supported by the market—how much we’re getting paid, how much it costs to operate it,” Bays said. “The child care providers are taking a

loss, the parents are taking a loss, and it’s not benefitting the child in any way.”

With a laugh, Bays noted that her “big dreams” of running a small business quickly met the cold, hard facts of the industry. The salary she pays herself boils down to $5 an hour, and if she operates below capacity, even that meager salary puts the business at a loss. She makes even less from the families she serves who get government subsidies to pay for care, which pay her less than $2 an hour per child. And yet she knows how much it costs parents. Many families who don’t qualify for subsidies can’t afford to send their children to her day care.

“What am I supposed to do? Do I take the loss?” she asked.

It’s a tough equation. Families spend, on average, nearly 10 percent of their incomes on child care, 40 percent higher than what the government considers affordable. They’re spending more to send an infant to a child care center than what they spend on food, transportation, or health care, and in many parts of the country it’s even more than housing.

To afford care, most families have to cut back on other necessities.

Binns charges families $38 a day, but her monthly expenses come to $3,000 and she’s only making a small profit. First the rent gets paid, and then she tries to cover other bills by the 15th. She gets $500 a month through an Illinois state food program, but that doesn’t always cover her needs. She only just started paying herself $10 an hour in May. “I can’t even remember the last time I bought myself something,” she said.

As a single mother, she’s struggled to get her three kids what they want and need. Her oldest wants a car, but she just doesn’t have the money.

Hernandez doesn’t get paid extra for staying open for 24 hours; the

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS state doesn’t offer extra overtime or overnight subsidies. When all is said and done, Hernandez makes less than $7 an hour. California hasn’t raised its subsidy reimbursement rates in years, she said. But she still has to cover bills for the business like rent, power, and water, which keep climbing. “I would be doing a different type of business if I wanted to be seeing my income really high,” she said.

The Angels Learning Center in Minnesota charges parents who don’t get subsidies $322 a week for an infant and $272 a week for a toddler. Most families there receive government subsidies. The money is just about enough for Gigi Vaye, the assistant director, to cover rent and salaries. “You don’t get in this business for profit,” she said. “You’re in this business to help people, to change lives.”

Mason’s school is financially stable, and she typically has three to six months in reserves. The staff of 70 enjoys good compensation, health insurance, and a 401(k) plan. But the tuition isn’t cheap: She charges $2,075 a month for babies and $1,925 a month for kids ages two to three and a half.

But even for St. Albans, the profit margins are slim. “I can’t charge you what it really costs,” Mason noted.

Yet child care providers receive next to no direct investment from the government, earning only modest subsidies for lower-income children. Mason lays out the reality: “If you want us to charge a fair price, to have quality staff, to maintain our facilities, to implement an enriched curriculum, then we need funding.

That’s the bottom line.”

The business of child care barely

worked, then, before COVID-19 ever existed. The pandemic all but shattered an already fragile model.

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Unemployed parents could no longer afford child care; those working from home or fearful of sending their children into a potential outbreak pulled back. The changing schedules and work patterns played havoc with an industry that must adapt to its customer base. Eightysix percent of child care providers say they are now serving fewer children than before the pandemic; enrollment is down 67 percent on average. That’s a staggering loss of revenue for businesses that typically operate with no cash reserves and barely in the black.

Bays shut down when the pandemic hit, and her husband also lost his job as a school custodian. No children other than her own have since returned. “We’ve run through all our savings paying for the last six months of not having kids in here,” she said.

Vaye’s center has licensed capacity for 92 children, but they’re at 25— an increase from where they were at

the start of the pandemic. The loss in families equals a loss in income so steep that she hasn’t been able to bring most of her staff back yet.

She’s been trying to enroll more children, but it’s tough. One family did a tour after their current center had a COVID outbreak, but they just decided to keep their child home. “We’re trying to stay above water,” she said.

“It’s a day-by-day process.”

Even worse than the financial stress has been the logistical stress, as child care providers became essential workplaces. Most providers have had to buy extra supplies to ensure safety on their own, and about 14 percent haven’t been able to get what they need. In addition to cleaning supplies and personal protective equipment like masks and shields, many facilities need more toys and furniture to ensure that each child can be socially distanced with whatever materials they use. Some rooms have needed to be reconfigured to

Catherine Lieberman, child care provider, Fletcher, NC Even before COVID-19, maintaining a child care center is a challenge.

There becomes a threshold where there’s no more that parents can pay.

So, you can’t raise the tuition any more, but you have to raise it enough to have a highly educated teacher who you can give an appropriate wage, and still keep the lights on, and keep the water flowing, and make sure the building looks appropriate and the driveway isn’t falling apart, and you have equipment and supplies.

Early education is often walk-

ing a tightrope between running a business and doing what we know is appropriate for care for young children. When the pandemic hit, we chose to stay open, but we had to make some very tough financial decisions, including taking me off the payroll. I have not taken a paycheck since March 16.

The challenges for early care were there already, and the pandemic just put a spotlight on it. I am hopeful that the pandemic will help people understand how important child care is.

—Blaise Malley

account for distancing. Overall, the cost of providing child care with lower enrollment has increased 47 percent for centers to meet all of the new health and safety requirements. For home-based providers, it’s increased 70 percent. Few providers have extra money to cover those kinds of costs.

Binns is spending an additional $200 a month, and the costs of basic goods are rising. “Everything’s so high now, it’s cutting from your profit,” she said. She’s been searching high and low for Clorox wipes or Lysol disinfecting spray—she even woke up early on a Saturday to try at Walmart, to no avail. She finally found two cans, but they were $45.

“I can’t even afford that,” she said.

She’s asked parents to bring supplies if they can.

Binns and I spoke on the third of the month, and she hadn’t yet paid her rent or any of her bills. In May, a quarter of providers said they were behind on their rent or mortgage payments. Half had delayed paying other bills.

Even at a school with the size and revenue of St. Albans, where Mason works, things have been tough. The school experienced two major moves and a renovation in the last four years that ate into her reserves. During COVID, the school closed from March 12 until June 29. What got Mason through was a $427,000 Paycheck Protection Program loan, made possible by the CARES Act passed by Congress in March. Coupled with a month’s rent deferral from her landlord, that allowed her to make payroll for two months and keep things relatively stable. She was lucky: Overall, the industry received just $2.3 billion in PPP funding out of a total $659 billion pot.

But Mason has applied for a handful of other loans and gotten no other assistance. She’s now spending

$5,000 to $6,000 a month on PPE. She estimates she lost $150,000 in revenue in April and $300,000 a month in May and June. Even though she’s open now, she still lost $100,000 in July and another $75,000 in August.

“I’m bringing in just enough to pay the bills, nothing more,” she said.

“But I’m OK with that, because I’m still providing a service and I’m still able to stay in business.” She just has to cross her fingers that no major catastrophe hits when she has nothing in savings. “We’re in survival mode,” she said.

Hernandez is one of the unlucky ones who couldn’t get a PPP loan, nor an Economic Injury Disaster Loan available through the Small Business Administration. “I really was very hopeful I was going to get the PPP loan, because … I didn’t want to lose my staff,” she said. Instead, she’s had to dip into her savings to make payroll. She’s cut back on her own expenses, only preserving her Starbucks coffee run to stay awake.

“I’m very scared,” Hernandez said.

“If I run out of the funding for me and my staff, or funding for getting the supplies … we would have to close our doors.” She began to cry. “It’s hard.

It’s frustrating. I get emotional.”

Congress included $3.5 billion in

extra funding for the Child Care and Development Block Grant in the CARES Act. But it’s a small drop in a vast sea of need. In April, the National Women’s Law Center and CLASP estimated that it was costing $9.6 billion above what the federal government already offers for child care providers to stay solvent each month.

Sens. Elizabeth Warren and Tina Smith proposed a $50 billion child care bailout. Republicans incorporated substantially less than that in child care grants in their proposals.

But a deal for any relief legislation

has been stalled since April. No other federal money has materialized.

A few weeks before we spoke, Binns had been excited about a new grant to help child care providers, attending a webinar to make sure she got everything right. It was only the day the grant was released that she found out that she was ineligible because she only has capacity for eight children, and the grant is for those with ten or more.

“There’s so much on our plates now, and we’re not getting assistance,” she said. “It’s been a struggle.

Sometimes I want to give up, but I know I can’t, because this is the only source of income I have.”

Without more help, an estimated 4.5 million child care slots could disappear, cutting the country’s capacity in half. A July survey found that about 40 percent of providers are certain they’ll shut their doors permanently without financial assistance.

Only 18 percent of programs expect they will survive longer than a year.

The paradox is that child care is desperately needed as a bizarre school year begins. The Brookings Institution estimates that there are 41 million working parents with children under the age of 18. Those without in-person school need child care to return to work. Child care providers are more critical to the functioning of the economy than ever. Yet they feel invisible, ignored by a political system that has taken them for granted for decades.

“Everybody talks about nurses or doctors, our local fireman and policeman,” Hernandez said. “All this work we’ve done, sometimes I feel like nobody recognizes it.” n Bryce Covert is an independent journalist writing about the economy. She is a contributing op-ed writer at The New York Times and a contributing writer at The Nation.

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

Care Workers Organizing for Dignity

Faced with low wages and uncertain financial futures, workers are raising their voices.

By Marcia Brown Rosa Carreño, a child care provider

in San Jose, California, for 19 years, begins her day before 4 a.m. Her entire home is dedicated to the early learning she provides for her young charges, who arrive as early as 6 a.m. The school-age children are in her care before and after school; in between, she cares for and educates at least one infant and several toddlers, feeding them three homecooked meals and two snacks every day. The last children are picked up around 6 p.m., and Carreño cleans and prepares her home for the next day’s rush.

As the coronavirus took hold, schools closed and many have not reopened this fall. But many parents of young children cannot work from home. So they have left their children with Carreño, and thousands of other child care providers across

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the country. Now, Carreño must hope that her home’s Wi-Fi can handle ten or more users, and that she and her husband—her assistant—can guide children through the distance-learning sessions, in addition to attending to their younger-age kids.

This is the new normal: unionized schoolteachers conducting lessons online from home, and mostly nonunion child care workers supervising groups of young learners who can’t stay at home. Each student may have a different schedule, a different lesson plan, and varying levels of computer competence. Each student must also follow strict handwashing protocols, keep six feet apart, and wear a mask; Carreño must supply most of the protective equipment herself. Keeping the mask on toddlers and even school-age children, Carreño says, is an all-encompassing task. She’s not just conducting what amounts to in-person schooling in one classroom, but in several, all at once.

It’s difficult for Carreño and providers like her. “I’ll be very honest, it’s hard for me, but I have to give it a big old smile so my kids think everything is OK, even though I hate it,” said Ayde Jaime about managing her home child care business in Kern County, California, during the pandemic.

Child care providers, similar to other caregiving workers, toil in one of the fastest-growing and lowest-paid professions in the economy. Nearly all child care workers are women, and roughly half of them are Black, Latino, or Asian. Many are undocumented. Few workers have benefits and, according to the National Women’s Law Center (NWLC), “close to half of child care workers live in families assisted by one or more public support programs.”

Paradoxically, despite workers earning barely enough to make ends

meet, early-childhood education is often too costly for parents. This leads to many women, unfairly burdened with caregiving responsibilities, opting to leave their jobs to raise their children, adversely affecting their long-term earning potential.

Some women also choose to become early-childhood educators, joining a center or turning their own homes into early-learning environments.

But those who do struggle to support their own families. Child care providers made a median wage of

just $11.65 an hour in 2019, a number that has hardly budged in years.

While there’s a lot of demand for child care, there’s little government support for the workers and children for whom they care. The coronavirus has exposed and exacerbated the problem, but workers are seeking real change through organizing.

In California, child care providers

recently pulled off a major organizing victory. Roughly 43,000 home-

based child care workers, most of them women of color, won acceptance of a new union called California Child Care Providers United. A whopping 97 percent voted to join the union, for workers who care for children from poor and workingclass families that get state subsidies for child care. They will now bargain directly with the state over pay and work conditions.

The victory, making California the 12th and largest state to enable

child care workers to organize, was the culmination of a 17-year effort.

Family care and other domestic workers were excluded from collective bargaining in the National Labor Relations Act—largely because the workers were and are disproportionately Black women. But states have the ability to grant those rights. In 2003, workers demanded that California pass legislation authorizing a union, but Republican Arnold Schwarzenegger’s victory dashed those hopes.

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS Legislation finally advanced last fall, and organizers kicked into campaign mode. Before the pandemic, providers went door to door, asking each other for support. Afterward, they had to get more creative, with calling, emailing, texting, and Facebook groups. Valeska SanchezReyes, who worked in Kern County, where many providers are close to the farmworkers’ union victory of the 1960s, started in 2014 with just a few dozen providers, and ended the county’s campaign with between 400 and 500 providers in the union.

Jono Shaffer, an organizer with SEIU, one of two unions that backed the campaign in California (along with AFSCME), said that “captains” were responsible for staying in touch with lists of providers and helping them cast ballots. Some captains hand-delivered the ballots. Another provider, a Somali immigrant in San Diego, operated a table with a ballot box every day in the main Somali market to reach her community, and collected over 200 ballots.

Both Carreño and Jaime worked on the campaign, helping to organize a dispersed workforce with no traditional “watercooler” or gathering place. Jaime told the Prospect that when SEIU organizer Valeska Sanchez-Reyes first approached her about organizing providers she was dubious, but willing to give it a chance. Now, with a union victory under her belt, she has become a trusted resource for other providers—ensuring that they always have children in their care, helping them apply for loans during the pandemic, and advising on other best practices.

Zoila Toma, a provider from Signal Hill, California, said that the pandemic’s exposure of a broken system helped motivate providers in the last months before the vote. “I think all the providers were kind of feeling more empowered to do it.”

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Paradoxically, despite workers earning barely enough to make ends meet, early-childhood education is often too costly for parents.

There have been other campaigns,

too. In 2015, child care providers in Cincinnati joined forces with city organizers and pushed for a universal pre-K initiative to deliver more services to targeted communities, as well as bolster the fortunes of family care businesses and their workers.

Called the AMOS project, it began as “a more corporate-led initiative that wasn’t thinking about racial equity and building power” in one of the nation’s most residentially segregated cities, said Prentiss Haney, co-executive director of Ohio Organizing Collaborative. At the time, Haney was an organizer with the Ohio Student Association, and he helped assemble a community-based team of local providers and organizers to work on the initiative. The group coordinated grassroots Black and white evangelical support for the new tax to fund universal pre-K, and coupled the work with registering 40,000 people to vote.

“It changed the conversation around preschool in the state,” Haney said, adding that they pushed through a sister initiative in Dayton, Ohio.

While there is still plenty of work to be done, he acknowledged, the organizing helped to create an avenue for workers to push for higher wages.

Wendoly Mar te, director of economic justice for Community Change Action, which coordinates and guides local organizing in lowincome communities, said that her group began to work on child care and early-childhood education issues more than six years ago. They wanted to look at the broader care economy, and within that, to focus on a national campaign that would lift up lowincome people of color and women.

In doing that, they partnered with advocates around the country: OLÉ in New Mexico, Parent Voices Oakland, and SPACES in Action in Washington, D.C. “It’s a space that had been very much driven by a broader advocacy community that was very middle- and upper-class,” Marte said. That advocacy focused primarily on parents rather than on workers. As a result, efforts often focused on professionalization and credentialing, rather than raising wages for workers who have been historically undervalued.

Despite early-childhood education being a kitchen-table issue that impacts families nationwide, it’s tackled individually, with no standard pay or workplace protections for workers.

“We need a public kind of response to this public crisis,” Marte said.

Community Change first started with 15 partner groups in 13 states, assessing whether to attack the issue through local revenue fights, state subsidies, federal legislation, or something else entirely. The AMOS fight was one of their victories. The effort in Oakland in 2018 won major investments in child care subsidies.

In New Mexico, OLÉ helped secure hazard pay for child care workers during the pandemic, setting a precedent.

SPACES in Action rallied in July after learning that D.C. Mayor Muriel Bowser was planning to cut $5 million from the child care subsidy program. They were able to reverse the cuts, while also adding $5 million for emergency funding for child development centers and $1.4 million to help with new costs for protection from COVID-19. Advocates argue that providers represent essential building blocks to economic growth.

“Child care providers work so that other people can work, and that’s not recognized,” said LaDon Love, executive director of SPACES in Action.

But pandemic-related revenue shortfalls have paralyzed cities’ and states’ willingness to meaningfully improve conditions for care workers.

Funding streams for care providers

have always been inadequate. In one analysis by the Center for the Study of Child Care Employment at Berkeley, at a 40-child center where parents pay an average of $10,000 per year, just 65 percent of the budget goes to personnel, stretched over the salaries of ten people. This is an intrinsic challenge of the work. One provider can only safely care for four infants, and for slightly older children, the ratios are still extremely low—making the cost of safe, quality early education expensive by its very nature.

Current federal subsidies also don’t fund enough children. There

are more than 13 million children eligible to receive child care subsidies, but just 1 in 6 got a subsidy in 2013 (the latest year for which data are available), according to the NWLC. Those subsidies directly affect how much providers are paid, either in a center or an in-home operation.

This crisis extends to in-home elder care as well, where workers are similarly underpaid and marginalized. Hundreds of thousands of these home care workers, paid through patients’ Medicaid coverage, lost the ability to have unions deduct their dues from Medicaidfunded wages in 2019, thanks to a rule from President Trump’s Centers for Medicare and Medicaid Services.

States like Michigan have also instituted this prohibition, so even if a future president reverses the rule, some home elder care workers will be blocked from unionization.

Critically, this is not a full portrait of the care workforce. Thousands of workers also provide informal care in their homes and to family and friends—

There are more than 13 million children eligible to receive child care subsidies, but just 1 in 6 got a subsidy in 2013.*

Leigha Rosario, earlychildhood educator, Baltimore, MD

Leigha Rosario understands the importance of quality child care.

“When I was younger, I did not attend child care and I found myself shying away. I was very quiet and reserved because I was not as advanced as some of the kids in my grade. I had to go to speech [therapy] and stuff because my language was not as advanced as other children were.”

Now, she works as a teacher for two-year-olds in the Weinberg Early Childhood Center, a center managed by Downtown Baltimore Child Care. Rosario notices that she has trouble connecting with many of the parents who are preoccupied with other issues and who do not appreciate the value of early care.

Since the pandemic, Leigha’s class of nine kids has been reduced to three, and overall enrollment at the center has been reduced by a third to a half. On the other hand, parents are more aware of the difficulties of caring for children and more curious about how they should do so.

In the aftermath of the pandemic, Rosario says it may become more clear that “everyone would benefit from the government providing child care.”

—Blaise Malley

*the last year data are available.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 21

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS known as family, friend, and neighbor care (FFN). Few state or local governments offer any sort of compensation for this work. A 2013 Economic Policy Institute paper concluded that median wages for these workers, worked out in private transactions with parents or guardians, is just $7.53 an hour.

For an industry on shaky ground before the virus hit, the aftermath has been horrific. “Instead of child care deserts, we have fossils now,” says Gladys Jones, a prov ider and organizer in New York City.

“There’s people closing every day.”

Since February, 1 in 5 child care jobs have been lost. Meanwhile, undocumented workers—centeror home-based—face even more difficult hurdles during the pandemic, because their status makes them ineligible for unemployment insurance, PPP loans, or other statebased aid. Immigrants without an Individual Taxpayer Identification Number—the tax ID for nonresidents and their families—as well as those who lived in a family without an ITIN were also barred from stimulus money.

Karina, an undocumented provider in New Mexico, said that she is the only early-childhood educator in the center where she works who is willing to speak up about working conditions. She worries that if she uses her full name to advocate, her job will be in jeopardy, she told the Prospect through a translator. Other providers at the same center, she said, agree with her but fear speaking out. Karina said one provider left in protest of the low wages after asking for a raise. But for Karina, leaving is not an option. She needs the job, despite the low wages.

The center, Karina says, is struggling to give children of varied ages the instruction they would receive in a classroom. But low-income parents who must continue to work outside the home, she said, have no other

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options. (That includes Karina’s own children, who accompany her to the center because their school is closed.)

Karina said she feels inspired by hearing other providers speak up.

“It’s frustrating and scary, but you have to do it,” she said of demanding fair wages and benefits.

Jones expressed frustration that during the pandemic, unionized teachers are working 8 a.m. to 2 p.m. from home and early-childhood educators are working with children from 7 a.m. to 6 p.m. with a lot less money. “That’s the type of injustices,” she continued, and it’s disproportionately Black, Latino, and Asian women providers, but disproportionately white teachers. Politicians, especially the men, she said, don’t think or talk about child care, despite calling broadly for public-school support during the pandemic.

Child care workers, early educators, and in-home support for the elderly perform work that cannot be outsourced or automated. When essential workers go to their jobs— as grocery clerks, bus operators, nurses—they can’t leave anyone behind who cannot fend for themselves. The workforce necessary to care for people is growing. Organizing can give this work the value it deserves, and ensure these workers are treated with dignity and respect. Workers across the country are demanding that the next administration invest in the care economy, and by association, invest in the children and elderly individuals for whom they care.

“Before I die, I would like to see this industry be recognized and respected as a business,” Jones said.

“What should happen is that our industry should be like electricity, a utility, that society has evolved, and we cannot do without electricity or light and so that’s the same way child care should be looked at.” n

The Aging of Migrant Domestic Workers

Too poor to retire, elderly care workers often find themselves caring for elderly patients.

By Rhacel Salazar Parreñas Letty, an elderly Filipina, lives with

two of her children in a three-bedroom bungalow in a working-class neighborhood of Los Angeles. She first moved to the United States in 1985, entering as a tourist after she was unexpectedly widowed in her late forties and left with the responsibility of having to support five of her seven children through school.

Letty initially settled in New York City, where she worked as a live-in nanny for a wealthy family on the Upper East Side. After a few years, two of her children relocated to the United States. They entered legally as professional migrants with H-1B visas sponsored by a small accounting firm in Los Angeles. Letty soon followed them to California. She became an American citizen through the sponsorship of her son.

Whether she is caring for chil-

dren or the elderly, Letty has continuously worked as a domestic worker for more than 30 years in the United States. I first met Letty in 1995, when I interviewed her for my dissertation research on domestic workers that later became the book Servants of Globalization. When I touched base with her after more than 20 years, Letty still worked as a domestic worker. At the age of 78, she helped care for a 96-year-old woman as a “reliever” during the weekends.

About a decade earlier, after one of her patients—weak from dialysis— fell on her and fractured Letty’s femur, she transitioned to weekendonly work. She said she could manage the work because her patient didn’t require ambulatory care.

Letty did not receive any sort of disability compensation for her workplace injury. This is not unusual. In fact, Letty has never received any sort of employment or state benefits for her labor, including unemployment, medical insurance, or a pension. This is despite the fact that she is a citizen, and the fact that the U.S. government

requires employers who pay household workers at least $1,900 in annual cash wages to deduct Social Security and Medicare taxes.

The informal nature of her employment has clearly worked against her.

One employer even deterred her from accruing sufficient credit to later qualify for Social Security benefits by discouraging her from paying taxes. Not having done so is Letty’s biggest regret: “I should have gone home with my pension now … I was already paying my income tax for two years, and then Mona [her employer] said, ‘Letty, don’t pay [those] taxes, because you’ll pay more than what you get.’ That’s what she told me. So that is why I stopped paying.”

Letty would like to return to the Philippines “for good,” but with neither savings nor a pension she depends on approximately $700 per month of Supplemental Security Income (SSI), a retirement benefit for Americans with limited resources.

Letty subsidizes this with her twoday earnings of $250 each weekend as a part-time elderly caregiver.

While receiving a monthly SSI payment allows Letty to partially retire, it makes the option of retirement in the Philippines elusive. This is because SSI recipients cannot leave the United States for more than 30 days without risking forfeiture of their stipend. Also preventing Letty from retiring is the continued financial dependence of her family in the Philippines—four adult children, three of whom are single parents, as well as grandchildren.

Letty lives a modest life in Los Angeles, living rent-free with her son and relying on the assistance of her three children in the United States.

Still, she is unable to retire, which undermines the common assumption that migrants, even if earning low or sometimes below-poverty wages, will eventually accumulate enough savings to allow them to retire in their home country. Without question, many do. Yet, Letty’s situation suggests that not all are able to do so. Economist Teresa Ghilarducci likewise found that most Mexican migrants in the United States do not

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 23

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS have sufficient funds for retirement even though the majority receive some Social Security benefits.

Letty’s story is emblematic of the emergence of an international division of elder care—a chain in which elderly are paid to care for other elderly. The challenge of retirement for migrant domestic workers such as Letty suggests our need to pay attention to the rise of older migrant caregivers, and the challenge of retirement for domestic workers generally.

A Global Overview of Migrant Domestic Workers

A large number of the world’s migrant workers—an estimated 11.5 million— are domestic workers. According to the International Labour Organization, domestic workers comprise some of the most vulnerable workers in the world. They are said to constitute 24 percent of the 16 million estimated victims of labor trafficking worldwide. This suggests that approximately one-third of migrant domestic workers are victims of human trafficking. The United States is no exception. The Polaris Project found that 23 percent of approximately 8,000 labor trafficking cases between 2007 and 2017 in the United States involved domestic workers.

Labor trafficking, by definition, refers to the transportation of a person under some cloak of duplicity for the purpose of their exploitation.

An example would be a domestic worker recruited from the Philippines to work in Lebanon for a salary of $400 a month only to learn that their employer intended to pay them only $250 per month. What makes migrant domestic workers susceptible to such mistreatment is not just the informal and isolated setting of their occupation but also the legal terms of their residency.

In most countries, the visa of domestic workers is contingent on

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their live-in employment in one household, where their employers are the main assessors and administrators of the law. This is the case not only in countries such as Lebanon, Israel, Malaysia, and Singapore but also the United States, where domestic workers sponsored by diplomats or returning expatriates are bound to work solely for their sponsoring employer.

The susceptibility of migrant domestic workers to labor trafficking suggests not only the likelihood of their poor labor conditions, including low wages, but also the challenge of ever meeting their migration goals.

We see this in the case of Letty, who finds herself duped by employers against contributing to her retirement as they themselves avoided doing so. In the Philippines, domestic workers bound to work under a twoyear contract in the Middle East are forewarned in a government-run predeparture orientation seminar that they will likely have to migrate more than once before they can meet their different goals of migration, including purchasing a house, sending children to school, and accumulating enough savings to open a small business in the Philippines.

In Italy, at Rome’s central train station of Termini, one is likely to find groups of unemployed elderly Filipinas actively looking for live-in employment as elder care providers. I learned of this when I visited Rome in 2012 and ran into someone who had participated in my dissertation research on domestic workers 20 years earlier. Fe looked much older with her now gray and brittle hair but had still been quite recognizable, with her distinctively dark skin and impeccable English.

She had been a grade school teacher in the Philippines before becoming a domestic worker in Italy. When I asked Fe and her friends why they did not return to the Philippines, reunite with their family, and retire, they all admit-

The challenge of retirement for migrant domestic workers invites us to examine their plight in old age. ted that they could not afford to do so.

Like Letty, they either did not have an adequate retirement pension or still needed to support family in the Philippines, or worse, they confronted both.

Older Domestic Workers

Domestic workers are aging, and continuing to work because they have to. A survey I conducted with Jennifer Nazareno of 100 Filipino domestic workers in Los Angeles indicated the average age of our respondents was 57.5 years old. Most were elder care providers, a job that domestic workers come to prefer as they age. In conversations with migrant domestic workers over 50 years old, many told me, “Ayaw ko ng bata,” meaning, “I do not want a child.” As 63-year-old Lilly explains, “At my age, I’d rather take care of old people, not kids. I could not run after them anymore.”

Older domestic workers prefer to care for the elderly because of the relatively lighter one-on-one workload. As Letty says, “It’s only you and the lady.

If she sleeps, you sleep too.” Whereas younger domestic workers prefer child care and housecleaning, older migrants are also said to prefer elder care for its slower pace. In contrast,

younger domestic workers are said to prefer child care, as they wish to avoid the slow, monotonous, and isolated routine of caring for the elderly; elder care is said to be “boring.”

Elder care, however, is not without its challenges. Elderly patients who suffer from Parkinson’s, Alzheimer’s, and other forms of dementia increase the demand and stress of the work.

Letty for instance recalls the stress of being kicked out almost every morning by her patient with Alzheimer’s: “Oh my God … in the morning … when I would say, ‘Good morning,’ she would say, ‘How did you come here?!’

I would say, ‘I stay here with you.’ She would say, ‘No, no, no, you go out, you go out.’ Then you know what, I go to the bathroom. I stay there for a few minutes, and just pray there, and then I go out and say, ‘Good morning,’ and she would be nice already.” Additionally, elder care can bring physical challenges such as lifting nonambulatory patients. Those who can walk also impose their own set of physical challenges. Fighting elderly with Alzheimer’s in the bathtub has been described as a one-sided “boxing match” with water splashing everywhere.

Another challenge of elder care is said to be its 24-hour shift. The job requires most workers to wake up in the middle of the night to bring their patient a glass of water, take them to the toilet, respond to their crying and requests to sleep on the same bed, or check on any noise they make. The majority of our survey participants had to get up at least twice in the middle of the night. Add to this the usual duties of domestic work. The vast majority, about 70 percent, of survey participants reported their primary tasks to include cooking, laundry service, ambulation assistance, bathing, toileting, grooming, and feeding, with a slightly lesser percentage adding housework.

Elder care also demands unrequit-

Caregiving in the U.K.

By Brittany Gibson In the United Kingdom, more than 1.5 million

care workers are charged with daily responsibilities for the elder population’s long-term care, either in their own homes or in nursing homes. Carers, as they’re called in the U.K., can be responsible for everything from cooking and cleaning to bathing and making sure clients take their medications. However, the caring system needs more funding and staff, as it struggles to keep pace with the aging population.

The elder care system in the U.K. is not part of the National Health Service. In theory, this means it sits outside the public health care system, and people must cover their own costs. In practice, a portion of lower-income people over age 65 can receive assistance from their local council. But following Britain’s years of austerity under the Conservative Party, spending on carers was cut by onefifth in a ten-year period, from 2004 to 2014.

A study from the BBC found that, over that period, council budgets for care fell by 6 percent, while the over-65 population that would most rely on these services rose by 17 percent.

The strain on supply of carers meant that the standard of care slipped. An investigation from The Telegraph in 2015 found that more than half a million home care visits lasted less than five minutes. The National Institute for Health and Care Excellence created new requirements that all home care visits last at least 30 minutes, but the following year one in five councils were still commissioning 15-minute “flying visits.”

On top of shorter and less-comprehensive visits, carers in the U.K. are often not paid according to the national living wage. While carers are paid about £9 per hour for their time with patients, 54 percent of councils said they don’t pay for their travel time between homes, which can be up to 30 minutes apart on public transport. Carers have been forced to cut back visits to fit in the daily rounds of patients.

The low pay contributes to the U.K.’s job vacancy rate in frontline care work, which is about 8 percent. The staff turnover rate is about 30 percent, according to a 2019 study from Skills for Care. Another report said Britons were less likely to become carers because of the unsteady pay and hours. However, the British care system is dependent on non-British workers. One of every five carers is born outside the U.K., and that rate increases to three in five in London and the Southeast. They come from around the world, with significant percentages from Eastern Europe, Asia, and Africa. Similar trends are found between white carers and carers who identify as Black, Asian, and minority ethnic (BAME, the British equivalent classification for people of color, or POC).

Additionally, about 80 percent of all carers in the U.K. are women.

As with many sectors in Britain, there is speculation on how Brexit will affect carers. European carers already in the country should simply be able to apply for the British “settlement” program, but any labor trade deal changes could affect future recruitment, potentially creating more shortages of carers.

Some foreign carers also told The Guardian that they felt “belittled” in their roles in the U.K., compared to their native countries.

The professional carers in the U.K. are joined by the more than five million people who provide unpaid care to family or friends, usually in addition to their employment.

This gendered responsibility falls mostly on women. Since the coronavirus hit, many more people have taken on unpaid caring roles as well, leading to vast increases across demographics of Britons caring for each other.

The U.K.’s elder care system shares aspects with the United States, in that it’s underprioritized, undercompensated, and undervalued. n

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 25

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS ed loyalty. According to Luz Ibarra, who writes on Latino elder care providers in Southern California, moral norms dictate that elder care providers commit to the job until their patient dies, and provide care as they would to their own parent. However, the experiences of domestic workers I have met indicate that this loyalty is rarely reciprocated; raises are infrequent, compensations upon the passing of a patient are likely not to be extended, and gifts, small tokens of appreciation, are frequently disappointing. “I made $80 a day when I started and I asked for a raise after five years,” one respondent told me, a complaint echoed by many others.

Receiving inexpensive presents for their birthdays and holidays is another common occurrence. Shares one caregiver: “I took care of a 103-yearold, and she gave me earrings for Christmas, and she told me they were real, but they were fake.”

Despite its many challenges, elder care is a job that older-aged domestic workers much prefer. This is because this job allots them more rest time than other types of domestic work.

Comparing child care and elder care, Letty explains, “It is better than if there are family around with children.

It is hard because you would have to keep on working. You don’t have rest because you are ashamed also. But if you are only two … if they say, ‘I want to rest,’ then you can rest too.” Domestic workers such as Letty suggest the emergence of not only older-aged domestic workers but the rising case of elderly caring for elderly, or unretirable elderly caring for retired elderly.

According to the Administration for Community Living, the nearly 50 million individuals who comprise the older population—those who are 65 years and older—make up more than 16 percent of the U.S. population, about one in every six Americans. Their population is expected

26 WWW.PROSPECT.ORG/FAMILYCARE

Americans age 65 and older

50

98

million

million

2020

2060 to almost double to 98 million by 2060. Due to the rise of the aging population, elder care is one of the fastest-growing occupations in the United States. With its designation as low-wage employment, those who are most likely to respond to this demand are migrant workers.

The Elder Care Chain

The phenomenon of elderly caring for elderly indicates the emergence of an elder care chain. Aging baby boomers—individuals born between 1946 and 1964—are paying elder care workers to care for their parents, who are in their eighties and nineties. The Filipino elder care providers I have met include a 62-year-old who cares for a 96-year-old, a 60-year-old caring for an 89-year-old, and a 71-year-old caring for a 78-year-old. These care providers give the baby-boomer children of their elderly parents the freedom to retire. This suggests that the inability of domestic workers to retire works to the advantage of aging baby boomers in their early years of retirement; to give themselves greater freedom during retirement, they hire a crop of workers who tend to be former nannies and housekeepers.

One such elder care provider is 63-year-old Lilly, who cares for an 85-year-old woman 60 minutes south of Los Angeles in Orange County.

The woman has mild symptoms of dementia and Parkinson’s, and she had become increasingly forgetful in

the months prior to when I met Lilly.

Living close to Lilly’s elderly patient is her 65-year-old daughter Mary, who remains active in her mother’s life. Mary handles the grocery shopping for her mother and Lilly.

Because Lilly does not know how to drive, Mary also takes her mother to her weekly therapy appointments.

Mary leaves it to Lilly, however, to see to the day-to-day needs of her mother. Bearing the brunt of managing Mary’s mother’s dementia, Lilly also has to provide emotional support, including constant reassurances against the frustrations and insecurities caused by memory loss and diminished comprehension.

Without question, Lilly relieves Mary, a retired schoolteacher, of the time-consuming burden of watching someone with dementia. Mary’s freedom hinges on the work of Lilly.

Despite the friendship Lilly has cultivated with Mary’s mother, she knows better than to romanticize their relationship. As she told me, “You just care but [do] not emotionally get involved … You care; you do your job.

It is my job. If someone asks, ‘Lilly, how can you do this?’ It is my job.”

Lilly knows to keep her emotional distance because she is aware that she lacks job security, or as another caregiver put it, “security of tenure.”

If the mother dies, then her job ends.

From experience, Lilly also knows she is unlikely to receive any form of compensation for her long-term service to Mary and her mother. Other elder care providers I have met agree, as only two had ever been included in the will of their patients but neither one received “enough to retire.” Most others complained that they were not materially compensated for their loyalty: “Nowadays, even if you work for someone for 20 years, because of economic pressures, Medicare, taxes, and the children are there too … So, they don’t really give.” After the

passing of an elderly patient, workers usually receive no more than what is equivalent to a week’s salary, which is not enough to cover their living expenses while they transition from one employer to another. Expecting any more, they say, would be similar to “waiting for nothing.”

“Can I Ever Retire?”

The aging of domestic workers is an issue ignored in policy discussions.

The question of retirement is absent in the International Labour Organization’s Convention on Decent Work for Domestic Workers. Adopted in 2011, this convention signals a significant advancement toward the formal recognition of domestic work and the implementation of employment standards. It calls for the use of written contracts in accordance with national laws, regulations, or collective agreements in domestic work; safe and humane working conditions; freedom of movement; and, among other things, regular pay.

Missing, however, is the question of retirement and the insecurities of aging among domestic workers.

In the survey Nazareno and I conducted with domestic workers in Los Angeles, the challenge of accumulating retirement funds along with job security and access to health care were the three biggest concerns identified by participants. They struggled to acquire funds sufficient for retirement because first, wages are often too low; and second, the informal arrangement of their occupation allows employers to avoid paying their share of taxes mandated by the Federal Insurance Contributions Act, namely, Social Security and Medicare taxes.

In a focus group discussion with 30 elder care providers, many participants reported inadequate savings because their daily expenses, including the money they have to send to family in the Philippines, eats

up most of their earnings. They also mentioned that the informal arrangement of domestic work puts the onus on them as the worker, and not the employer, to secure their retirement.

Employers are legally mandated to pay 7.65 percent of their employees’ wages to cover Social Security and Medicare taxes, but most do not. Of 100 survey participants, only 14 had employers who did so. This pattern fits historical trends. Luisa GrilloChope and Carlos Ramos, writing for the National Council of La Raza, found that, according to the U.S. General Accounting Office, nearly 96 percent of private household workers lacked pension coverage in the 1990s.

Enabling the poor remuneration of elder care providers is the assumption of their natural affinity for this labor, which is a claim that Filipino domestic workers seem to embrace.

Says an elder care provider in Los Angeles: “I think the role of Filipinos is as natural-born caregivers. And so,

in a country that needs assistance specifically for the aging population, first and foremost, we Filipinos are the ones in the front lines of it … We are being the ambassadors of our own country to do this work.”

Mirroring these comments, another elder care provider, Thelma, asserts that Filipinos have a “sixth sense” when it comes to providing elder care. Lilly agrees: “I think Filipinos are like the most caring people … It is inherent in us, I think.” What are we to make of the insistence of Filipino elder care providers that they have a “care gene”? Why do they pride themselves on having a genetic disposition to provide care? It is actually to their advantage to do so as it establishes their indispensability as domestic workers—yet this pride in their work also facilitates their exploitation.

Elder care providers frequently spoke with pride about the deep loyalty they held for their elderly patients. This includes Betty, who

Mackenzie Leech, disability care provider, Crystal Lake, IL Just before the pandemic, I started a new job as a home care provider for a high school–aged boy with a developmental disability. When the pandemic hit, I became the main person providing his care. The shift to online schooling meant he’d spend more time in the house, and the abrupt change in his schedule created a new level of discomfort, which made the transition quite challenging at first.

But my experiences prepared me for it. I started providing care for disabled individuals when I was 16 and began a job at a special recreation center.

It’s oftentimes a thankless job, but I think most people in the field aren’t

doing it for a thank you. When I was going into first grade, I was placed in a learning disability class due to my reading level. I connected with the individuals with disabilities in my class who inspired me to pursue this line of work.

While I find fulfillment in this job, it’s fatiguing for many and has a high turnover rate. The shifts are long. Support is often limited. And the clients’ behaviors can be unpredictable. Those I know in the field hold a great deal of passion for their work. However, passion should not be an excuse to withhold adequate compensation for those providing this type of care.

—Alex Rouhandeh

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS says, “My heart and my life are dedicated to taking care of the elderly because, if you put it in your heart, you will do everything to take care of them.” Betty, an undocumented worker who is in and out of the hospital as she fights cancer, forgoes caring for herself to care for others. Her deep commitment is not one materially reciprocated by her employers; Betty is without medical insurance.

Claims of Filipino workers having a natural affinity for elder care, one that supposedly results not only in their “deep loyalty” but also their emotional and spiritual fulfilment, often come at the cost of their material compensation. However, this need not be the case. Believing that material motivations would taint one’s emotional and spiritual motivations, and diminish one’s job performance, assumes they inhabit separate spheres. Sociologist Viviana Zelizer criticizes this “hostile worlds” view, the belief that money must be kept separate from the intimate and sacred for the latter two to retain their value, as it ignores the ceaseless interplay between love and money that defines many of our social relationships. Churchgoers donate money to their pastor, parents send their children to school, and so on.

In contrast, employers often do not reciprocate for the allegiance of care workers. However, the emotional and spiritual fulfilment of doing elder care should not justify the monetary devaluation of this work.

Domestic workers provide a necessary service to maintaining society.

Recognizing their labor—the work of caring, feeding, bathing, and clothing the population—requires that we acknowledge their reproductive rights. This refers not just to their right to a family life but also their right to retirement. The inability of domestic workers to retire signals the emergence of new kinds of inequality in American society. Perhaps an apt

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description of their situation is one of modern-day servitude, as their dismal compensation as informal, lowwage workers turns domestic work into compulsory labor. The situation of Lilly suggests as much. The security of her labor demands her loyalty to Mary and her mother. They in turn ensure her dependence by minimizing her payment and refusing to cover her taxes, thereby disqualifying her from unemployment, pensions, and health insurance. The work of older-aged domestic workers such as Lilly—most of whom are elder care providers—also signals an elder care chain that links unretirable elderly with retired elderly.

We see Lilly, an unretirable elderly woman, allow Mary, a retired elderly woman, to enjoy her retirement.

The inability of domestic workers to retire poses a challenge to global advocacy efforts for the recognition of domestic work. How do we remedy the elusiveness of retirement? Imposing heavy penalties on employers who fail to contribute to Social Security and Medicare taxes seems to be a worthwhile first step. Pressuring employers to financially reciprocate for the loyalty elicited by the emotional and spiritual fulfillment of elder care is another. For elderly people who need care but cannot afford to pay, we need social subsidies so that care workers can receive decent pay for their labors.

Finally, placing retirement in the forefront of domestic work advocacy and policy efforts highlights the struggles of workers such as Fe, Letty, and Lilly, making it a necessary step to standardizing their occupation. n Rhacel Salazar Parreñas teaches sociology and gender and sexuality studies at the University of Southern California Dornsife College of Letters, Arts and Sciences. She is the author of Servants of Globalization: Migration and Domestic Work.

Why Americans Need Paid Sick Leave

More than 100 million of our compatriots don’t have it— which poses all kinds of risks to the rest of us.

By Sarah Jaffe Before the pandemic, gig work had

been a good choice for Jonathan Perales. He was a single parent in Arlington, Texas, trying to spend more time with his young daughter, and, he said, because driving for Uber, Uber Eats, and Postmates allowed him to make his own schedule, “when I’m with my daughter, I can be with her 100 percent. Then, when she’s with her mom, I can go out and work just as much as I need to to pay the bills.”

But in mid-March 2020—early enough in the pandemic that he’d been dubbed an “essential worker,” but when there was no place to get tested for the virus—he came down with symptoms, and reached out to Uber to let them know. “They told me the only way for me to get any money for being sick would be to come back

with a positive COVID test. I kept explaining to them that there are no tests, but that I was recommended to stay home and self-quarantine.”

Like millions of other workers across the U.S., Perales scrambled to figure out how to pay the bills while also doing his best to comply with doctor’s orders and public-health guidelines. Without a state or local ordinance requiring paid sick time, and as a gig worker technically classified as an independent contractor, he was entitled to no pay for his time in self-isolation. The pandemic brought home the fact that the roughly 33 million people who have no paid sick leave often have to choose between caring for themselves and their community or making the rent. It also brought home that so many of those lacking paid time off when ill are those we call “essential,” whether delivering food, like Perales, or working in a meat processing plant, a grocery store, or even a health care facility. The very people uncovered by current law are the ones most likely to pick up the virus at work, and whose work means they may well pass it on if they are not given time to care for themselves.

Uber had announced in March that it would be providing up to 14 days of paid sick leave to drivers if they needed to quarantine due to the coronavirus. (Uber did not respond to a request for comment for this article.) But Perales, like other workers, found that actually getting the pay required jumping through hoop after hoop. He was told he had to have a doctor or state official send paperwork to the company, but health department officials asked why he couldn’t just submit it himself; finally, he got it through, but by the time he heard back from the company, he’d run out of money and lost the room he was renting in a motel.

“They basically told me, ‘Kick rocks.

We’re not going to let you expose our customers, but at the same time, we’re not going to pay you.’”

Perales was homeless for five months, living out of the car he’d used to make his deliveries. He chokes up even now, talking about it.

“They called me and they said, ‘We’re sorry we didn’t do anything before.

Here’s $314 to quarantine for two weeks.’ I told them, ‘That wouldn’t even cover my motel fees, rent, even if I did still have a place.’ They told me that without a positive COVID test they weren’t able to do anything else.”

Out of desperation, he made a couple of deliveries while he was supposed to be isolating; he doubted that he was the only one who’d worked sick. He held off from seeing his daughter, not wanting to expose her to the virus; he’s only recently been able to begin spending time with her again. A GoFundMe and the support of people who heard about his story—including the worker organization Working Washington— have helped him get back on his feet, and he’s taking classes now in information technology. “I’ve had people tell me before, ‘Go get a real job,’” he said, but it was hard to find other work. “My fallback was always warehouse work.

Not so much anymore. It’s a huge exposure risk. I used to work at Amazon. If I work there [again], I’m definitely not going to be able to see my daughter without exposing her.”

The one thing he’s glad about is that more attention has come to issues like the need for paid sick time.

“COVID created a situation where everybody could relate to it and realize that it’s something that could happen to anybody,” he says. “I’ve always felt that people who are homeless, people who are experiencing poverty, it’s not their fault. It wasn’t their fault before COVID and it’s definitely not their fault after COVID.” “It shouldn’t take a pandemic to

remind us how interdependent we are, that each of us is only as healthy as everyone else we come in contact with,” says Ellen Bravo, strategic adviser and co-founder at Family Values @ Work, an organization that advocates for sick leave and other policies that help workers have a livable working life.

In the 1980s, Bravo founded the Milwaukee chapter of the organization 9to5 for working women, and went on to become its national director. By the late 1990s, after welfare reform, she realized how many of the women she met who’d relied on welfare were there because of a caregiving crisis: A child or a parent would get ill, they’d need care, and the woman would lose her job and wind up relying on benefits. The organization had already been advocating paid leave for longer-term illnesses or the birth of a child, but, she said, “We thought, ‘It isn’t just paid family and medical leave. We need short-term leave for routine illness,’ and we all just start referring to it as paid sick days.”

There are millions of people with some sort of caring responsibility to worry about in addition to their own routine illnesses. And while many of those carers these days are fathers like Jonathan Perales, Bravo points out that the reason sick days are considered an afterthought is gendered: “Workplaces were designed as if all workers were men who had a wife at home full time to take care of those who needed care and that those men would tough it out.”

What Bravo calls “the movement for time to care” has always seen short-term sick leave and longerterm family leave as interconnected. Yet they tend to be structured very differently. Paid sick days, she explained, sets a “minimum labor standard, like minimum wage, that all employers can do.” The employers themselves are required to pay

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for short-term paid sick days under the laws that have passed; workers normally accrue the leave based on the time they’ve put in at the job, as in New York City’s law, where employees must accrue at least one hour of sick time for every 30 hours they work, up to 40 hours sick leave for the year, or employers can choose to simply offer 40 hours to each employee. Small businesses, Bravo noted, tend to like the paid sick time laws because they level the playing field, rather than costing a small employer who wants to do right by their employees more money than a big employer who might not care to.

In contrast, longer-term paid

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family leave is or would be a socialinsurance policy. In California, for example, the Paid Family Leave program is paid for through state disability insurance taxes and provides up to 60 or 70 percent of a worker’s wages for up to eight weeks.

Many unionized workers have paid sick time through a collectivebargaining agreement—according to the Economic Policy Institute, nine in ten workers who are covered by a union contract have access to paid sick days, and 97 percent of those in the public sector who have a union contract do. But as union density in the U.S. has fallen to 10.3 percent, no matter how good a sick time arrange-

ment might be in a contract, few workers have access to them, underscoring the need for federal legislation to set a baseline.

The first federal bill to provide paid sick time was the Healthy Families Act, introduced in 2004 by Sen. Ted Kennedy of Massachusetts. There’s a 2020 version of it—it still hasn’t passed—introduced by Sen. Patty Murray of Washington and in the House by Rep. Rosa DeLauro. The bill would require employers with 15 or more employees to provide up to 56 hours of paid sick leave, accrued at the same rate as New York’s law, one hour per 30 hours worked.

The first local paid sick days ordi-

nance was enacted in San Francisco in 2006, after a ballot initiative campaign led by young immigrant workers. The law there, which provides sick leave to all workers, including temps and part-timers, accrued at the rate of one hour per 30 hours worked, remains, according to Bravo, one of the best laws in the country.

But what happened in Milwaukee in 2008 reminded the movement that their opponents were not going away so easily. When a ballot initiative got 68 percent of the vote, the Metropolitan Milwaukee Association of Commerce sued. That case dragged on until 2011, when an appeals court upheld the ordinance. But by then, Scott Walker was governor of Wisconsin, and in May of 2011 he signed a law preempting local sick leave ordinances. A court upheld Walker’s ban, and Wisconsin still lacks paid sick time.

All told, 38 localities and 14 states have enacted such laws. The idea is widely popular. A May poll found that support for paid sick days pushed undecided voters toward candidates who backed the policy;

another spring poll found 78 percent of Americans wanted guaranteed paid sick leave for workers.

A number of these laws, however, exclude many workers, particularly those who work for smaller employers. In jurisdictions without such laws, or where the laws fail to cover many eventualities, paid leave policies can leave much to be desired. They may cover a worker’s sickness, but not their children’s. They may bundle sick days with vacation days, and some companies with this provision require advance notice to qualify—as if an illness gives advance warning.

Some companies even put workers into “PTO debt” if their illness eats up more sick time than they’d accrued, meaning they have to work it off or even pay it back in cash if they leave before they’ve earned their time back.

And then there are gig workers like Perales, who are not classified as employees. In July, though, Seattle passed an emergency measure that would provide paid sick time to gig workers who drive for companies like

Cambodia

Djibouti

Ecuador

Malta

Afghanistan

0

0

0

0

0

0

Source: Center for American Progress, 4/17/2020

United States of America

Germany

Workers uncovered by paid family and medical leave

106 million

Uber or do food delivery. Backed by Working Washington, the law allows those workers to accrue paid time off during the duration of the COVID-19 emergency. Orlando Santana is one of those drivers, working for Instacart, Amazon Flex, and others. His background is in graphic design, but he began picking up gig work when he was let go from a media job, and it’s now his main source of income.

There was a restaurant in the area, Santana says, that had to temporarily close because a couple of its employees tested positive for COVID. “If I had delivered from that store, the right thing for me to do would be to stop working, go get tested, wait for my results. Well, those few days that you’re waiting for your test results, you can’t work, so you’re losing income. Having access to sick leave for those times, it helps to lift the burden a little bit.”

These emergency measures, Bravo says, are helpful but insufficient. “It was heartening to see Congress quickly pass the Families First Coronavirus Response Act, but it is important to know how many people are not covered: up to 106 million.”

What is necessary now is to build on the sense of urgency that the pandemic created, so that all workers, including those we now call “essential,” have the ability to stay home when they’re sick.

“We always knew that for everyone to be covered, we had to have federal law. It needed to be uniform and inclusive and cover the whole country,” she continues. “We can’t be a country that says, ‘We want to stop institutional racism’ and then not look at the actual institutions that are perpetuating it.”

Some workers, frustrated at being

repeatedly at risk of firing if sick, have taken things into their own hands.

In Raleigh, North Carolina, LaMe-

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 31

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS aka Moses began work at Bojangles fast food in October of 2019. She said there was always pressure on her to work sick. “I got sick one day and they didn’t even want me to leave. I mean vomiting and everything!” she said. “I have numerous co-workers [managers] tried to write them up for calling out of work because they think they’re lying.”

When the pandemic began, Moses continued to work, but she began to notice people missing from her shifts. Around August 3, she heard rumors that someone at her workplace had the virus. She paid it little mind. When she went to look at the new schedule, however, another piece of paper drew her eye because it said, “COVID-19.” The paper stated that an employee had tested positive for the virus, wished them well, and gave some guidance for what to do if workers felt ill. “At that point, for me, it was just the final straw.”

That morning, Moses and her colleague Lisa Foster walked off the job.

Foster’s son, Dekembe Black, who

had begun working the night shift, joined them on strike.

“Enough is enough,” Moses says.

“I felt like they were playing with my life. I felt like management and every supervisor and people up the ladder made a decision for me that I was supposed to make for myself, but they didn’t give me a choice.” She has three daughters, and when the company chose not to notify her, she says it put her children at risk. “They said they only notified three that were in close proximity to the individual, but everybody is in close proximity to everybody.

There is no way that you can be six feet apart working in Bojangles.”

Amanda Arnold, director of human resources for Tri-Arc Food Systems, the local Bojangles franchise, said in an email, “Employees that were identified as close contacts, defined by the Centers for Disease Control (CDC) as being within 6 feet for more than 15 minutes, were immediately contacted and were asked to self-quarantine for 14 days. Those employees will be paid during that time. Response bul-

Liz O’Donnell, author, Dedham, MA I was experiencing what I now know is the caregiver creep. I was working full time, I had two kids, I was married, pretty busy life, and my parents were in their eighties and needing more. I was mowing their lawn, driving them to doctor’s appointments because they had stopped driving, I was sorting pills, you know, some household chores. I thought that was pretty busy, and then they got sick.

My dad was in one hospital.

He was then admitted to a geriatric psych unit, and that’s where he was indeed diagnosed with Alzheimer’s dementia. I was told he could never go home again. In the meantime, my mom, I had moved her into an assisted living near her house because you can do respite care for 30 days at a time. Well, while she was there, she was sent to the ER with stomach pain. The local hospital sent

32 WWW.PROSPECT.ORG/FAMILYCARE

her up to Boston, where she was diagnosed with ovarian cancer and given three months to live.

So it was a really, really intense, you know, the next I’d say three to six months. I moved my father into memory care, I moved my mother into assisted living. I was going to their house, digging through piles of bills and paperwork to find, where do they have a will, and do they have a burial plot? There were medical diagnoses to deal with, there was financial information to deal with, there was end-of-life planning to deal with.

And I was the breadwinner for my family. I was trying to hide the fact from my boss just how bad things had become, because I knew she would say, you should take a leave of absence.

And I was terrified to hear her say that.

—Shera Avi-Yonah

letins were posted in the location on August 7 to notify all employees of the positive case.”

Moses and Foster didn’t just walk out, though. Moses reached out to local news reporters, who reported on the story, and she also called the state health department and reached out to the Occupational Safety and Health Administration to file complaints. The health department, Moses said, called her back after they spoke to Bojangles’s head office, telling her that they said the store had been deep-cleaned—which Arnold also emphasized in her email to me—and there was nothing to be done. No one at OSHA called her back, though when the local Fight for $15 campaign heard about the strike, they reached out to support the workers and helped her file an OSHA complaint.

Moses, Foster, and Black responded by demanding proof of professional deep cleaning of the store, $15 an hour hazard pay, and two weeks of paid leave to self-quarantine. To Moses and Black, giving the workers time to selfisolate should have been an obvious move. “My life should be more important than your dollar because y’all are not hurting. You are a multimilliondollar company,” Moses says.

When he began working at the store, Black, like all the employees, had been given a shirt that said, “Risk it for the Biscuit.” It encapsulated, to him, his mother, and Moses, how the company thought about its workers.

“Do y’all really want us to risk it for the biscuit?!” Moses asks. “Risk our lives, really, for Bojangles?” n Sarah Jaffe is the author of Necessary Trouble: Americans in Revolt and the forthcoming Work Won't Love You Back: How Devotion to Our Jobs Leaves Us Exploited, Exhausted, and Alone (Bold Type Books, January 2021).

The Collapse of LongTerm Care Insurance Attempts to have the private market manage support and services for the elderly or people with disabilities have utterly failed.

By Alexander Sammon The first announced American

death from coronavirus came in February from a nursing home in Kirkland, Washington. Within weeks, an astounding two-thirds of inhabitants and staff had contracted the virus, with 37 deaths among just 108 residents. It was the beginning of a painful record of long-term care facilities like nursing homes as the most deadly theater of the coronavirus pandemic.

By May, one-third of all coronavirus deaths were nursing home residents or workers. By September, some 46,400 deaths had been confirmed, even with states providing spotty and partial data. Roughly 1 in 10 people who were in long-term care facilities when the pandemic started in New Jersey were dead by May.

It’s a chilling reminder of the importance of quality care for a needy and rapidly growing segment of the population. But the coronavirus descended upon a long-term care landscape in America already beset by crisis. For years, private long-term care insurers have been fleeing the market, while a public option doesn’t exist. The issue was perhaps too niche to garner any interest during the last Democratic primary, amid the hotburning Medicare for All debate.

But there is perhaps no component of health insurance where the private sector has failed more profoundly than long-term care, making this one of the worst and most rapidly faltering aspects of our impossibly expensive, wildly inefficient, and poorly performing health care system.

The problem begins at a very basic level: Many Americans don’t even know what long-term care is.

It refers to a broad sweep of services and supports that elderly patients and people with disabilities need in their daily, basic activities. Nonmedical help in things like bathing, dressing, and eating are all part of long-term care, as well as medical support for patients battling diseases like Alzheimer’s, dementia, and other chronic conditions. It can take place in nursing homes, in assisted-living facilities, or at home.

Common estimates say that about 50 percent of older adults will need long-term care at some point in their lives; for adults over 65, the odds shoot up to 70 percent. But, like much of our health care system, just because there’s demand doesn’t mean there’s supply. Though longterm care can be exorbitantly expensive, the percentage of Americans currently in possession of insurance coverage is just a small fraction of those who are likely to need it. Right now, fewer than 1 in 30 Americans own a long-term care (LTC) insurance

policy, and only about 7 percent of adults over 50. The raw figure of 7.5 million insured has barely budged since 2008, despite an increasing aging population.

Private insurers began offering LTC insurance in the 1970s, and sales ticked steadily upward into the 2000s. At its peak in 2002, about 750,000 individuals successfully purchased LTC insurance in a single year. By 2018, that number had plummeted to 57,000, a more than tenfold contraction, even as the percentage of the American population in the prime purchasing demographic, ages 60 to 69, expanded rapidly, from 9.5 percent in 2010 to 11.4 percent in 2018, according to a study from the Treasury Department.

Part of that trend is explained by a wild mispricing error by the insurance industry, which severely underestimated the cost of such plans. As the industry paid out huge sums for relatively cheap plans year after year, they scrambled to make up the difference by surging premiums and trying to minimize outlay. In 2005, a buyer between the ages of 55 and 64 paid an average annual premium of about $1,900. By 2015, LTC premiums had ballooned almost 40 percent, to more than $2,600, in spite of the fact that policyholders were receiving far less coverage for their buck. In 2005, the average policy topped out at $270,000 in benefits; by 2015, it had sagged to $235,000. In 2018, LTC insurance covered only about $10 billion in costs, while individuals paid $55 billion out of pocket.

Meanwhile, insurers have strained to deny policies to as many people as possible. According to recent estimates from the American Association for Long-Term Care Insurance, the industry’s top trade group, somewhere between 44 percent and 51.5 percent of people over 70 who apply for a longterm care policy are now declined.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 33

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS Almost one-third of those between 60 and 65, a less risky demographic, are turned down. Even 21 percent of people in their fifties, more than one in five, can expect to have their applications rejected. Any combination of two or more chronic conditions is grounds for near-automatic disqualification, as are diseases like AIDS and multiple sclerosis, a history of strokes, or diabetes requiring insulin shots.

Yet despite rates rocketing up, and plans being increasingly difficult to even qualify for, claim losses have still managed to exceed expectations since 2008, as insurers have found it impossible to structure a long-term care program in a profitable way. Some insurers have simply abandoned the LTC insurance market altogether; there were over 100 policy providers in 2000 and fewer than a dozen today.

Confusion about long-term care helps the industry avoid even worse losses, though it will lead millions of Americans into financial catastrophe. A significant percentage of people wrongly believe that they’re covered for long-term care via their employer-provided health insurance; others believe that some combination of Medicare, Medicaid, or

the Affordable Care Act will handle their needs. A study by the Nationwide Financial Retirement Institute found that only 28 percent of Americans age 50 and older with an income of over $150,000 know that the ACA does not cover long-term care costs, while 70 percent of baby boomers falsely believe that Obamacare covers long-term care.

They’re not entirely off-base in thinking that. The Affordable Care Act did initially include a provision for a national, public long-term care insurance system, called the Community Living Assistance Services and Supports (CLASS) Act. A pet program of the late Sen. Edward Kennedy, CLASS would have allowed all working adults to apply for insurance that would provide up to $50 a day in cash benefits, money that could be used to help with in-home assistance or nursing home care.

CLASS was derided as an accounting feint rather than a serious attempt to manage the long-term care problem. Because the program collected premiums for the first decade before paying out any benefits, it was scored as saving $70 billion inside the ten-year budget window. Former

There is perhaps no component of health insurance where the private sector has failed more profoundly than long-term care.

34 WWW.PROSPECT.ORG/FAMILYCARE

Republican Rep. Denny Rehberg of Montana, the former chair of the House Labor, Health and Human Services appropriations subcommittee, slammed it as “a budget gimmick to make the cost of Obamacare look better and cheaper.”

There were some savings with CLASS, particularly on the crushing long-term care costs absorbed by families across the country. But by 2011, it became clear that the Obama administration had no intention of actually pursuing it. Because the insurance was voluntary, and wasn’t supplemented with federal subsidies, the $50-a-day benefit would cost as much as $391 per month, and without a huge participation rate it still would not have remained financially solvent. So the White House announced they wouldn’t move forward on it.

CLASS was formally repealed in the American Taxpayer Relief Act of 2012, replaced by a Federal Commission on Long-Term Care. The commission went on to complete its study, replete with some of the data seen in this article and a handful of suggestions for limiting costs. And that was that.

The end result has been a powerful

combination of denial, wishful thinking, and severe financial shock. Most older Americans have not looked into long-term care options at all, while just 8 percent consider it “very likely” that they will ever experience a long-term care need (again, something like 70 percent will). Medicare only covers short-term use of nursing home and home health care services, up to 100 days, strictly curtailed and narrowly defined.

Medicaid, meanwhile, currently the single-largest source of funding for long-term services, only kicks in at a point of financial ruin. Most states require long-term care recipients to draw down their financial resources to the very last $2,000 before Med-

Average annual LTC insurance premiums, ages 55–64

1,900 $2,600 $

2005

2015

Average policy benefits

270,000 $235,000 $

2005

2015

icaid kicks in, even requiring them to empty out IRAs and 401(k)s and assets like real estate. Of course, financial ruin is not some far-off possibility; Americans making the median wage have a 1-in-6 chance of needing long-term care that entirely eclipses their financial resources.

But forcing people into penury to get assistance to feed and bathe themselves robs the elderly of dignity.

Many are forced into nursing homes because they can no longer afford living on their own. The only other option is uncompensated long-term caregiving by family and friends, which “costs” nothing, except health stress and financial insecurity.

There’s no reason to believe any of these trends will reverse on their own. The cost of policies will continue to skyrocket, the amount those policies pay out will continue to drop, the number of people in need will continue to grow, and the number of applicants rejected will continue to increase in lockstep. According

to the Congressional Budget Office, the cost of long-term care in the U.S. went from $30 billion in 2000 to $225 billion in 2015, compounding annually at nearly 15 percent. And yet the United States remains one of only a handful of developed nations whose government does not provide at least some universal long-term care benefits funded by taxes.

Long-term care is a market-breaker; there’s no meaningful way for it to conform to market principles, or to keep it from losing money. Private firms don’t want to compete for business despite a glut of demand, and a public solution holding itself to similar market-based principles failed before it even got started. But the need for long-term care is an absolute certainty, and herding a huge percentage of our fast-aging population into the corral of bankruptcy is not a solution either.

Some policymakers are finally coming around to this reality. Washington state passed a long-term care social-insurance program last year, which reimburses at $100 per day for in-home care up to a fixed lifetime maximum that translates to one year of daily support. It’s funded by a small payroll tax on all wages. The tax begins in 2022 and payouts in 2025. This mirrors numerous successful efforts abroad, and allows elderly people and those with disabilities the ability to live within their communities with some measure of dignity. But as with any expensive and necessary public-health program, piecemeal solutions at the state level are not likely to be sufficient. Which side of state lines you find yourself on shouldn’t determine the level of dignity and care you’re afforded in old age, and the federal power of the purse is most ably equipped to fund such a program.

The Evergreen State has shown that this, like so many other crises we face, is solvable. It will take federal commitment to get it done. n

The Corporatization of Nursing Homes A tragic history of how we’ve treated elderly citizens, for profit

By Maureen Tkacik Maureen Dittmar of Rochester, New

Hampshire, was sifting through junk mail one Saturday in early August when she found an envelope obviously sent by a human being. It began: “The content of this letter may be hard to hear … But you deserve to know the truth.” The anonymous author was a staffer at her mother’s nursing home.

Dittmar’s rush of cortisol was familiar. Every day for months, the virus had engulfed another crop of facilities. Residents are elderly, frail, and housed in close quarters; they are sitting ducks for a pandemic.

By mid-September, the nationwide death toll from long-term care facilities had reached more than 77,000 residents and staff, 40 percent of the country’s total. For some reason, New Hampshire had only lost a relatively small number, but Dittmar

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

Roughly 70 percent of the nation’s 15,400 nursing homes are for-profit, and gross understaffing is the flip side of extreme profiteering. knew better than to believe everything she was told, or assume they were out of the woods.

There wasn’t an outbreak, though; the letter was about staffing. Genesis HealthCare, the 357-facility nursing home chain that ran the Colonial Hill Center and by late May had already seen about 1,500 of its residents die, had slashed payroll so drastically that on many shifts, the primary unit had one nursing assistant responsible for 39 patients. Supervisors helped out on the floor whenever they could, but the last nursing manager who had gone to bat for them had been fired.

New Hampshire had been lucky to avoid the worst of COVID-19, but the minimum staffing requirements it imposed on nursing homes were the most lenient in the Northeast— and now their residents were paying the price. “It has always been a known rule in any health care facility to NEVER mention to family or residents that we are having staffing issues,” the author warned. “We feel that the current restrictions on inhouse visitations from the families is allowing a veil of protection for corporate and management. Families are unable to see the full affects [sic] on their loved ones.”

Roughly 70 percent of the nation’s

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15,400 nursing homes are for-profit, and the gross understaffing on display at Colonial Hill is the flip side of extreme profiteering. Hundreds of thousands of nursing home residents survived the bloodbath of 2020, only to spend the summer, no doubt, wishing the virus would come back for them. State health departments suspended Medicare inspections during the pandemic; it has been 18 months since Colonial Hill saw one. So management is no longer even trying to avoid the most conspicuous signs of neglect: filthy clothing, odd facial hair, urine on the floor and in the air.

In many hard-hit homes, dead friends are being replaced with psychiatric referrals from psych wards and homeless shelters; in more selective ones, dementia sufferers are being ejected into psychiatric hospitals. At a facility in Pennsylvania with one certified nursing assistant for every 22 residents, eight assistants teamed up to tell the evening news their patients were going months without a bath. The average resident in one facility in suburban Illinois lost 3.7 pounds between February and April alone, with nearly a quarter losing more than 5 percent of their body weight. The evening news in Minneapolis in late September tells us

of a bird-watcher in his eighties with Lewy body dementia whose daughter takes him home after spying him through a window, disheveled and confused and so bottomlessly sad. He has bruises everywhere, an untreated infection has turned his genitalia bright red; he dies quickly.

Amplifying this neglect are the dozens of state laws passed hastily in the spring, granting the entire health care industry immunity from legal liability.

“Dehydration, malnutrition, falling, bedsores—they’re saying, ‘Look, we’re not liable for any of that right now because of COVID,’” says Steven Levin, an Illinois trial lawyer who has spent his career suing nursing homes and is working on more than 100 wrongful-death suits right now. These laws comprise the single coherent national policy response to the nursing home bloodbath of spring 2020.

In the absence of an accessible long-term care system for all families, older Americans are callously warehoused in these institutions, which in the crisis have descended into death traps. But for decades before the pandemic, for-profit nursing homes have been robbing seniors of their dignity and their money. And where you find extraction of value and indifference toward horrors inflicted on human beings, you inevitably find a financier’s spreadsheet.

The American nursing home indus-

try is a hellscape whose history is generously paved with bad intentions. I began my research under the assumption that senior care facilities were much like other private equity–stripped health care institutions: bought up and saddled with debt and forced to cut costs wherever possible, leading to unconscionable outcomes for workers and residents.

I assumed financial firms perverted a formerly well-intentioned system for providing vital care. The truth

is almost the inverse. The private equity guys learned a lot of their tricks from the original nursing home predators. Most good people were driven out of the business generations ago, and the ones who have hung on have been mostly punished for refusing to play the game.

“Bad nursing homes seem to be contagious,” wrote the pre-eminent nursing home muckraker Mary Adelaide Mendelson, in her 1974 exposé Tender Loving Greed: How the Incredibly Lucrative Nursing Home “Industry” Is Exploiting America’s Old People and Defrauding Us All. She traced the origins of this devolution to about 1950, when an amendment to the Social Security Act allowed nursing homes to collect benefit checks and stipends from the Veterans Administration directly, on behalf of their residents, generating a small windfall for operators shrewd enough to appoint themselves middlemen between senile geriatrics and their assets. Twenty years later, of the more than 200 facilities Mendelson had personally toured, “I could honestly call only one a good home.”

As Mendelson explains, the entire nursing home system had by the late 1960s come under the near-total control of a predator class known in some corners as the Syndicate, a sprawling and incomprehensible collection of nursing home owners, front men, and ethically deficient mortgage bankers, doctors, and public officials made famous by an Orthodox Jewish rabbi who was its New York boss, Bernard Bergman. Dubbed the “meanest man in New York” by the Village Voice, Bergman by 1975 had reputedly built a nursing home fortune worth $100 million dollars (a lot of money in those days), according to the memoir of one of the endless string of attorneys he retained to defend it, the then-youthful Alan Dershowitz.

We think now of the inception of

Medicaid and Medicare as a glorious milestone to recognizing health care as a human right. The Syndicate correctly saw a massive fire hydrant of cash with the capacity to make them all rich, though its leaders got a bit too greedy in the early years. Social Security Administration economists had forecast that Medicaid would spend $25 million to $50 million on nursing home care in its first year of coverage; when the reality turned out to be something more like $300 million, auditors began sniffing around.

Much of what we know about the Syndicate emerged in a probe into a gruesome nursing home on 106th Street near Central Park called the Towers, which under the ownership of a mysterious figure named Anne Weiss—who turned out to be Bernard Bergman’s wife (it took the health department, by its own admission,

“quite awhile [sic] to figure out” this little nugget)—had billed Medicaid for 926 days of care for eight patients who had died or been discharged from the home. Inside the facility were flies, urine stench, and dirty beds with no sheets.

The ownership of the Towers and many other nursing homes had gone to dizzying lengths to conceal itself.

Wherever Mendelson went she heard rumors, often from government officials, of Mafia connections—who else would be so diabolical? But her digging yielded evidence of a specialized nursing home mafia, a linked set of dons that attached itself parasitically to our most honorable social programs.

Two of the era’s most prominent bosses were Bergman and a Rolls Royce–driving former duffel bag manufacturer named Joseph Kosow, known in New England as “King of the Nursing Homes.” Like Bergman, Kosow had his own endless network of associates, straw buyers, shadowy front groups, and highly placed regulatory and law enforcement officials.

Kosow had some troubles with the feds, but only Bergman ever served any time, and when both died in 1984 extremely rich, protégés brought their business model into the modern era.

Abe Gosman was a longtime associate of Joe Kosow’s, probably from their days in the Boston shoe business. He was a quintessential Bonfire of the Vanities mogul, with a 143-foot yacht named Octopussy, an oceanfront palace in Palm Beach bought from Les Wexner that he would later sell to Donald Trump, and assets worth nearly a half billion dollars, following a string of deals in which he repeatedly sold, bought, and repackaged the same group of nursing homes and psychiatric facilities. Bernard Bergman’s lower-key protégés Moshael and Daniel Straus, the sons of his old Connecticut deputy Joseph Straus, launched a nurs-

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

Mendelson’s digging yielded evidence of a specialized nursing home mafia, a linked set of dons that attached itself parasitically to our most honorable social programs. ing home chain called Multicare in 1984 that they sold for more than a billion dollars cash in 1997 to Genesis Health Ventures, another of the high-f lying chains founded in the ’80s during the Reagan era of deregulation. Daniel Straus’s second act, the nursing home chain CareOne, suffered by far the worst outbreaks in their home state of New Jersey, but made lots of money doing it, as a ProPublica investigation explored.

Many profitable industries are incestuous and dominated by the sons and grandsons of tycoons. It’s just harder to track in nursing homes, whose trade publications fill my in-box each morning with incessant announcements of the buying and selling, recapitalizing and reorganizing of assets. The New Jersey consultancy commissioned to review the state’s devastating nursing home death toll found that some changed hands “multiple times in a single week.” When a registered nurse named Angela Ruckh decided to sue her old nursing home for defrauding the government, she ended up suing seven different companies. A defense attorney who tried to sue the same chain for wrongful death discovered it was spread out over 15 different enti-

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ties. But all those entities originated with Formation Capital, a private equity giant founded by Arnold Whitman and his shadowy partner, Steve E. Fishman. “You could spend forever trying to untangle this stuff,” said Ernie Tosh, an Austin-based attorney who runs a side business analyzing nursing home data. “The nursing home industry as a whole should not be looked at through the lens of normal corporate America. If you think of it as organized crime it will make a lot more sense.”

Whitman, a former college basket-

ball player from just outside Boston who had dabbled in advertising and worked at a brokerage, entered the nursing home scene in 1984 when he was 31. Abe Gosman was bringing Joe Kosow’s business model into the junk bond era, and he saw in Whitman a natural networker who could bring in deals. “I was one of those guys who wanted to be in something glamorous—advertising, entertainment, something along those lines,” Whitman later said of his younger self. But then he went to meet Abe Gosman in the basement of one of his “totally depressing” nursing homes.

“I remember being overcome by the

indignity,” he said. But “I realized that, unglamorous though the nursing home industry is, it was where a good future might indeed be had.”

A fixture of Syndicate nursing homes was an early version of what is now called the OpCo/PropCo model, wherein the nursing home’s operating company (OpCo) was separated from the real estate property company (PropCo) in a series of complicated transactions that usually left the OpCo paying massive interest payments, rental payments, or both.

The setup lowered taxes for both the OpCo, which appeared to be losing money, and the PropCo, which used the structure to trade the real estate back and forth between entities, collecting profits each time that were taxed as capital gains. OpCo/PropCo, also known as sale-leaseback, is today a common feature used by private equity firms to suck assets out of its portfolio companies, and keep them out of the hands of vendors, employees, and plaintiffs’ attorneys in the (likely) case that the OpCo is forced to file for bankruptcy.

Gosman was one of the first nursing home moguls to establish his PropCo as a publicly traded real estate investment trust (REIT), which didn’t have to pay any taxes so long as it paid out most of its profits as dividends to investors. Gosman dispatched Whitman to find other nursing home chains interested in sale-leasebacks through the REIT, and he brought in hundreds of millions of dollars in deals before striking out on his own in 1992.

By the late 1990s, most nursing home OpCos were going bankrupt, done in by a destructive feedback loop of debt, austerity, and illegality. Congress had cut Medicaid reimbursement rates in many states, which caused nursing homes to slash labor and investment in their facilities. A report commissioned by former Rep.

Henry Waxman (D-CA) revealed that reports of serious elder abuse had more than doubled between 1996 and 2000, by which point they had implicated nearly one-third of the nation’s nursing homes. Litigation insurance premiums had surged as a result, especially in Florida, where lawsuit and legal costs for nursing homes had risen tenfold between 1990 and 1998.

Whitman saw this cycle of despair as a window of opportunity. Along with Fishman and the owners of a nursing home chain near his office in Atlanta, his company Formation devised a strategy of buying up distressed homes, with a focus on Florida, outsourcing operations to contractors and letting standards fall even further. He paid an unheard-of $27,000 a bed, virtually all of it debt, for a portfolio of 54 facilities previously owned by Beverly Enterprises.

He kept going back to the strategy, buying unwanted, mostly Floridian properties for rock-bottom valuations from Genesis, Mariner Health Care, Laurel Health Care, and others.

Most states have minimum staffing requirements for nursing homes, though they’re usually far lower than experts say they should be. But the new chain, which would come to be called Consulate Health Care, had no compunction about scheduling well below Florida’s minimums. A 2018 presentation for a Formation deal with another private equity firm called Allegiant gives a sense of how these policies are pitched to investors. The new consortium promised to generate 12 percent annual returns by ending the “mismanagement and spiraling costs” of its “infamous” previous operator, vowing to chop annual payroll $16 million a year across 18 homes.

Formation set a model mimicked in the 190 private equity deals in the nursing home industry since

2015, a $5.3 billion bonanza. The script, written by Arnold Whitman, is familiar: facilities saddled with debt, short-staffed and underpaid workers, residents left to rot, a lack of preparedness that looms large in a pandemic. Much of the tumult seen today is a by-product of the slashand-burn strategy practiced by Formation and its imitators.

This year, thousands of infected humans have been gratuitously transferred in and out of different nursing homes, depending upon where they would be the most profitable. More than 6,400 residents found themselves evicted to homeless shelters and other

Susie Rivera, nursing home employee, New Braunfels, TX I started this work in 1986.

My first job was taking care of a lady in San Antonio. After she passed away, I didn’t know what to do, so I started working in nursing homes and I got a lot of good experience there.

Before the pandemic, I was working between 100 and 110 hours a week, mostly because my wife retired. She was a forced retirement because of her health. She worked at a nursing home almost 30 years, and she was no longer able to perform her duties because of health issues. I was kind of forced to work all these hours to provide her health insurance.

Right now, I’m working roughly 80 hours a week.

But you know, it’s really strange. I’ve always been used to working a job and having a part-time job or little job on the side, and I could do it. And now it just seems like, it’s so stressful now, our working environment.

We’re really paying close attention to the folks we take care of because we don’t want them getting sick.

They’re scared of catching the coronavirus. They’re the vulnerable age, they have health issues. Even my wife, I don’t want to bring it home. She has health issues. It’s really a lot of stress on caregivers.

—Shera Avi-Yonah

facilities. In New York, 4,500 patients infected with coronavirus were sent back to nursing homes, where they spread the disease. Others were dumped into ambulances to die in hospital parking lots, or stuffed into a closet for the police to find, for reasons unclear but possibly having to do with life insurance policies purchased in their names. Hundreds of operators seized $1,200 CARES Act stimulus checks of their patients. After the Federal Trade Commission banned the practice, some threatened to evict residents who didn’t “voluntarily” hand theirs over. Dozens more residents participated in massive amateur hydroxychloroquine experiments.

Nurses were fired for wearing masks, calling out sick, or speaking to the media about how direly they needed PPE and extra help. Nursing assistants, whose pay is so abysmally low that they are more likely to work three jobs than one, shared microbes with dozens of other homes as they ferried from morning job to afternoon job to overnight job in cramped shuttle buses and Uber pools. An 88-year-old advanced dementia patient, found wandering the highways after his nursing home evicted him to make way for COVID patients, ended up spending his 89th birthday in jail after he stabbed the nephew who had taken him in with a kitchen knife. A nursing home resident in Brooklyn who died of COVID19 was buried in a Catholic cemetery and billed $15,000 for makeup, limousine service, and $200 in rosary beads before anyone at the home informed her Jewish family—which had long before informed the facility of her already-purchased family burial plot in a Jewish cemetery—that she had died. A nursing home watchdog and attorney told me about nursing home bosses in Connecticut emptying one of the facility’s supply closets for PPE to sell on the black market, and says that when the street value of N95 masks

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

Between the roughly 150 Consulate Health Care facilities it now controls, Formation has given close to a million dollars to elected officials. peaked in April, multiple investors approached her to draw up documents enabling them to discreetly sell off their inventories.

These borderline or sometimes f lat-out criminal activities, which became front-page news during the pandemic but were a feature of the industry for years, are born of a frantic desire to feed interest and rent payments to legal loan sharks and their investors. The typical COVID-19 superspreader home was afflicted by the same problems that abuse and kill residents in ordinary times: minimal supply budgets, threadbare staffing, and “zero infectious disease avoidance protocols,” which regularly wipe out dementia wards during flu season.

When critical senior care is given over to the free market, their well-being is subordinated to the balance sheet of people like Arnold Whitman. And the would-be regulatory guardians of the elderly, housed mostly in the Centers for Medicare and Medicaid Services and focused on other matters, are at best unaware of the abuse, and at worst complicit by their negligence.

There were a few important excep-

tions to the radical austerity imposed over Formation’s Florida homes, of course. The budget for incentivizing Medicare fraud, for example,

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expanded considerably. In a whistleblower suit filed by a consulting nurse who went to work coding Medicare claims at two Formation homes in 2011, spreadsheets defaulted to the highest possible “ultra” level of care, even though no one got anything approaching that.

The whistleblower’s bosses schemed daily to rehire the drug-addict predecessor who’d been escorted from the facility in handcuffs during his third week on the job for stealing thousands of painkillers, because nurses like him understood “how to boost the bottom line.” Bosses gave cash bonuses to nurses for bringing their average reimbursement levels up, while patients’ open wounds went undressed for days at a time, a patient’s leg brace went missing for a month, and one resident subsisted on a liquid diet for a full year because a nurse couldn’t be bothered to retrieve his dentures from a dresser drawer.

In a particularly brutal scene, a 40-something Medicaid patient immobilized from a violent mugging begged an administrator to see a physical therapist as someone at the hospital had told him he would.

After his repeatedly being told there’s “no payor” for physical treatment because he’s on Medicaid, the administrator said: “You will never

walk again.” The patient died of a painkiller overdose a few years later.

Formation also spared no expense, predictably, on political contributions.

Between the dozens of Consulate Health Care facilities it now controls, Formation has given close to a million dollars to elected officials. Two months after former Florida Gov. Rick Scott signed into law a 2014 bill granting immunity from liability to “passive” investors in nursing homes, he received the beginnings of what would be $240,000 in contributions. Consulate and its related entities also spent between $260,000 and $540,000 lobbying in favor of the bill. The following year, Formation helped a near-identical bill pass in Georgia. This isn’t anything new; nursing home tycoons have been investing in high-placed friends since Bernard Bergman cultivated New York Gov. Nelson Rockefeller and Joe Kosow bought off the Massachusetts health department. In May, Politico called nursing homes “the lobbying world’s quiet powerhouses.”

Formation homes also got creative with liability insurance, buying a new product for the Consulate homes called an “eroding policy,” allowing the company to deduct its own legal fees from its ceiling. This enabled the homes to tell plaintiffs a few months into litigation that the money was all gone. “A lot of lawyers won’t even take a case when they learn there’s an eroding policy on the other side,” says Tom Edwards, a Jacksonville trial lawyer who has won numerous outof-court settlements from Consulate.

In 2007, The New York Times published an investigation into the efforts of a few mourning family members to sue a Formation property where 15 residents had died over the course of three years. “Lawyers were suing nursing homes because they knew the companies were worth billions of dollars, so we made the companies smaller and poorer, and the lawsuits

have diminished,” Whitman matterof-factly told the newspaper.

The chain has since won some unlikely allies in its bid for tort reform. In June, after a judge reinstated $255 million of the $350 million a jury had awarded Ruckh in her whistleblower case against Consulate, representatives of both the Center for Medicare Advocacy and the nursing assistant union expressed concern that the judgment would cause the chain’s standards to fall even further.

That wouldn’t be a long fall: In a survey of the 54 worst nursing homes in Florida conducted by the Naples News in 2018, 26 were run by Consulate, and 55 of its 77 statewide facilities were in danger of losing their licenses.

When things grow untenable, Whitman trades himself out of trouble. Formation sold the underlying real estate of the Consulate homes to the nowimploded General Electric Capital in 2006 for $1.4 billion. The sale of the real estate netted more than twice what Formation had paid for the homes, and nearly ten times what it had invested in cash, freeing Whitman and company to set about replicating their successes, and our health care system’s failures, hundreds more times. By 2017, Formation had acquired—at minimum, because it’s not easy to track—an additional 60,000 beds in 590 facilities in the United States, along with rehab hospitals in four states, a mobile diagnostics company called Trident, and 275 nursing homes in the United Kingdom, some of which endured their own vicious COVID-19 outbreaks in February.

Genesis HealthCare was the biggest prize. Formation took it private for $1.7 billion in 2007, sold its real estate to a REIT for $2.4 billion in 2011, spent an extra $275 million buying the remains of Gosman’s Mediplex, then in 2014 merged with another nursing home chain in California in a “backdoor” IPO. Having

financed all the deals with debt, and having used more than $700 million of the proceeds to pay Formation a dividend, “Genesis went public with 531 homes, virtually no real estate and $17.6 billion in long-term financing obligations,” on which it was paying interest rates as high as 22.2 percent. The company was glaringly insolvent, and it had sold most things of value it had owned. So it did the only thing it could: cut staff.

A Boston Globe analysis of the deal’s aftermath reported that nearly half of the homes under Genesis management had seen their Medicare star ratings downgraded since 2010. These ratings, designed to give families insight into the quality of nursing facilities, are based on limited and often self-reported information, making the downgrades all the more remarkable. In line with Formation’s other properties, more than 70 percent of Genesis nursing homes now had either a one- or two-star rating on the five-star system, and registered-nurse hours were drastically lower than the averages; meanwhile, serious infractions were on the rise.

“I would argue that the traditional REIT structure in skilled nursing has been proven to be a failure,” Genesis CEO George Hager told an industry panel in 2019. There was, he reasoned, just too much money in the real estate, and it was too tempting to cash it all out and leave seniors and nursing assistants holding the bag.

This unusual admission of something like guilt offers a painful lesson to

policymakers interested in designing a more sustainable and humane elder care system. Although Genesis oversaw thousands of deaths, although it undoubtedly committed innumerable sins of both commission and omission that caused the pandemic to spread much further in both its homes and their surrounding communities, and although the company’s fiscal woes are rooted in its structural embodiment of a system that siphons billions of dollars from our taxpayer-financed insurance system and exports them gratuitously into the offshore bank accounts of billionaires, it is not an anomaly relative to its peers in the nursing home business. The model of anything-goes for-profit facilities is as perfunctory as it is immoral.

There are solutions available.

The federal government supplies a significant portion, as much as 72 percent, of the nursing home industry’s revenue, a figure that will undoubtedly rise this year as taxpayers blanket the sector with bailouts. It must overhaul the ways it both follows that money—to curtail the amount that can legally be consumed on rent, interest payments, and pricey “management fees”— and administers it in the first place.

Rotating Medicaid patients in and out of $600-a-day Medicare-funded rehabilitation regimens has become an art form at many chains; the system as currently designed literally rewards homes that chronically neglect patients to the point that they require hospitalization.

$5.3 billion Value of 190 private equity deals in the nursing home industry since 2015

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS What we actually need is a public-health corps that can assume the reins of a perilous health care provider. The Federal Deposit Insurance Corporation has the ability to temporarily nationalize banks when it senses they have devolved into Ponzi schemes; health care regulators need to recognize that a nursing home that pays 22 percent interest on its credit lines but fails to bathe its patients is just a Ponzi scheme with humanitarian implications, and develop protocols for intervening before these develop into mass casualty situations.

After all, anyone who follows nursing home finance could have told you companies like Genesis and Consulate were going to have an especially tough time fighting a pandemic. “I mean, we all knew it was going to be bad,” says Alex Spanko, an editor at Skilled Nursing News. “It still kind of surprises me that it was as bad as it was, given that they all knew it was coming. But we knew it would be bad.”

Genesis, having spent the past four or f ive years trying to sell its way out of its fiscal hole, has tapped former Trump official and CNN regular Jim Schultz, a bald, broad-shouldered, sleepy-eyed former White House counsel, to lobby for a bigger bailout. In August, George Hager told the one analyst who still covers the company’s stock, which trades below $1, that they wouldn’t make it without one.

A slide into bankruptcy would inevitably lead to another shadowy LLC or two picking through the remains, repeating the churn cycle again. Whatever the case, without substantial reforms, our elderly, our nurses, and our tax dollars are likely to again be the losers. n Maureen Tkacik is a senior fellow at the American Economic Liberties Project.

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The Neglect of Disability Care Home care workers and unpaid caregivers who support disabled people are often left out of publicpolicy initiatives.

By Sara Luterman Alice (not her full name) has been a

direct-support professional for 12 years. Direct-support professionals are paid caregivers who support disabled people, particularly those with intellectual and developmental disabilities. Alice describes herself as “Hispanic, originally from Texas,” and she currently lives in Ohio. By her own reckoning, since the pandemic began, she has been working 80 hours a week, helping her clients use the bathroom, shower, and otherwise go about their daily lives. “I have to cover hours that are not covered by other staff,” she explained over instant messaging.

Alice makes $11.75 an hour, but gets paid time and a half for overtime, at least. She has also been receiving “hero pay,” which is just a couple of extra dollars per hour. She doesn’t know how long that will last. When asked about unionization, Alice replied, “I don’t know what that is.”

Alice’s experience is shockingly typical. According to a recent report from the ANCOR Foundation and United Cerebral Palsy, 43.8 per-

cent of all direct-support staff quit within a year. In every interview conducted for this piece, it seems that this problem has only worsened in the pandemic. As schools closed and coronavirus spread, workers scrambled to organize adequate child care, or were afraid of contracting the virus and sickening their own vulnerable family members. Care work is intimate. It’s not a job where one can reasonably keep social distance.

Already high, attrition seems to have only accelerated.

The median hourly wage for direct-support workers was $12.09 in 2017, and it rarely moves much.

While that is above the federal minimum wage, the work is hard, and the hours are long. State Medicaid programs dictate reimbursement rates—the amount of money a provider can request from the state in exchange for delivering a service. Ari Ne’eman, senior research associate at the Harvard Law School Project on Disability, explains, “States are very reluctant to take on direct spending obligations, so [direct-support workers’] pay generally rises very slowly, even as other industries increase wages to respond to market conditions.” As a result, hourly wages for direct-support workers don’t increase enough from year to year to keep up with inflation in many states. In addition, most direct-support workers do not have paid leave. Ne’eman points out, “Direct-support work becomes employment of last resort.”

As reported by Rachel M. Cohen last year, more than 500,000 home care workers have been unionized through the Service Employees International Union, which represents approximately 1.9 million workers in the United States and Canada. But unionization is still not widespread in the industry. According to the Bureau of Labor Statistics, there were over 1.4 million home

care workers, according to the most recent report from 2015.

Professor Evelyn Nakano Glenn has written extensively on the sociology of care work, most recently in her book Forced to Care, which explores the way caregiving is often coercive in our society. In particular, she focuses on the ways that race and gender are inextricably connected with how we conceive of care work. “In some ways, care work is being seen as unskilled because it is something that women know how to do naturally,” Nakano Glenn noted in an interview with the University of Minnesota’s Gender Policy Report. “Very often, the care worker is praised for going above and beyond what the requirements are by investing in that work emotionally.”

At once, care work is both priceless and somehow beyond monetary value.

As Nakano Glenn notes in Forced to Care, there is also a racial element to how we conceive of care work. “[Employers] view women from the global south as coming from traditional cultures in which families honor and take care of the elderly. Employers feel that they are more likely to work without complaining and show proper deference,” Nakano Glenn writes. “If caring is viewed as a cultural trait or a natural attribute of women from Latin America, Africa, and Asia, then their labor can be seen as effortless and not real work.” By extension, poor pay and long and uncompensated hours are viewed as natural too.

In her old age, Evelyn Coke, a Jamaican immigrant and home health aide, had become disabled herself. She needed dialysis three times a week and used a wheelchair.

During her career, she was not compensated at the minimum wage, and she did not receive overtime.

She sued, but in Long Island Care at Home v. Coke (2007), the Supreme Court ruled that she was not entitled to back wages, because home health

care workers were still exempt from the protections of the Fair Labor Standards Act extended to most other categories of employment.

The judgment against Coke was unanimous, and included Justice Ruth Bader Ginsburg, who is remembered as a champion for women’s rights. The court opinion, authored

by Justice Stephen Breyer, raised concerns that higher home care costs would lead to higher rates of institutionalization for disabled people.

Ironically, disability organizations have long advocated for higher wages for caregivers, on the grounds that it would improve quality of care. The desire to keep costs low is, primarily, in the interests of the private caregiving agencies and their profit margins, as well as budget-hawk lawmakers.

Since the start of the pandemic, the

federal government has done little to support caregivers. When he isn’t

rambling about television ratings or baselessly speculating about voter fraud, President Trump occasionally makes comments about “protecting seniors,” seemingly forgetting the existence of millions of vulnerable and disabled Americans under the age of 65 who need care. This gaping oversight has, unfortunately, been reflected in federal policy. The Department of Health and Human Services announced millions in no-strings-attached provider relief funds earlier this year, but only for nursing homes. The 2.5 million disabled Americans receiving services in their own homes and group homes are out of luck, and the agencies and advocates that support them are bracing for budget cuts and disaster.

Expected state and local austerity could bite even harder. “The way the Medicaid law is written, the first place to cut comes from optional programs, and [home care is] optional,” says

Kendra Scalia, disability care receiver, Newburgh, NY I was born with a disability called spinal muscular atrophy. When I finished my graduate program, I got a job. By any standard, you would look at my income and say I was doing very well, but almost 25 percent of my income was going to pay [caregivers’] salaries, as well as their health benefits and insurance programs.

I had gone through a medical procedure in 2012. I was in bed for two months, and my body deteriorated. When I got out of that, I needed significantly more help, more than double the amount of time that I was using prior, and I could not afford it as well as pay my rent and my bills. I was really forced to leave

my career so that I could receive the amount of care that my body needed in order to stay healthy.

I lost all of my consistency and care because the folks that I’ve been paying out of pocket were earning over $18 an hour working for me, and going back onto the Medicaid funding program, at the time, they would be earning just $11 an hour. Every single one of them had to turn the job down and find work elsewhere. It’s been a continued theme of difficulty in my life, eight years later. Finding people to work for a low wage and no benefits is almost impossible.

—Shera Avi-Yonah

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BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS Nicole Jorwic, senior director of public policy for The Arc of the United States, a leading nonprofit serving people with intellectual and developmental disabilities. Medicaid is required to provide nursing home care, but it is not required to provide any alternatives. Essentially, all non-medical home care is optional, legally speaking. Medicaid is generally the secondlargest line item on any state budget, after education spending. When budget shortfalls loom, Medicaid is one of the first places state policymakers look to make cuts. The majority of adults who need long-term services and supports live in the community, according to AARP. If cuts are administered, millions of Americans could soon have to choose between nursing homes and no state support at all.

This was nearly the case after the Great Recession. The 2009 American Recovery and Reinvestment Act provided dedicated funding for states that averted cuts to home and community-based services—assistance disabled Americans rely on to do everyday, basic tasks at home like dressing and showering. So far, legislative efforts during the pandemic have failed to provide similar relief, despite pressure from advocates.

Jorwic paints a grim picture: “It’s pretty safe to say that people with disabilities and caregivers have been ignored by Congress.”

For paid caregivers, unpaid caregivers, and community advocates, one key point of contention has been the legal definition of “caregiver” itself, which may not include caregiving outside the immediate family.

“There’s some paid leave provisions in some of the relief packages,” Jorwic said, “but they haven’t been broad enough to cover, for example, grandparents or siblings that may need to take time off work” to care for disabled family members.

Paid leave for caregiving was most

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When budget shortfalls loom, Medicaid is one of the first places state policymakers look to make cuts.

Millions of Americans could soon have to choose between nursing homes and no state support at all.

vices for the entire state. In March, they struggled to find PPE to protect their employees and the disabled people they serve. “Part of the difficulty is that we weren’t viewed as a medical facility,” explained Celine Fortin, associate executive director. “PPE was being held for essential health care workers, and we didn’t meet the official definition of essential health care worker.” It took months to secure necessary supplies.

Professional caregivers in New Jersey are still not considered essential in a legal sense, according to Fortin, but it has become easier to acquire PPE. “I think the biggest supply really came from the tenacity of the people who work for The Arc, making phone calls, going online, tapping into every person and resource they could think of,” she said. In particular, she praised a FEMA program that partially reimbursed some expenses. “Coming up with the money to pay for all of this is pretty difficult, but we’re doing the best we can, and we have to have this equipment,” Fortin told me.

prominently featured in the Families First Coronavirus Response Act, but “the text of the law said school closures and child care centers,” explained Kathleen Romig, a senior policy analyst at the Center on Budget and Policy Priorities. “It did not allow for adults who have caregiving needs,” meaning care for disabled adults and seniors.

Another contentious definition: the meaning of “essential,” as in essential workers. Initially, most states did not include home health and disability support services in that definition, and in some states, that is still the case. That means many professionals did not have access to personal protective equipment, or PPE. The Arc of New Jersey, for example, operates 20 local county chapters, which provide direct ser-

Unpaid caregivers have also strug-

gled during the pandemic, with little to no assistance. Sarah Coletti lives in Massachusetts and describes herself as a “retired software developer, mother, and daughter.” In April, her father, who has Alzheimer’s, was moved to the hospice unit at a VA hospital. Due to the virus, he hasn’t been allowed to have visitors. Coletti hasn’t seen him in months, except for video calls. In May, her mother died.

Coletti suspects the cause was coronavirus, despite a negative test. “Everyone who was closely involved with her care wound up getting COVID,” she explained over the phone. And through everything, Coletti and her husband have been providing roundthe-clock care for their son, Adam.

Adam is 31 and has a develop-

mental disability. He likes music and making noise, particularly by tapping on or shaking things, but he does not speak. He also loves being around other people. “In ordinary times, he’s very social,” Coletti told me. For the past nine years, Adam has lived in a group home and attended an adult day program.

The group home was already having difficulty filling shifts and retaining staff before the pandemic, and Adam needs a substantial amount of support. In March, the state of Massachusetts closed all day programming for disabled people, along with schools, state parks, and other public services. Around the same time, the group home stopped allowing visits. “You can’t put somebody who’s nonverbal in a house and not be able to visit them,” Coletti explained. “[Adam] can’t make a phone call and say, ‘I think I have athlete’s foot,’ or whatever. Minor things don’t necessarily get caught by [staff].”

Coletti was also concerned about what would happen if Adam ended up in the hospital alone. Because Adam does not speak, it can be difficult for unfamiliar doctors and nurses to understand him. “Whenever he’s been in the hospital, we’ve just arranged to be there with him, so we could interpret,” Coletti said.

So despite already providing care for her elderly parents, Coletti and her husband decided to move Adam home to care for him. They have been doing everything direct-support staff normally do, but without any pay.

Adam’s world has shrunk significantly since the start of the pandemic.

Like many people with intellectual and developmental disabilities, he struggles to wear a mask, being sensitive to touch on his face and head. “He keeps a bandana in his teeth, which doesn’t work like a mask, but at least when we’re taking a walk people don’t freak out,” Coletti told me. There are

many activities Adam is now excluded from; he can’t go with his parents to run errands like he used to. “[Adam] used to love to go grocery shopping, but now we don’t do that.”

Coletti is adamant about the importance of increasing direct-support worker pay. Many of Adam’s support workers have multiple jobs; just working as a direct-support professional often isn’t enough to cover the bills. “The pay scale for direct-service professionals should allow them to work one job and be good at it,” Coletti said. She also stressed the importance of paid sick leave. “[Group homes] are so short-staffed that if somebody’s calling out sick, it throws everything out of whack. So people who are dedicated don’t do it. They don’t call out sick when they’re sick.”

Some states, including Massachusetts, provide some financial support for family members who provide care at home. Coletti praised the program, which her family was enrolled in before Adam moved into the group home. But the program is not technically available to her family right now, because in order to access it, Adam would need to give up his spot in the group home. Waiting lists are years long, and there’s no guarantee he’d be able to go back. Adam seems to prefer living in his group home, and the transition back to living with his parents has been difficult. “He’s normally a pretty happy guy, but he got unhappy

2.5 million: number of disabled Americans receiving care services 3.4 million: total home health and personal care aides in 2019 $12.15: median hourly wage for direct-support workers in 2019

after about two months of hanging out with Mom and Dad,” Coletti said.

When there isn’t a pandemic, respite care is an important service for family caregivers, in which paid caregivers provide care for a short period of time. Caregiving is work, and even the most devoted and loving family caregivers need breaks. “We could really use some respite care,” Coletti told me, then paused. “We’re probably too nervous to accept it, even if it existed, but it doesn’t exist,” she said.

Adam’s day program recently reopened with some modif ications, and while Adam is still living at home, this has given Coletti the opportunity to have some time for herself. “I was feeling really ragged, but now that I get in a couple hours [of sleep] every day, now that I’m starting to exercise again, I’m starting to feel better, and I’m better at caregiving when I’m feeling better,” she said. Adam is happier to have a small sliver of normalcy back too.

“My son is very particular and develops strong relationships with certain people,” she said. “More of the staff that he was used to have come back, and his favorite people have come back. And now, he’s much happier.”

The future is uncertain. The pandemic isn’t over, and a second wave is looming as we head into winter. State budget cuts are looming, too. If Congress doesn’t act, if Congress doesn’t secure relief funding for Medicaid home and community-based services, if care workers are not deemed “essential,” and if the needs of Adam and the people who care for him, paid and unpaid, are ignored, some of the most marginalized members of our society will suffer in silence. n Sara Luterman is a freelance journalist and opinion writer who focuses on disability policy. She is based in Washington, D.C.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 45

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

How the Pandemic Disrupted Care

Families have been forced into impossible decisions to ensure that their loved ones get the assistance they need.

By Tasmiha Khan As millennials become parents while

baby boomers age, care across generations is needed more than ever. However, during the COVID-19 pandemic, a lot of the options once in place for family care have been badly disrupted, further exposing cracks in the system.

This has brought tremendous hardships on families at an already difficult time, as they navigate personal financial struggles: parents losing income, families being foodinsecure or lacking access to basic needs and health care. Plus, with classes resuming throughout the country in the fall, and most schools beginning with either fully remote learning or a hybrid model, parents need continued child care support in order to return to the workplace, adding additional burdens they didn’t previously have. The act of social distancing, an act of compassion, has

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isolated families, making them more reliant on care networks that are buckling amid the economic crisis.

Despite these novel conditions, however, the pandemic has reiterated what was already known: The care system is broken, and families need a much stronger safety net.

For years, U.S. care and education systems have been underfunded and undervalued. When the pandemic began, parents, teachers, and child care providers stepped up, devising new ways to help children learn, putting their own lives on the line to care for children, and investing their own resources to keep themselves, their families, their colleagues, and communities safe. While other industries, like airlines, have received a large influx of funds to help them stay afloat, no such rescue package has yet been available for family care or public education—both of which should be essential public assets for society.

The Bipartisan Policy Center’s Early Childhood Initiative reports that over 70 percent of child care providers are closed or operating with limited hours or space. As a result, 44 percent of parents are unable to work without child care. Some providers remained open during the pandemic to care for the children of essential workers, while others closed in keeping with public-health guidelines. Eventually, closures became permanent, as providers became unable to sustain operations. Many others are now looking at reopening, amid concerns about health and safety and lower enrollment, which will decrease revenue at the same time costs for cleaning and health and safety supplies are going up.

The lack of options has been enormously taxing on families. Myra A., an Illinois resident who asked to use a pseudonym due to family dynamics, explains how she has had to change jobs because she could not find child

Stan Chen, restaurant owner, Syracuse, NY The coronavirus pandemic hit my restaurant hard. With less dollars making their way to our register, we decided keeping our babysitter was no longer feasible and decided to start bringing our kids to work.

Sometimes I give them chores, like clearing tables or peeling carrots, so they have more to do and can feel like a part of the business.

When my wife or I are unable to have our eyes on them, our employees offer us help. Though it’s not an ideal situation, we’ve had a lot of fun spending extra time with them, and I think for the most part they’ve enjoyed being able to spend their time around us.

My wife and I know we’re lucky though. We cannot afford to offer our employees the same option, and if we didn’t own the business this would never be feasible. I think if child care was cheaper, more couples would be able to make a dual income, which would help alleviate a number of financial struggles.

However, I also don’t think this cost should be placed on people who choose to not have kids. Perhaps a fair way of providing child care, without adding a substantial financial burden, would be through reforming the school system by implementing universal pre-K and offering extended hours.

—Alex Rouhandeh

care. Her original job required long hours in the office with little time for child care. She switched over to a project manager role, where she is able to work remotely. While she initially wanted to move into her own place with her husband and two daughters, because of the child care issue coupled with her husband’s aging parents, Myra and her family decided it was not affordable to leave the premises. Instead, she decided to stay with in-laws.

For Safa Khudeira, a resident of Illinois, her grandfather had a caretaker who would come in the morning and leave at the end of the day. “My mother had to send the caretaker home to his family for good and quarantined herself with him for months,” Khudeira tells me.

“I couldn’t see my mom for months because she was too scared to see anyone or let anyone anywhere near her.” Khudeira also isolated from her family to protect her father, who is immunocompromised. “It’s obviously difficult for everyone to live through a pandemic like this, but for some people it becomes a question of when will I be able to see my family members up close and personal without endangering them,” she adds.

Khudeira’s grandfather was in a nursing home for rehab before the pandemic, and even then the situation there was bleak. While family would visit her grandfather, others had few visitors, which became the standard after the virus hit and visitation was restricted for the safety of residents. “After COVID-19 hit, it felt so lonely to not see anyone and it made me so sad to think about how their senior citizens in the nursing homes felt. I couldn’t even imagine it,” Khudeira explains.

For others, the dangers to elderly populations have posed additional challenges. A 26-year-old resident

who did not wish to be named, from Dover, Massachusetts, works at a hospital school as an essential worker. “Hazard pay ended before the hazard did,” he tells the Prospect. He had to fundamentally change his life to protect those around him, including physically moving away from his elderly grandparents and restructuring his financial obligations to pay rent on a new apartment that would allow him to socially distance. He accepted this financial and social burden in order to continue working at his health care job, because he cared about the children he works with, while also needing to keep his grandparents safe. Help from the hospital school was not forthcoming. “My union representative works night shifts as a nurse, so I cannot contact her for assistance with this situation,” he says. He has resigned himself to the financial cost of keeping his patients and family safe.

Dominique Hail, who has been working at a nursing home in the suburbs of Chicago, has seen the stark changes for residents and their families. “There has been a severe toll

on patients and their loved ones as they cannot come into the rooms or the facilities. Loved ones are passing away and no one can see them,” Hail explains. “The uncertainty adds to the anxiety,” she adds.

As restrictions have eased, Hail’s nursing home has allowed for 30-minute outdoor visits. That has provided huge relief, since families are able to exchange food and see each other while still observing social-distancing protocols. But it’s no substitute for full connections, and it puts strain on care workers dealing with lonely and stressed individuals.

Unfortunately, care has been disrupted not only for grandparents but also uncles and aunts—especially if they are elderly. Saira Yousef, a baker who runs Tootie’s Treats, from Illinois, has family members who have been unable to see her two elementary school–aged children for several months now. Her husband has a cab business that completely shut down since the pandemic. Together they are trying their best to make ends meet. As independent business owners, they have had access to no paid

The pandemic has reiterated what was already known: The care system is broken, and families need a much stronger safety net.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 47

BUILDING UNIVERSAL FAMILY CARE: CAREGIVING IN CRISIS

leave or other types of benefits to help offset costs. “It’s really sad and the pandemic has taken a toll on us mentally and emotionally,” Yousef says.

Emijah Smith from Seattle invests her time working toward racial jus-

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tice and eliminating forms of oppression, as the community engagement manager at a prominent nonprofit.

When speaking to her about intergenerational care, she mentioned how mainstream institutions define

family from white-centered cultural norms. “Our institutional policies are steeped in white supremacy and anti-Blackness. To be equitable, we must value the dynamics of BIPOC [Black, Indigenous, and People of

The many cracks in our system of care have left the economy reeling, and exacerbated racial, gender, and economic inequality.

Color] families when determining public policy,” she urges.

When it comes to care, the definition of family needs an upgrade, Smith says. She applauds organizations that implement family leave policies that define “family” by blood relationship as well as affinity, as defined by the individual. She explained how cruel and evil acts of U.S. enslavement stripped Black/ African American families apart involuntarily, separating children from parents, siblings from siblings, and husbands from wives as a standard practice. Determined to survive, Black people took care of one another and created family, whether blood-related or not. “In an effort to determine a family connection, it is very common today for Black/ African American people at first introduction to ask, “Who are your people?” Smith says. “My first cousins are like sisters and brothers to me. If anything happened, I would need to be there for them, their children, and their parents.”

Leave policies have different definitions at the federal level and depending on the state, and cousins, aunts, uncles, nieces, and nephews often do not qualify. The pandemic has expanded this gap, limiting who

can take time off to help give a family member the care they need. “Our institutions and systems continue to produce public policies that deny access and opportunity to families who do not fit white-centered cultural norms,” Smith says. “Unfortunately, our federal and state paid leave policy follows suit. We must do better. No excuses.”

Others find themselves sandwiched between providing care for both the young and old. As lifespans increase and wages stagnate, this burden has grown for families that have few resources to get outside help. Nadia Hussain, a campaign director at MomsRising, an advocacy organization for mothers and families, has one child in kindergarten and a five-month-old. During the crisis, she asked her older parents to move in, to protect them from COVID19. Her father suffered a mild stroke recently and requires assistance. Her mother can help with the youngest child, but doesn’t have the technological savvy to ensure the kindergartener stays online. So Hussain must simultaneously assist with her young child’s remote learning, take care of and breastfeed her baby, and provide care for her father, all while working full time.

“I am very lucky to be able to be at a job where I was already 100 percent remote and with great paid leave benefits,” Hussain says. “Even with the benefits in terms of a supportive remote job and economic stability, I struggle with trying to handle everything. I can’t fathom what workers without access to paid leave are doing.”

Hussain worries about the future, with fewer child care options due to closures and bankruptcies, and with parents unable to take work due to child care, or losing income due to a lack of paid leave. “This isn’t just about the economy; it is a life-anddeath situation,” she says. “We must support paid leave for all workers.

Not doing so would literally destroy lives, it would torpedo our economy, the job market, and the livelihoods of so many families.”

The many cracks in our system of care have left the economy reeling, and exacerbated racial, gender, and economic inequality. Whether Americans stay home with children, work in a school with teenagers, run a family child care home with infants, strive to both work and parent, or provide care at a center with the young and old, they must sort through an impossible set of options to care for children and parents, with next to no government support.

While the country faces incredible uncertainty in almost every aspect of life, one thing we are certain about is that Congress has the ability to make this time substantially safer and less burdensome by providing significant additional federal relief funding for care. n Ta smiha K han wr ites about issues that impact families as a result of policies, and her work has appeared in National Geographic, The New York Times, and Vanity Fair, among others. Follow Khan at @CraftOurStory.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 49

Everyone Deserves Care

50 WWW.PROSPECT.ORG SEP/OCT 2020

A sustainable and equitable economic recovery requires big investments in our care infrastructure and must include child care, paid leave, and home- and community-based services and support.

All of these groups agree.

If you do, too, join us: www.caringacross.org 9to5

Demos

Alabama Institute for Social Justice

Disability Rights Education and Defense Fund (DREDF)

All Our Kin

Economic Opportunity Institute

National Respite Coalition

American Association of Caregiving Youth

Economic Progress Institute

National Women’s Law Center

Economic Security Project

New Jersey Citizen Action

Autistic Self Advocacy Network

Equal Rights Advocates

A Better Balance

Family Forward Oregon

New Jersey Time to Care Coalition

Better Life Lab, New America

Family Values @ Work

North Carolina Justice Center

BlackHer

Florida Black Women’s Roundtable

Pacific Community Ventures

Georgetown Center on Poverty and Inequality Economic

Paid Leave for the United States (PL+US)

Security and Opportunity Initiative

PHI

Capita Caring Across Generations

Groundwork Collaborative

POWER-PAC IL

CCD Long-Term Services and Support Taskforce

Hawai’i Children’s Action Network

Public Health Institute

Center for Economic and Policy Research

Insight Center for Community Economic Development

The Arc of the United States

Center for Law and Social Policy (CLASP)

Institute for Women’s Policy Research (IWPR)

The Women and Girls Foundation

Center for Public Representation

ISAIAH (MN)

TIME’S UP Foundation

Children’s Defense Fund Minnesota

Justice in Aging

Women Employed

Labor Project for Working Families, FV@W

Women’s Rights and Empowerment Network

Maine Women’s Lobby

ZERO TO THREE

California Association for Adult Day Services California Work & Family Coalition

Closing the Women’s Wealth Gap COLAGE

MomsRising

CommunicationFIRST

Mothering Justice

Community Change Action

National Association of State Head Injury Administrators

Community Organizing and Family Issues Connecticut Women’s Education and Legal Fund (CWEALF) ILLUSTRATION BY JAMES QUARLES

National Employment Law Project National Health Law Program

Paid Leave for All

Poder Latinx

Public Justice Center

National Domestic Workers Alliance

SEP/OCT 2020 THE AMERICAN PROSPECT 51

BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION

An Interview With Ai-jen Poo

The head of the National Domestic Workers Alliance talks about her vision for a unified, integrated family care infrastructure.

BUILDING UNIVERSAL FAMILY CARE THE SOCIAL INSURANCE SOLUTION

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By David Dayen Nobody over the past 25 years has done more to uplift the historically downtrodden profession of care work in America than Ai-jen Poo. A MacArthur “genius grant” winner and the director of the National Domestic Workers Alliance, Poo began organizing nannies, housekeepers, home care, and child care workers in 1996, winning real benefits at the local level for a workforce largely composed of immigrant women and women of color.

Last year, a coalition Poo codirects—Caring Across Generations— developed the concept of Universal Family Care, a social-insurance program not unlike Social Security. Out of one fund financed by broad incremental taxation, families would be able to count on early childhood care and education, paid family and medical leave, and long-term supports and services for elderly family members and people with disabilities. It would create a single access point for

families to manage their ever-changing care options; and it would supply an expanded care workforce to handle those needs, making a living wage in a respected profession.

I talked to Poo about the basics of universal family care, the critical racial-equity component of the effort, and how to organize the vast constituencies of those who give and need care.

She compared the effort to improve the standing of care workers today to the labor fights in manufacturing in the last century. And she centered the need to value caregiving as a central component of quality of life.

A transcript, edited for brevity and clarity, follows.

Can you lay out for us how a Universal Family Care program would work?

Ultimately, what we need is a big public investment in all of our caregiving systems. So child care should be universally accessible and affordable, and child care workers should earn living wages with benefits and union representation. Paid family leave should be universally affordable and accessible regardless of where and how you work. And then long-term supports and services should be universally affordable and accessible, and the entire workforce that holds up that system should earn living wages with benefits and representation. Those are the pillars. That’s the goal that we’re trying to get to.

The idea of Universal Family Care is to create a framework where those pillars of a care infrastructure will be fully funded in a durable way and integrated, unified, and interdependent. One financing mechanism that we’ve explored is social insurance.

The reason why we like that idea is that, in the history of this country, social insurance has been a way that we’ve been able to sustain programs

that become a fundamental part of our social contract.

I also believe that there are other ways of doing this. Ultimately, it’s a question of priorities and values.

I think that Congress, today, could decide to fully fund our child care programs, expand Medicare to provide long-term services and supports, and expand Medicaid and rebalance it to [offer] support. I think, for example, the care economy plan that the Biden campaign has laid out is a really strong step forward in that direction. It also centers the needs of the care workforce in a way that is unprecedented. I think that’s a critical piece, especially when you look globally: There are other countries that have stronger child care infrastructure and even stronger long-term care infrastructure, but the piece about the workforce is always one that is sidelined.

Why did this concept appeal to your organization? We’ve seen elements of universal systems for one long-term support services

program or one child care program, but could you explain why you felt a holistic, family care system was so important?

When you look at all of these programs, the user is essentially an intergenerational family unit. The need for paid leave is often connected to the need for long-term supports and services, which is not just for elders but also impacts children in a multigenerational household. And so having a holistic approach that’s unified and really understands the independent and interconnected needs of families that are intergenerational is really the future. Looking at the problem in silos doesn’t get to that root issue that care should be fundamentally supported across the lifespan in an economy where most adults in a household work outside the home.

Part of the devaluing and underfunding of these programs has meant that the public-policy approach to these programs is really one of scarcity. The wages of workers are pitted against access to services for families. So consumers and workers are

“Having a holistic approach that’s unified and really understands the independent and interconnected needs of families that are intergenerational is really the future.”

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BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION pitted against each other. When in reality, the way that care functions is also interdependent and more in a teamlike setting. Take [for example] care for someone with Alzheimer’s.

You actually need family caregivers involved, you need oftentimes home care support, you need paid leave.

The workers and the families in the practice of providing care need to work together. And the fact that their interests are often pitted against each other is a huge problem.

Universality of access to these programs is not just a “nice to have,” but fundamental to any of these programs. As is a really strong care workforce. When we think about care, it really is infrastructure.

Yeah, it’s dependent on human infrastructure. And you wouldn’t build half a bridge.

Exactly.

How would universal family care specifically help minorities and promote racial equity?

Historically, this work has been associated with women in our families.

Some of the first domestic workers in this country were enslaved Black women. And ever since then, this work has been disproportionately held by an underpaid and explicitly excluded workforce of Black women and other women of color.

There’s a deep history here. As the labor laws were being enacted in the 1930s as part of the New Deal reforms, there were debates in Congress. And Southern Dixiecrats refused to support a number of the labor laws if they included protections for farmworkers and domestic workers, who were Black workers at the time. That exclusion in the laws really did shape the treatment of this workforce in our labor policy. That, combined with our failure culturally to really invest in caregiving systems

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that would support working families, has led us to a time now where families don’t have an infrastructure of support to support their child care or elder care or support for people with disabilities.

And you have Black and Brown working-age adults disproportionately concentrated in low-wage service jobs where the numbers don’t add up, and they’re not able to afford the care that they need. Whether we’re looking at it from the lens of care consumers or from the lens of an underpaid care workforce, it’s disproportionately and overwhelmingly impacting Black and Brown families.

It’s one of the reasons why Black women have been on the forefront of organizing to improve the wages, improve the working conditions, address the exclusions in the labor laws. And there have been many generations of Black domestic workers who have fought and made real gains. Everyone from Black washerwomen in Atlanta in 1881, to the National Domestic Workers Union that Dorothy Bolden started in Atlanta, Georgia, to the work of Carolyn Reed in New York, to our work today at the National Domestic Workers Alliance.

Just recently in fact, the Black domestic workers within our movement have launched an agenda called the Unbossed Agenda. Which is really a vision for how we can value and care for Black women who are doing the work to hold up the care economy. And it includes support not only for the federal Domestic Workers Bill of Rights but also Universal Family Care within that vision.

With respect to the workers, if there’s large funding support, people will want to not only be in care work but stay in it. The quality of the workforce is going to improve as the standards of the

workforce improve. Do you see these jobs in the same class in terms of size and value as the manufacturing economy was in the 1940s and ’50s?

Care jobs are a large share of the jobs of the future. They are jobs that cannot be outsourced, they’re not going to be automated, at least not anytime soon.

They’re essential, as we found during this COVID crisis. And they’re jobenabling jobs. So when you raise the wages and you improve the conditions and make these jobs more sustainable, it not only benefits those workers and their families. These are jobs that enable other Americans to go to work more sustainably, knowing that their families actually have the care and supports that they need. And without a big public investment in our caregiving systems, we won’t get there.

Right now, we lose some of our most talented caregivers to other

“Care jobs are a large share of the jobs of the future ... These are jobs that enable other Americans to go to work more sustainably.”

low-wage service professions like fast food and retail. They cannot survive on the wages they earn doing care work, and have been forced to supplement [income] with driving for Uber and Lyft, piecing together an income as opposed to understanding that this is a valued profession.

Those manufacturing jobs were at one time dangerous, precarious, lowwage jobs that were done by women of color and immigrant women, women of marginalized social status. And we transformed those jobs into living-wage jobs with real economic security and mobility, where one generation could do better than the next. And a sense of real pride and dignity in the work. That’s what we must do with the care workforce.

The first half of this issue of the Prospect is basically the stories of people who are stressed out because of the lack of support that they get. Do you think that more than anything, this is about liberty and peace of mind?

I absolutely think it’s about liberty, freedom, and in many ways democracy-enabling jobs. I don’t know if you’ve ever had someone in your life who has had a stroke, or has had a form of dementia, or even just dealt with raising children. It is emotionally and energetically challenging enough without the crushing pressures of affordability and navigation of eligibility for programs. The added stressors are definitely an inhibitor on our collective quality of life in this country.

Right now, the only way some families have to solve this crisis is through uncompensated care.

Do you see as part of this proposal a mechanism to compensate family caregivers who choose to stay home and take care of loved ones?

Absolutely. I think that care in America, because of the huge need, especially on the part of a growing aging population, is an all-hands-on-deck situation. We’re going to need a really strong care workforce, we’re going to need supported family caregivers, and we’re going to need friends and family all providing care. And the government needs to play a role in supporting all of that.

It will have huge ripple effects across our economy, including sup-

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BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION porting women’s labor force participation as a whole. We’re hearing so many stories of women who are dropping out of the workforce right now because they can’t navigate or get access to care they need during the pandemic. It’s undermining and rolling back decades of progress when it comes to gender equity. We should be thinking about all of that when we think about the payoff of investing in our family caregivers and our professional care workforce to really be part of the solution here.

You mentioned Joe Biden and the care piece of his Build Back Better agenda. We have seen more attention paid to this issue in recent years. What more is needed to make family care a top political priority? Do you think that outlining a definitive universal policy in the way that you have plays into that?

We need to have a concrete framework that candidates can really champion. I think we do need as voters to show up as care voters. And to have a public demand and to be able to see ourselves as a constituency. At Caring Across Generations, we very much see our work as about building the caring majority. The theory is that in this country there are at least 100 million people who are directly affected by the need for care. That is a huge and powerful force for change in our country. And if we would just recognize that identity that we all share and the need to really come together to demand more of our candidates and our elected leaders, I think you start to see the action comes in the reaction. That starts at the grassroots level in the community. Every level of office, from municipal city councils, to state legislatures, to Congress. I think that the political infrastructure needs to hear from us

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as care voters. That this should be a national priority for policy change.

You mention the potential size of this coalition, 100 million people. That is extremely powerful, but at the same time, getting ten people in America on the same page can sometimes be difficult. How do you direct a coalition like that, with different aims and goals?

I do think that the dignity of work and the importance of caring for families are pretty core values that are shared across communities in this country.

The path to getting there? Certainly, there’s going to be lots of debates and different kinds of priorities within that. But I think having a foundation of core values that at least we aspire to in this country, if we’re not always good at reflecting back, are really key.

At Caring Across Generations, we’ve always centered equity, in that we’ve looked to highlight the stories and experiences of caregivers and care workers who face multiple challenges when it comes to realizing health and well-being for their families.

One thing we do quite often is we begin our meetings by asking people to share a story about someone in their life who’s cared for them, and the value of that relationship. It really does speak to something that first lady Rosalynn Carter used to say quite often, that there are only four kinds of people in the world: people who are caregivers or will be caregivers, people who need care or will need care. Most of us occupy more than one of those identities at any given moment. And I think if we can anchor into that shared experience, and also put at the forefront people who are facing the greatest amount of pain and challenges when it comes to care, then I think you have a formula for building a kind of majoritarian movement. n

Building Back the Care Economy We have a moment to right many historical wrongs for care workers, which create racial and gender inequities.

By William E. Spriggs By its nature, the care economy has always been the place where clashes of gender, class, and race meet. It is the marketplace for the most genderized of work—the personal care for the social production of families. Historically undervalued because it is “women’s work,” when caregiving has market value, it is for services for the privileged who employ those who lack privilege by class, race, gender, and immigrant status.

This intersection, in all economies, leaves workers who provide these most intimate of personal care services—to nurse the young, cook and clean for adults, and care for the elderly—outside the bounds of work regulations and social protections. In the United States, it was the work of slaves and immigrants, more recently still the work of African Americans and newly arrived immigrants, and always a workforce dominated by women—

though for the wealthiest, “prestige” required Black male chauffeurs or butlers, or in California a male Japanese gardener. By virtue of their status, these workers were deliberately excluded for issues of race, gender, and class from the New Deal–era protections of the Fair Labor Standards Act, the Social Security Act (including its provisions for unemployment insurance), and the Wagner Act. Changes in our economy and advances of the civil rights movement repaired some of the earlier damage to care workers, but as we’ve seen in the coronavirus crisis, the changes were not enough.

The integral role of the care economy is ignored by the consensus of economic policymakers. Because the non-market activity of care is ignored by the gross domestic product, it goes unmeasured and is marginalized (for example, when it is done off the books by those who are undocumented or still in the shadows) and buried in some residual of activity. No thought goes into this critical sector when arguing for economic stimulus.

Further, the care economy is the ultimate in “trickle down” eco-

nomics, since the market activity is commanded by the privileged at the top of the economy to purchase the services of those at the bottom of the economy. To the extent the care economy makes it into the discourse at all—in discussions of how prohibitively expensive child care has become, for example—it tends to center on the problem that when a service is dependent on the rich to provide the market, the price is out of reach of those in the middle. So, while we acknowledge the advantages to women’s labor force participation from having the help of the care economy, the debate focuses on delivering those same services to the middle class at lower cost. Too often, this does not translate into broad public support, but instead ways to reduce costs through deregulation of services or labor standards, pitting middle-class women against those further down the income scale. Even the more progressive discussion that calls for broad public support too often leads with “pathways” and “training,” not so subtly accepting the low wages and labor standards of the care industries, and demanding of care workers that they

For all women, one of the biggest components of their gender wage gap is derived from care worker wages being set low.

continue to earn low wages until they can prove themselves worthy of decent working conditions and livable standards.

The coronavirus has made these fault lines crystal clear: the disparities in who is exposed to the disease because they continue to provide care to the elderly, and who is unemployed and outside the safety net because social distancing has shuttered their job opportunities.

The death toll in elder care facilities has been staggering and, considering our national outrage during the Vietnam War at loss of life, callous to the extreme, because this death toll was far larger. On the job loss side, in the child care industry alone about 66 percent of jobs were lost from February to April, dipping to an employment low of 668,000.

Those workers were dumped onto unemployment rolls that mushroomed because of our poor planning compared to other industrial nations, which protected payrolls when they shut industries. Policymakers had to scramble to deliver relief to these quickly disemployed populations, because in a normal economy fewer than 8 percent of unemployed workers in low-wage service industries get unemployment benefits, a number made low because of the persistence of issues when they were initially excluded from the New Deal worker protection framework.

With school-age children now sheltered in place and learning at home, the broader discussion and appreciation for the central role of social production in our economy is front and center. Thanks to the Progressive movement of the late 19th and early 20th centuries, the education of our children, a central role of the care economy, has been fully measured as part of our GDP. What happens to cafeteria workers, bus

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BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION

$470 billion

Uncompensated care work is not included in the measurement of gross domestic product. A 2019 AARP report found that unpaid care was worth $470 billion in economic value, or 2.2 percent of GDP.

drivers, school crossing guards, and teaching aides is fully measured, and their loss of jobs is not off the books, but visible and borne by our safety nets. Many of those workers are in unions and can exercise their voice, at work and in shaping policy. And women, as caregivers, have been left to struggle with a growing set of responsibilities pushed back into their laps.

This would be a great moment to once and for all have society recognize the necessity of the care economy. Pulled from the shadows in the pandemic, we can all recognize the positive externality of its production. As with all goods with positive externalities, the government must boost the price through all means to increase quality and quantity. Boosting the price begins with boosting the wages and working conditions of the care workers.

For all women, one of the biggest components of their gender wage gap is derived from care worker wages being set low. Undervaluing the social production women do “for free” reduces the reservation wage for women generally. This low set of

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wages in female-dominant occupations is in large measure because of the low shadow price of care.

This is also key for the racial wage gap. The majority of Black workers are female. Lost in the shuffle and misdirection of American race dynamics has been that Black women have always had a much higher labor force participation rate than white women; despite having much higher unemployment rates, a higher share of Black women are employed. Amidst the idiocy of claims of “welfare queens” who bred and reproduced laziness, it has always been the challenge for Black women to fill the obvious strain of providing adequate socialproduction functions in the Black community, while working so many more hours than white women outside the home, where care service is provided. The intersection of race and class similarly created a layer of jobs held by Black men in personal services (landscaping, doormen, porters) that pull down the earnings of the Hispanic men who took over this work, and still haunt some Black men.

So, in this moment, to build back a better economy, let’s take the obvious first step and fully protect all workers, especially domestic workers, with the full breadth and weight of the law. We can raise the minimum wage on a path to $15 an hour and provide all Fair Labor Standards Act and Social Security Act protections for all workers (no exceptions). We can modernize our unemployment insurance system to cover all workers, and not just average-wage, full-time workers— read: male workers. We can give all workers paid leave and sick days, like other advanced economies. We can grant all workers the rights to organize and bargain collectively, including adopting a domestic workers’ “bill of rights.” And we can pass meaningful equal-pay laws. In short, we can pass laws that respect the work of all women, accord all women equal rights with men who work, and afford equal protection to all work. We now have studies showing that during the COVID crisis, unionized nursing care facilities suffered fewer deaths and less spread of the disease, showing us

that empowering workers is something we all benefit from.

The second step is to finally recognize the necessity of the care economy and social production.

We do that by implementing paid paternity and family leave (like all industrial nations) and by using government support to fully cover early-childhood and quality child care (like other advanced economies). The unconscionable level of deaths in nursing homes and the current pressures of nursing homes to expel low-income patients highlight the need for expanded, consistent, quality care for late life. As our nation’s demography changes, a rising share of seniors will be people of color with no wealth. Our current elder care problems will show a deeper crisis level if we do not act now to set up a better system of elder care.

The hypocrisy that we celebrated white women who stayed home to do care work, but castigated Black women on welfare, is rooted in the race and class divide that in the end denigrated all care work. Let us put care work fully into the monetized portion of the GDP, so we value it.

Hopefully, it is now clear to everyone how much easier it would have been to manage this crisis if we had a fair value on the cost of care. These policies would have made handling this crisis easier. It would have made our economy more equal, and therefore less fragile. Correcting these errors has proven too costly, only made palatable because of the much bigger costs we would have incurred by even more loss of life, but for social distancing. n William E. Spriggs is a professor of economics at Howard University and chief economist for the AFLCIO. He serves as a Prospect board member.

Economic Rights as Industrial Policy Family care policies can be part of a transformation that centers the worker in economic relief efforts rather than companies.

By Cassandra Lyn Robertson and Darrick Hamilton The coronavirus recession has had a deep and rapid impact on our economy, exposing both the economic precarity of American families, and even worse, enormous hardship disparities by race. Millions remain out of work, and 22 percent of small businesses are predicted to close. The Black unemployment rate remains far higher than the white unemployment rate, and 41 percent of Black-owned businesses have succumbed to economic collapse. The virus has revealed our collective vulnerability and the important role of race in conditioning economic and life outcomes.

The extent of the pandemic’s

destruction of both lives and livelihoods was not inevitable. It has been the result of poor policy choices. Unlike other developed nations, our patchwork health care system that ties insurance to employment has led to millions losing coverage in the middle of the pandemic. The unemployment insurance program is purposefully stingy, and there is no county in the country in which a family can live on unemployment insurance alone. (Federal supplements to unemployment kept people af loat until they expired, but the real scandal is that they were needed at all.) The destruction of unions meant workers had little power to advocate for better workplace conditions to protect themselves.

Structural racism manifested in economic and political vulnerabilities that made Black and Brown Americans more likely to contract and die from COVID-19. This was all preventable.

We need new policies and policy frameworks to ensure widespread economic security. As Congress debates future policies, instead of asking the habitual question of how can we keep businesses afloat, policymakers should examine what is good for the worker. This should center on universal social benefits like child care, elder care, health care, and housing. An explicitly anti-racist and anti-sexist Economic Bill of Rights for the 21st century has never been more necessary. Economic rights for workers in particular, including paid family and medical leave, should be central to any recovery from this pandemic.

Though industrial policy and labor policy have often been conceptualized as two different domains, this division is unhelpful and unnecessary. Industrial policy has traditionally focused on supporting sectors and firms. For example, the federal

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 59

BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION government provides tax subsidies for the energy sector, encouraging oil and gas production. Similarly, states provide tax credits to encourage businesses to open headquarters in particular locations. These types of policies are based on the faulty assumption that encouraging business will lead to economic dynamism and job growth that proverbially “lifts all boats.” What is not considered is whether the stimulus actually leads to net quality job gains. Instead of hoping good jobs will trickle down, the government should ensure that workers directly benefit from government interventions in the economy.

Worker-focused labor policy could lead to overall economic growth, while dampening the broader impact of any future downturn by ensuring a base level of worker support.

It would produce economic growth by focusing on the infrastructure that counts the most—green energy, public-health systems, and a care network for all Americans.

A new industrial policy that centers the worker would promote a fairer economy grounded in shared prosperity. During the Great Recession, the banks were bailed out by federal intervention and kept solvent, while many workers had their life savings wiped out and their homes foreclosed. Rescuing the banks was inadequate to ensure security for the American worker, and as a result the recovery from the last recession led to increased inequality.

We have a better model for economic intervention in the New Deal and the postwar era, when the government invested in and supported workers. For instance, Social Security is a portable retirement benefit that has cut poverty and provided security for millions of Americans.

The New Deal also ushered in public jobs and a broad increase in worker

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We have a better model for economic intervention in the New Deal and the postwar era, when the government invested in and supported workers. benefits, leading to a sustained era of economic growth that was both fast and broadly shared. At the same time, this enhanced the private sector by investing in our human and physical infrastructure. The right to collectively bargain via unions facilitated advocacy for the needs of workers, fair wages, and other economic protections.

Although these programs were exclusionary of agriculture and domestic workers, they proved the theory that a worker-led intervention can support broadly shared prosperity. Between 1948 and 1979, productivity rose 108.1 percent, and worker compensation increased 93.2 percent. Although not fully extended to Black, Indigenous, and other people of color, the middle-class lifestyle became far more accessible. In contrast, as deregulation and lower taxes for the wealthy prevailed, from 1979 to 2018, productivity rose 69.6 percent and worker compensation only rose 11.6 percent.

We need to create a new economy that prioritizes our shared prosperity with a just distribution of resources. Centering worker livelihoods in industrial policy through an Economic Bill of Rights

is one step toward reframing what a healthy economy looks like. The post–New Deal era shows that we can have an economy that serves the worker without sacrificing economic growth overall.

Though unions have always been a powerful force for worker rights, a bill of rights would make the protections unions have fought for available to all. Manufacturing jobs were not good jobs because they were in manufacturing; they were good jobs because unions fought for them. If all jobs were required to abide by a bill of rights, millions more Americans would have access to the middle class.

This would have a significant impact on worker power. By definition, these new worker rights would be portable. If workers were guaranteed access to child care and elder care, they would be less beholden to employers, increasing f lexibility on the part of the workers to seek out better jobs. This would prevent job lock, and enable workers to seek higher wages, as employers would no longer be providing benefits.

At the same time, we need to learn from failures of the past. The

next worker-centered interventions should be anti-sexist and anti-racist, ensuring that those who have long been left out are explicitly included in government programs. While it assisted many, Social Security was exclusionary by design, as it purposefully did not include domestic or agricultural workers, which meant that over half of Black men and about 90 percent of Black women were left out. A universal social-insurance program that protects workers, giving them security for child care, paid leave, and elder care, must be truly universal to ensure adequacy and racial equity.

Universal Family Care will be particularly beneficial to women and Black and Latinx workers.

Women and Black and Latinx workers are disproportionately left out of labor market protections and also disproportionately employed in the care economy. Sixty-two percent of Black workers and 73 percent of Latinx workers are either ineligible or cannot afford to take unpaid leave. In addition, 44.2 percent of child care workers are nonwhite,

and 59 percent of direct-care workers are nonwhite. An Economic Bill of Rights would provide benefits to this population, while also hopefully leading to greater economic protections for those employed in these industries. In fact, care work could be an attribute of a broader federal job guarantee program, where the public sector ensures decent wages, benefits, and universal and quality access to care.

This type of labor policy will benefit firms as well as workers. Social insurance for family care would decrease overhead for firms, as they would no longer have to provide these benefits, while also mitigating the lost productivity hours that might require workers to address inadequate care for their loved ones.

When companies provide child care, employee absence decreases by up to 30 percent, and job turnover can decline up to 60 percent. This helps the bottom line.

Finally, an Economic Bill of Rights would improve the economy overall. Child care and elder care would be removed as a barrier for entering

Worker-Led Interventions Work Productivity

Compensation

108.1

69.6

93.2

Cassandra Lyn Robertson is a senior fellow at the New Practice Lab at New America. She holds a Ph.D. in sociology from Harvard University.

11.6

1948 1979

the workplace, allowing more Americans who want jobs to have them.

Care work is a growing sector of the economy. For example, almost 3.5 million people work as home health and personal-care aides, providing essential care to over 7.6 million Americans. If everyone had access to care, it would grow even more, particularly as the baby-boom population ages.

Employment of home health aides and personal-care aides is projected to grow 41 percent from 2019 to 2029, much faster than the average for all occupations.

By 2026, over 4.5 million people will be employed in this industry.

These workers must have access to adequate wages, job training, and career trajectories. These are jobs that cannot be outsourced or automated, and a workers’ bill of rights would make sure that these new jobs are good jobs. Ensuring quality wages and working conditions for care work is not only the moral thing to do, it is also vital infrastructure for our economy overall.

By reframing policies that benefit the worker as industrial policy, we can imagine new ways of intervening in the economy that directly benefit the worker and the economy overall. With this framework, the next economic package should focus less on reviving companies that have invested more in profits than in their workers, and more on ensuring that workers emerge from this crisis whole. n

1979 2018

Darrick Hamilton is a University Professor and the Henry Cohen Professor of Economics and Urban Policy at The New School.

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BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION

Family Care: Good Policy, Good Politics

Advocates believe that universal coverage for care work doesn’t just make economic sense but is also a political winner.

By Rachel M. Cohen In late July, then-presumptive Democratic presidential nominee Joe Biden gave a speech announcing the third and final plank of his economic recovery plan: a ten-year, $775 billion investment in care work.

If elected, Biden promised, he would bail out struggling child care centers, invest in building more facilities, and raise the pay and benefits of all caregivers, including those who care for seniors. Biden also pledged to expand universal preschool, and give low- and middle-income families tax credits for child care.

“We are trapped in a caregiving crisis within an economic crisis within a health care crisis,” Biden said at the July campaign event in New Castle, Delaware. Emphasizing his experience raising his son as a single father, Biden touted his proposed

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investments in care work as “a fresh, bold way to build up a critical part of our labor force and help us recover faster and stronger.”

Aspects of Biden’s care work plan overlap with child care legislation backed by Democrats in Congress, as well as parts of the child care proposal Sen. Elizabeth Warren (D-MA) ran on during her presidential campaign.

In 2016, Hillary Clinton championed new investments in child care in her run for the White House.

Biden’s proposals don’t go as far as Bernie Sanders’s plan to make child care free and universal. Marie Newman, who is likely headed to Congress in January after ousting Rep. Dan Lipinski (D-IL) in a primary in March, also made universal child care a key plank of her campaign. Mondaire Jones, who won an open seat in New York’s Westchester County, foregrounded universal child care as well.

Biden’s ideas also don’t amount to so-called universal family care— the policy idea unveiled in 2019 by Caring Across Generations, which would provide child care, paid leave, assistance for people with disabilities, and elder care, all through a new social-insurance program. But his rhetoric has gotten a lot closer to that idea. That Biden has decided to make caregiving a key facet of his run against Donald Trump reflects the growing recognition among mainstream politicians that these caregiving issues are not just crucial economic issues, but also winning political ones.

Jess Morales Rocketto, the executive director of Care in Action, which leads political advocacy for the country’s 2.5 million domestic workers, described Biden’s care work plan as a win for activists, despite falling short of universal family care, which is their ultimate goal.

“It’s a very significant step and

reflects what we’ve been saying, which is that care is the future of how we keep people safe,” she said. “This is a real opportunity for us to help show people that universal family care is more than just a message frame or rhetoric, but a real and serious policy plan.”

The need for affordable child care and elder care isn’t new, so many may wonder why it’s taken so long for politicians to get to this point.

Vicki Shabo, a senior fellow at the think tank New America, points to three reasons the U.S. has moved at such a sluggish pace when it comes to care work.

The first, she says, is a perception problem. Unlike the rest of the developed world, which has robust public investments in care infrastructure, the U.S. has left care work as something to figure out privately outside of government. As a result, child care and elder care have been dismissed within public policy as “individual issues that people need to navigate on their own,” Shabo says.

The next hurdle involves the antiregulatory stance of businesses and the Republicans who cater to them.

Powerful corporations and conservatives have foregrounded the idea that workers and employers should be sorting out these types of family issues individually, free from rules dictated by government.

The last reason, Shabo says, is that for a very long time politicians in the U.S. treated care work as a “woman’s issue,” as somehow less important than other economic policies legislators prioritize.

That last point is starting to change. While child care and elder care still are largely women-led issues in Congress, some male politicians are stepping up. “I’m excited to see people like Sherrod Brown, Ron Wyden, and Cory Booker take these issues on in the Senate,” said

Shabo, adding that there is also energy coming from younger and more diverse members of Congress like Rep. Jimmy Gomez (D-CA).

Advocates say they feel encouraged, too, by the fact that Republicans have seemed more open to family care proposals, even if the bills fall far short of what’s needed. Sen. Marco Rubio (R-FL) teamed up with Ivanka Trump in 2018 on a paid family leave bill funded by clawing back future Social Security benefits, leaving families in a retirement hole. But compared to the nonexistent conservative proposals for family care in years past, it was at least a start. Sen. Bill Cassidy (R-LA) has been working on a bipartisan version of a paid family leave policy.

The pandemic has unquestionably helped shift the politics around child care, forcing long-standing problems around care work into the public eye, and helping millions of Americans grasp the health and economic implications of not having robust systems in place.

The shifting politics are evident in the way the ongoing coronavirus stim-

ulus debates have played out. In the Senate, Republicans included $15 billion in “back to work” child care grants in their COVID-19 stimulus package released in July. And in a coronavirus package passed in mid-March, lawmakers included ten paid sick days for employees of certain businesses suffering from COVID-19, and up to 12 weeks for parents caring for a new child, though only ten are paid.

“That was the first-ever federal paid leave mandate,” said Shabo. “It’s flawed, and up to 106 million workers could be denied, but it matters that it was included.”

Activists hope to capitalize on the political momentum and help steer the public conversation more to their “North Star”: universal family care.

In some ways, that shouldn’t be too heavy a lift, given how many people could benefit from such a policy.

According to government statistics, roughly eight million families pay for someone to watch their kids while they’re at work. Sixty-three percent of married couples with children have two working parents, and single

parents are even more likely to need help balancing work and child care.

The costs for these services have skyrocketed, and even before the pandemic access was a huge problem.

Increasingly, adults are balancing not just child care but caring for their aging parents at the same time.

This kind of dual-caretaking situation falls disproportionately on Hispanic Americans, but is increasingly common for all families, especially as millennials rely longer on their parents for support than children in earlier generations did.

Long-term care is an expensive proposition and the costs are not generally covered under Medicare.

For roughly half of Americans 65 years and older who will have longterm care needs, the average cost is more than $266,000, and more than half of that is paid out of pocket. The AARP estimates that relatives spend 20 percent of their own money on these caregiving costs.

The idea of some sort of publicly funded long-term care program has real political support. A 2018 Asso-

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BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION Would you support a payroll tax of 2.5 percent that would fund universal child care, elder care, long-term care, and paid family leave?

21%

30

13

17

STRONGLY SUPPORT

SOMEWHAT SUPPORT

SOMEWHAT OPPOSE

STRONGLY OPPOSE

20 DON’T KNOW

SOURCE: DATA FOR PROGRESS

ciated Press-NORC Center for Public Affairs Research poll found that approximately two-thirds of adults support a long-term care program like Medicare, including 76 percent of Democrats and 56 percent of Republicans.

While most politicians have tended to think of care work legislation as coming in discrete buckets—like one bill for paid family leave and one bill for child care—advocates for universal family care think conceptually combining all these elements into one program will be easier for voters to grasp. It also expands the constituency to everyone who needs care, for a child or parent or even themselves, in the case of sick leave.

“Everyone has a care story,” said Morales Rocketto. “For the average family, all these costs come out of the same bank account, and we’re all just looking at the bottom line. So what we want is the government to just say, we’re going to make a program that ensures you have enough to afford your care obligations.”

Universal family care wouldn’t come cheap, but this is a government-sized problem, she adds, so “we

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need a government-sized solution.”

New polling conducted by Data for Progress over the summer provides some quantitative support for the idea. Likely voters were asked if they’d support a payroll tax of 2.5 percent of their income to create a social-insurance fund for universal access to child care, elder care, long-term care, and paid family leave. A little more than half of all likely voters expressed support in the poll, including 49 percent of women. Among people of color, the support was even higher: 61 percent of Black respondents supported the proposal, as did 53 percent of Hispanic respondents. Forty percent of independents backed it, and 20 percent of respondents said they didn’t know one way or another.

Polling conducted in 2019 by the People’s Policy Project found similar enthusiasm for federal grants to school districts for free public child care. Fifty-seven percent of registered voters backed this idea, including more than half of independents.

One advantage care advocates have in the political arena is that this need for people to take care of

themselves and their families is universally understood. “From a narrative perspective, we’re starting from a position of strength,” Shabo said.

To push the issue politically, advocates are hoping to link the fight for universal family care to the fight for racial and economic justice. When Seattle passed paid sick days in 2015, the UFCW was a critical partner to getting that through, as was SEIU when Massachusetts passed statewide paid family leave in 2018. Shabo says enlisting business allies early on has also been critical, since “the organized business lobby is almost always opposed” to new care policies.

Sen. Kirsten Gillibrand (D-NY), who has sponsored individual bills for national paid family leave and child care, says she thinks splitting the proposals up separately still makes more sense, but she agreed one could structure a universal home care policy that includes all care policies together.

Gillibrand pointed to her work on paid family leave, which began in 2013. “We worked so hard to make sure it was debated in the last two presidential cycles, and we know from state examples, like in California, that the business community has actually welcomed it once it’s in place,” she said. “All of these things would have made such difference during the pandemic if we had nationwide.”

She is optimistic about the political prospects for care work legislation. “I do think the country is open to these ideas, and Congress tends to be ten years behind the country on a good day,” she joked. “I think the pressure will grow because people need these solutions. We’re in a crisis and the landscape is ripe for change.” n Rachel M. Cohen is a journalist based in Washington, D.C., and a former A mer ican Prospect writing fellow.

How to Finance Universal Family Care Considering the options for building a new socialinsurance program

By Robert Kuttner Universal Family Care includes several distinct areas of support over the life course. What child care, paid family and medical leave, and longterm care for the elderly and people with disabilities have in common is that they are underfunded, the policies are a patchwork, and pay is so dismal that care workers are subsidizing the system with their low wages.

There are a variety of proposals for upgrading current family supports.

What are the costs and options for doing it right, including upgrading the pay and professionalism of care workers? What is the best strategy for financing them? Each of these options comes with policy variables and trade-offs.

Several progressive states already have a start on such programs, which can become national models. But what about state governments, especially in the South, with large numbers of poor

people and long-standing antipathy to social programs? Should we build on the existing mix of state and federal programs, or fold them into a new, comprehensive national program?

In the case of early-childhood education, it would be less costly to build on today’s substantially private system, but it would be better to extend public pre-kindergarten, as a few cities and states have done. For longterm care and home care, we might expand Medicaid, which pays most of the current costs (but only for the medically indigent). It would be preferable to develop a new comprehensive system that reaches everyone, perhaps with fees on a sliding scale.

For financing, we also face choices.

For the most part, social insurance in the U.S. is financed by payroll taxes, on the model of Social Security and Medicare. This is familiar and easy to administer, but tends to be regressive, in that lower-income people are taxed at higher rates. Should we instead finance new programs partly with general revenues, or dedicated taxes on the rich? These are the inevitable trade-offs with which advocates and policymakers must wrestle. In thinking and dreaming big, it makes sense to begin with the first best policy, rather than compromising before we start.

Early-Childhood Education Head Start, dating to the Johnsonera anti-poverty program, is federally funded, and pays teachers as professionals. The program currently costs about $10 billion a year and reaches only about 40 percent of eligible kids. If it were expanded to be available to all children who qualify based on income, it would cost more than $25 billion.

However, Head Start is a means-tested program that serves only the poor. It’s intended as added enrichment for kids from deprived backgrounds.

A more expansive approach is

universal public pre-kindergarten for three- and four-year-olds. Washington, D.C., has such a system. It has enrolled 85 percent of fouryear-olds and 75 percent of threeyear-olds, at a cost of $18,580 per student. Multiply this by the number of three- and four-year-olds nationally, and you get an annual cost of over $150 billion. However, the perpupil cost of D.C. far exceeds the national average. A more realistic figure is on the order of $10,000.

States and cities already spend an average of about $3,600 per child on pre-K. But only about 22 percent of three- and four-year-olds nationally are in pre-K at all, and only about 15 percent in public schools. So, assuming that existing funds could be rolled into a new, comprehensive program, the incremental cost of universal, school-based pre-kindergarten would be on the order of $80 billion a year. It’s necessary to have school-based pre-K if we want to maintain quality and pay teachers and teacher aides as professionals.

Expanding our current patchwork system would cost a lot less, but would produce lower quality.

About half of all public-school funding comes from property taxes.

These are regressive, since the communities most in need tend to have the lowest per capita property wealth and have to tax themselves at higher rates to produce adequate revenues.

Universal pre-K financed by property tax add-ons is a political and fiscal nonstarter. Expanded universal pre-K is a good candidate for either federal general-revenue funding, or financing based on specific new taxes targeted at the wealthy, as Joe Biden has proposed in his plan.

Child Care Child care, as distinct from earlychildhood education, serves working parents of school-age children

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BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION and toddlers. The current system is a patchwork. A good example of a national commitment to child care, done right, is the plan proposed by Sen. Elizabeth Warren (D-MA). Her plan envisions that the federal government would rely on a mix of centers and family child care homes. The local sponsors could be cities, school districts, states, counties, tribal organizations, or other nonprofit community entities, but all would be subject to certification for high standards, and pay staff at rates comparable to public-school teacher salaries.

According to a comprehensive study by the Center for American Progress, nearly 40 percent of child care teachers are forced to rely on public assistance at some point in their careers. CAP reports that the average kindergarten teacher salary is $55,000, compared to just $33,000 for child care teachers; and of course a lot of child care workers are not considered teachers and earn far less.

Good child care tends to be most costly for infants and toddlers, because of the higher staffing ratios needed, and less expensive for older children, who can have larger class sizes. For very young children, even custodial child care costs over $1,000 a month, while development-oriented care costs more than double that.

Given the very limited federal funding to subsidize child care, only affluent families can afford very high-quality care. It is another way in which economic privileges are passed along from generation to generation in the absence of universal social supports.

Meanwhile, poor and workingclass parents spend larger percentages of their incomes to get less.

Warren reports that low-income parents of children under six currently pay as much as 36 percent of their meager incomes for child care.

Unlike existing federal and state programs, which do not fully reach

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their target populations, Warren’s program would be universal and not just aimed at the poor. It would be free to families making under 200 percent of the poverty line, and other families would pay on a sliding scale.

Nobody would pay more than 7 percent of their income.

The total annual cost, as confirmed by an independent analysis by Mark Zandi of Moody’s, would be about $70 billion a year. Warren’s plan, like Biden’s, would be financed by taxes on the wealthy, such as through her proposed “ultra-millionaire tax.”

The Military Model Another good model is found in the military. Since the World War II–era Lanham Act, the Pentagon has subsidized child care costs for its personnel. As more women have enlisted in the all-volunteer military, these needs have increased. Today, the armed services have the nation’s most comprehensive, high-quality program, combining both kindergarten-quality pre-K and child care

for infants and toddlers, as well as after-school day care for older kids.

According to the Congressional Research Service, the military provides pre-kindergarten and day care to some 210,000 children of activeduty personnel, at an annual budgetary cost of about $1.2 billion, supplemented by fees paid on a sliding scale based on income. A family pays as little as $51 per week per child or as much as $210, reflecting the military’s relatively compressed pay structure. These slots are widely available but not guaranteed, and there are waiting lists. All meet the highest level of quality certification.

The average cost of the child care component ranges from $3,000 to $8,400 per child, depending on age and whether the care is in a Child Development Center or contractedout family day care. These costs slightly understate the true cost, since the Pentagon’s program operates in existing military facilities, where a new national program would also have to bear the cost of creating new ones.

However we finance this new category of social insurance, we need to conceive of it as a comprehensive whole, providing needed care for all Americans over the entire life cycle, and decently compensating caregivers.

Options for Early-Childhood Care and Education (annual cost): Expanded Head Start for poor children: $25 billion Universal, national pre-kindergarten: $80 billion Child care for all: $70 billion (Sources: National Institute of Early Education Research; Moody’s Economics.)

Paid Family and Medical Leave At present, the only federal policy provides for unpaid family and medical leave, to allow people who have spells of illness or who need to care for family members to take a leave and keep their jobs. Various exclusions mean that only 60 percent of the workforce is eligible for even this unpaid benefit under the Family and Medical Leave Act. (Federal disability benefits under Social Security are limited to people who are permanently unable to work.)

Thanks to a quirk of American history, we do have some experimentation with paid leave at the state level, which gives a good sense of what a national program might cost. In the mid-1940s, after the full-employment experience during World War II, state unemployment programs found themselves with large surpluses. The Department of Labor began suggesting to states that they spend some of that money on what was then called Temporary Disability Insurance, and today is called paid medical leave.

Before the political window closed as post-Roosevelt politics turned more conservative, four states created such benefits. These continue today, and have served as models for other states.

The four pioneer states were New York, New Jersey, Rhode Island, and California, and they pursued the social-insurance model of a “contributory” benefit—you had to be working and pay in to qualify—financed

by payroll taxes. Of these, California’s program is the most expansive.

It covers up to 52 weeks of paid leave, for family caregivers as well as people dealing with their own medical conditions, and pays benefits of 60 to 70 percent of actual wages, with a cap of about $1,300 a week. The program is financed by a payroll tax of 1.0 percent.

Since the 1940s, a total of 14 states have adopted similar programs, many with less generous coverage and lower costs. Since this approach was pioneered by the states, it may make sense to continue expanding them at the state level, though a national program would be more comprehensive.

At the federal level, the proposed FAMILY Act, co-sponsored by Rep. Rosa DeLauro (D-CT) and Sen. Kirsten Gillibrand (D-NY), would provide 12 weeks of paid family and medical leave, including for new and adoptive parents. It would provide 66 percent wage replacement, of up to $4,000 a month. The cost would be financed by a payroll tax of 0.4 percent to be divided evenly between employer and worker.

Extrapolating from the California program and the DeLauro-Gillibrand bill, a comprehensive national program that provides 100 percent of wages with a cap at something like median income for a full year (most people would need it for a full year) would cost between $40 billion and $70 billion a year. If financed by a

payroll tax alone, it would require a tax in the range of 1 percent of payroll.

Care for the Elderly The most costly single category of a comprehensive family care program is care for the elderly. The government’s largest single caregiving program for seniors is Medicaid, which was originally intended by Congress in 1965 as a general health insurance program for the very poor and the working poor, but soon became the insurer of last resort for nursing home care. To qualify for Medicaid, an older person must be medically indigent. For middle-class people, this means “spending down” assets to the point where no more than $2,000 in assets are left and the person becomes a ward of the state.

Currently, Medicaid pays about $100 billion a year for institutional nursing home care, which is more than half of total national spending on long-term facility care. The low reimbursement rates coupled with the profiteering of for-profit nursing home chains (about 70 percent of all facilities) leads to both low-quality care and very low pay rates for certified nursing assistants (CNAs), who make up the vast majority of the hands-on caregiving workforce at nursing homes. Medicaid also spends about $100 billion a year on in-home care, which is subsidized by other federal and state programs as well. Some 80 percent of the nation’s home health providers are for-profits as well.

With the exception of Medicare, which covers time-limited skilled nursing care (nursing homes) and a limited amount of home care (such as hospice nurses), virtually all other federally subsidized home care as well as facility care is means-tested and limited to the very poor. Thus there is a huge gap for the population that is not poor enough for Medicaid and other means-tested assistance,

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Paid family and medical leave options California: covers up to 52 weeks, 60-70 percent of weekly wages, capped at $1,300/week Washington, D.C.: up to 8 weeks, 90 percent of wages, capped at $1,000/week FAMILY Act (proposed): covers up to 12 weeks, 66 percent of wages, capped at $4,000/month but cannot possibly afford to pay out of pocket for needed home care or assisted living.

With only a small fraction of Americans able to afford private long-term care insurance, the cost of caring is put on family members.

According to a study by AARP, in 2013 about 40 million family caregivers provided 37 billion hours of care worth an estimated $470 billion to their parents, spouses, partners, and other adult loved ones. With increased costs, general inf lation, and population increases, the figure today is over $600 billion. And this doesn’t count the labor of ordinary child-rearing. Only a small fraction of this would be defrayed by an expanded family and medical leave program, which covers relatively short-term periods of care while a great many elderly people and people with disabilities need care for years and even decades.

Ideally, we need a comprehensive program that includes more generous Medicaid terms for nursing homes, as well as a dramatic expansion of home care subsidies. This would reach well into the middle class, presumably on a sliding scale; it would help to keep lots of people who would rather be at home out of nursing homes. Such a program would also dramatically raise the pay of caregivers, both in nursing care facilities and in home care. These

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are currently among the lowest-paid people in the caregiving workforce.

Estimates of the total annual cost vary, depending on how expansive the program. But if we subsidized a sliding scale for nursing homes, so that people who entered them would not have to become medical paupers, and increased wages for caregivers and home care eligibility, the cost would run into the low hundreds of billions annually. Unlike Medicare, Medicaid is a joint federalstate program, and the federal share is not financed by payroll taxes but by general revenue. Thus, a muchexpanded comprehensive program for both home care and institutional care for seniors would almost surely be funded mostly through general revenue, perhaps combined with surtaxes on the very wealthy. (The more progressive the tax code, the less “general revenue” taxes fall on working families.)

The Issue of Earnings for Caregivers The largest hidden subsidy in the entire caregiving infrastructure is the dismally low pay for caregivers.

According to the Bureau of Labor Statistics, the median wage of the nation’s 1.5 million CNAs is just $13.72 an hour, and 25 percent of CNAs make just $11.22 an hour or less. Most of these workers are immigrants. A great many would like to ascend the

career ladder and become licensed practical nurses (LPNs), who earn an average of $22.62 an hour, and an annual income of a middle-class $47,000. But even though it takes only a year of additional education to become certified as an LPN, the working and family conditions of CNAs are such that only a tiny fraction make this jump, even though in practice their hands-on experience gives them most of the skills of LPNs. Seemingly, there is a brutal tradeoff between expanding services and expanding pay. But in creating a comprehensive new category of social insurance, raising pay has to be a goal on a par with expanding services. Better-paid, -trained, and professionalized workers are in the interest of people who receive services as much as those who give them.

One very challenging question is how to compensate family members who provide free care, out of love, duty, or necessity, and who are not compensated at all. The preponderance of people who contribute unpaid family care are women, which also reinforces gender inequities. Some relief will be provided if we have expanded programs of paid caregiving for both the old and the young, as well as paid family leave. But in the case of elderly, disabled, or specialneeds family members, the need is often long term. How do we begin to provide equity for those who choose to care for loved ones, and deny themselves the income and the respite of working outside the home? Why does it make sense to compensate a home care worker who is sent by an agency, but not one who is a daughter, sister, or husband? While a budget category of $600 billion to provide full compensation for all family caregivers is a fiscal nonstarter, some partial compensation could make ethical and equitable sense, especially in cases where a family member is eligible for

paid social services and receives family caregiving instead.

Putting It All Together It would be ideal to package all of these categories of caregiving and receiving as a single master program of Universal Family Care, with a single source of funding. There are certainly efficiencies to be had in combining these elements into one program, for the care consumer as well as for the government. But the total cost done properly adds up to several hundreds of billions of dollars a year.

It’s probably not good policy to put all of this on the regressive payroll tax, even one with a less-regressive base such as the Medicare tax base, which unlike Social Security has no cap on taxed income. The best candidate for payroll tax funding seems to be family and medical leave, which is a close cousin to unemployment compensation and federal disability insurance, both funded by payroll taxes. Mandating some level of family and medical leave on employers, with subsidies above that floor, would limit that cost. The benefit of lower turnover and higher productivity could make that palatable.

It’s also the case that we are not starting from scratch, as the care economy contains a mix of federal, state, and local programs, some exemplary and others deplorable. Thus, the practical result will likely be a blend of programs, financed by a mix of different revenue sources. Even Social Security and Medicare, the two core social-insurance programs, are only partly financed by payroll taxes, and supplemented by general revenues.

However we f inance this new category of social insurance, we need to conceive of it as a comprehensive whole, providing needed care for all Americans over the entire life cycle, and decently compensating caregivers. n

What the U.S. Can Learn About Caregiving From the World

Most developed countries offer some form of family care coverage.

Here are some of the best models.

By Brittany Gibson Among the United States’ health care system’s many flaws is its failure to adequately fund and invest in caregiving, possibly an artifact of cultural messages about rugged individualism and self-reliance.

While the U.S. is not alone in its struggle to value caregiving while simultaneously preparing for an increase in the elderly population, some countries have led the way in creating more-sustainable models.

Policymakers should take their cues from these efforts.

Obamacare architect and codirector of the University of Pennsylvania’s Health Transformation Institute Ezekiel Emanuel recently told Vox’s Ezra Klein that the Netherlands and Germany have two of the best systems for long-term

care. “Unlike every other country we looked at, they have secured the financing for long-term care,” he said on the Ezra Klein Show podcast.

Emanuel’s latest book compared health care programs around the world, but he admitted that when it comes to elder care, these European countries are where he would personally prefer to live out his days.

Part of what makes the Netherlands and Germany so far ahead of the United States is their commitment to funding for the aging populations in government programs or compulsory insurance schemes. Any system that lacks dedicated funding for elder care shifts the responsibilities to the relatives of those who are aging, and most of the time those relatives are women.

The Netherlands was one of the first countries to make funding for long-term care mandatory, starting in 1968, and it has advocated for personal care budgets since the 1990s. It also spends the highest percentage of its GDP, at 3.7 percent, on long-term care, according to a study from the Organisation for Economic Co-operation and Development. The Dutch budget supports both medical and nonmedical care services, which can include cleaning, preparing meals, and other home chores.

In 1995, Germany’s long-term care law was implemented, creating an independent social insurance program that covers the majority of the nation’s elderly.

What’s unique about the Dutch health insurance program compared to its European neighbors is that all health insurance is provided by private, nonprofit companies, and purchased by individuals who receive government subsidies for their services. The private market is tightly controlled to prevent unaffordable prices, but it also mandates that everyone is covered—even

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Germany’s system is mostly government-run; about 90 percent of Germans receive their care from the government, with the remaining 10 percent enrolled in a tightly regulated private market. Despite these differences, both systems relieve the burden on relatives and friends of being responsible for someone else’s long-term care needs.

Making long-term care a priority has allowed for more consumer choice. Dutch and German people who need long-term care have more flexibility than in other countries as to where they receive their care, with more people opting to stay in their own homes.

Some European lawmakers have also taken an additional step to consider the many people who perform unpaid long-term care for a relative.

This is consistent with a global consensus on paid family and medical leave that the United States, virtually alone, has chosen to ignore.

Only three of the United Nations’ 193 countries don’t mandate paid parental leave: New Guinea, Suriname, and the U.S. On paid sick leave, America is one of only 13 countries without it.

Germany and Italy have the oldest people in Europe. Thanks to a 2012 law in Germany, full-time employees who need time off to care for a family member can borrow against their future wages. They may reduce their work hours to part-time for up to two years while retaining 75 percent of their normal salary, and when they return to work they continue receiving 75 percent of their wages until the borrowed balance evens out.

In Italy, employees are able to take three days every month to care for a family member with a disability up to three degrees of separation, which means it can include grandchildren caring for grandparents, as

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well as nephews caring for uncles, for example.

Admittedly, the United States ranks quite high on national polls when it comes to long-term elder care, but the system is mostly dependent on an individual’s ability to afford quality care. Alternatively, when elderly Americans can rely on family members for their care support, there are not mandated systems in place to support those family members, either through paid leave schemes or a federal paid leave program.

A complete federal program that sets rates and wages for nursing homes, long-term facilities, and workers both at home and in those facilities, and provides the necessary care for our aging population, without mandatory buy-ins or participation requirements is not a pipe dream. Countries like Taiwan and Finland boast a publicly funded, universal system open to every resident, guaranteed as a human right, and administered at the municipal level, with care recipients given broad choices on at-home or facility-based care. The program is widely celebrated, and it’s been effective at keeping costs surprisingly low. That it loses money is functionally irrelevant, as it should be in the United States. Longterm care is a social imperative.

On the other end of the care spectrum, the United States could also benefit from international examples to improve the quality of care for young children. Emanuel said the biggest return on investment in the U.S. health care system would be made by investing in children, especially the nearly 15 percent of children who are born into poverty every year.

For America’s potential model, it needs only to look north to neighboring Canada. Twenty years ago, Quebec introduced its universal child care program, charging people less than $4 a day for pre-kindergarten

education and care. That rate has increased to about $6 per day for middle-class families. The Quebecois government foots the remaining $1.5 billion of the universal child care bill, but the cost is sufficiently offset by the value of women re-entering the work force. The Swedes and the Danes also have similar programs.

The French model is similar to their former colony, but it goes further by offering an expanded universal child care program. In addition to les écoles maternelles, preschool for children ages three to six, there are crèches, which take children as young as three months old and are open for slightly longer than the length of an average workday, from about 7:30 a.m. to 8 p.m.

The hourly rate for children is based on a sliding scale adjusted for the parent’s income.

Preschool is not mandatory for children under six, but because it’s so affordable about 95 percent of eligible children attend. As a result, more than 80 percent of French mothers with one child work outside the home, compared to about 60 percent of their American counterparts.

There is also a tax break for families who prefer to hire a nanny. This in-home care worker can be either a child care professional or an assistante maternelle who is licensed by the government. The family pays for the nanny’s benefits and in return receives a rebate from the French government based on the family’s income. This differs widely from the situation in America. A 2017 survey from Park Slope Parents showed that 60 percent of nannies were being paid completely under the table, compared to 13 percent on the books.

At the minimum, there is a vast disparity in early child care choices between the U.S. and the world’s early child care leaders. When

considered with the limitations of long-term care in the United States, families can become sandwiched by caregiving responsibilities. A 2019 UNICEF study ranked the U.S. dead last among highand middle-income nations for family-friendliness.

Emanuel described the U.S. health care system as à la carte: “[If] you want socialized medicine, à la Britain, we’ve got that, it’s called the VA [Veterans Affairs]; if you want single-payer system, where the govern-

ment pays out to private hospitals on a fee-for-service basis, we’ve got it, it’s called Medicare; you want more like Germany and the Netherlands, where you put money in a pot and then you pay it to private insurers, and private insurers organize the care, we’ve got it, it’s called Medicare Advantage and the exchanges; we’ve got everything.” Emanuel also adds the private, nongovernmental system, which is like the system in Switzerland, which we call employersponsored insurance.

What America does not have is a federal family care infrastructure.

The complexity of managing different, mostly inadequate systems adds not only to the enormous administrative cost but also to the confusion for everyone involved, from providers to patients. While no countries have an integrated universal family care system, most have strategies that cover paid family and medical leave, early child care, and long-term care.

These models can form the basis of a transformed U.S. system. n

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Washington: The Caregiving State

In the Pacific Northwest, lawmakers have acted to help defray the exorbitant costs of family caregiving. More needs to be done.

By Gabrielle Gurley Most families cobble together caregiving arrangements for children, elders, and loved ones with disabilities through some mix of free care from relatives, modest home care options, or pricey institutional settings. Paying for these arrangements when necessary is one of the greatest trials facing American workers. The national caregiving crisis has been magnified by the COVID19 pandemic and the weak federal Family and Medical Leave Act of 1993, a dubious bargain of limited, unpaid time off.

In the face of federal neglect, states have begun to step up to lighten the burden, offering assistance to families struggling with child care, elder care, and paid leave. But nowhere has the care infrastructure been built as comprehensively as in Washington state.

In 2019, Washington catapulted into the vanguard of the social-insurance movement, becoming the first state to provide residents with a comprehen-

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sive long-term care program. Combined with a paid family and medical leave system that went into effect this year, a cap on child care expenses for low-income workers (with a goal of universal access by 2025), and a home care workforce training operation run through SEIU Local 775, Washington policymakers have inched closer to a vision of supporting families through all stages of life.

“When you have a state where a critical mass of voters values care in its policy and its priorities, I think that you see progress,” says Ai-jen Poo of Caring Across Generations, which has worked on policy issues in Washington. But the state’s trailblazing family care agenda forced several tough choices, revealing the need for federal support to supplement the vision.

For example, eight states and the District of Columbia have instituted paid family and medical leave programs, usually with complex, hybrid payment mechanisms based on payroll contributions from both employers and employees. So far, the District of Columbia is the only entirely employer-funded paid leave program in the country, providing 90 percent of wages for two to eight weeks through a 0.62 percent payroll tax.

In 2017, Washington state lawmakers crafted a bipartisan consensus on medical leave as a shared contribution, with family leave costs borne by employees. The family and medical leave program provides between 12 and 18 weeks of paid leave to employees who work a minimum number of hours in a 12-month period. Designed to keep low-wage workers in the program, Washington’s program is generous. Employees can receive up to 90 percent of weekly wages, capped at $1,000 per week.

The maximum benefit period of 16 weeks is far less than California’s

52-week maximum, but California workers recoup only 60 to 70 percent of their wages. Many low-wage workers who cannot afford a 30 to 40 percent pay cut forgo taking leave.

“Subsequent policies in other states have really increased the progressivity of those benefit formulas, so that everybody actually can take the leave,” says Kathleen Romig, a Center on Budget and Policy Priorities senior policy analyst.

On the f lip side, Washington’s 16-week cap keeps the cost of financing down: A payroll tax of 0.4 percent funds the program. Self-employed and tribal members are exempt, but can choose to opt in. Employers with fewer than 50 employees also are not required to pay the employer portion of the premium, though they still must collect it from workers.

To encourage participation, these employers are eligible for small-business grants if they contribute.

Long-term care services and supports present similar challenges for program design: how to keep it cost-effective and also meet the significant needs of Washingtonians.

A 0.58 percent payroll tax funds the Washington Long-Term Services and Supports (LTSS) Trust that will begin collecting payments in 2022 and paying out benefits in 2025. Individuals receive up to $100 a day toward a maximum lifetime benefit of $36,500 for services like in-home personal care, adult family home care, and nursing home care. The state auditor will monitor the program’s operations and finances, and assess recommendations for improvements.

With more people able to afford long-term care, the new program increases employment opportunities for home health care workers. SEIU Local 775 Benefits Group, a labormanagement partnership that trains and supports home care workers, is Washington’s second-largest educa-

tional institution after the University of Washington, serving nearly 50,000 caregivers across the state.

State home care workers must complete 75 hours of training and pass a certification exam, requirements similar to the federal certified nursing assistant standard, according to Adam Glickman, SEIU Local 775’s secretary-treasurer. An LTSS Trust Commission will determine if additional workforce training requirements should be implemented for home care workers and family members.

“You can get money for professional care supports and also money

to pay a family member to compensate for their work for taking care of [another] family member, so they can afford to leave the workforce for a couple of years and do that,” says Benjamin Veghte, director of the LTSS Trust and a lead author on the National Academy of Social Insurance’s 2019 “Designing Universal Family Care” report. “The desire to age in place with family supports is sharpening right now and increasing,” Veghte adds. “Nursing homes are no one’s utopia for how they want to spend their final years.”

The program may seem like a boon to families, and compared to

the lack of basic support for needs like elder care in every other state in the union, it is. But given the high costs of medical and in-home care professionals, equipment, and supplies, it’s actually a modest benefit, conceived more as a supplement to existing or future resources to tide over families. Medicaid-funded in-home care in Washington runs $24,000 per year; nursing home care is $65,000 per year. In most cases, the funding will provide one to two years of support, giving families the time to apply for Medicaid or develop alternative funding sources, according to Veghte.

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BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION Under Gov. Jay Inslee’s tenure, Washington has passed a paid family and medical leave program and a long-term care social-insurance benefit.

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and fail to reach even eligible families. No state has fully addressed how to pay for ECCE programs.

Washington passed the Child Care Access Now Act in 2019. For those families that meet incomebased eligibility thresholds, the law caps child care expenses at 7 percent of household income, subsidizing the balance. The subsidy

scheme, implemented through two state programs, Working Connections Child Care (for low-income families) and Seasonal Child Care (for seasonal agricultural workers), is subject to available appropriations, and so some families do end up on a wait list. The bill establishes a goal of universal child care access for the entire state by 2025,

Nowhere has the care infrastructure been built as comprehensively as Washington state.

TED S. WARREN / AP PHOTO

Washington officials say that the state has the fiscal resources to sustain the LTSS Trust. “We have worked hard to build a strong safety net in our state that is truly responsive to the many threats to economic stability that working families face,” says Mike Faulk, press secretary for Washington Gov. Jay Inslee, a former Democratic presidential candidate. “Building social insurance of this kind, with the flexibility it provides to choose the care arrangement that best fits a family’s needs, is a big deal.”

Early child care and education (ECCE) throws up another set of hurdles, being both prohibitively expensive for families and low-wage work for providers. Today, parents and guardians pay more than half of these costs out of pocket. There are federal dollars available, through programs like Head Start and the Child Care and Development Block Grant. But these are means-tested

Washington state programs Long-term care: $100/day with a lifetime maximum of $36,500, funded by 0.58 percent payroll tax Paid family and medical leave: up to 16 weeks, 90 percent of weekly wages, capped at $1,000/week, funded by 0.4 percent payroll tax Child care: caps low-income child care expenses at 7 percent of household income, subsidizing the balance Pre-kindergarten: provides pre-K for 14,000 low-income children; goal to enroll 90 percent of eligible children by 2023 but of course, access does not equal affordability.

But after the advances in paid leave and long-term care, early education stands to be the next big issue for debate in Olympia. Through its Early Childhood Education and Assistance Program, Washington provided prekindergarten for the 14,000 at-risk children “furthest from opportunity” in the 2019-2020 school year, and recently expanded income eligibility for the program, with a goal to enroll 90 percent of children entitled to qualify by 2022-2023.

Only a handful of other states have attempted universal pre-kindergarten coverage. Just 22 percent of four-year-olds are in state-funded pre-kindergarten programs, and just 3 percent of three-year-olds.

Only Florida, Georgia, and Oklahoma have statewide programs for four-year-olds. Of the six jurisdictions that plan to implement preK, only the District of Columbia and Illinois include programs for three-year-olds.

Absent ECCE programs that untangle the knot of federal and state programs and dollars, progress toward a true Universal Family Care insurance fund mechanism may leave states concentrating on family and medical leave and long-term support and services care programs. Accord-

ing to Veghte, ECCE could be constructed in such a way to require a small family contribution with the remainder paid by a social-insurance framework. But Veghte stresses that the way forward is one fund that provides payments for all three socialinsurance components.

The Washington social-insurance programs approach that goal. But even the most robust state approaches are ultimately piecemeal solutions to fill the void left by the federal government’s failure to move on social insurance, despite long-running worker and employer interest in a taxpayer-funded caregiving program.

A 2018 National Partnership for Women & Families poll found that majorities of Democrats, Republicans, and independents support a national paid leave program. The COVID-19 crisis has only intensified this demand: A Lake Research Partners poll conducted in June for Paid Leave for All Action found that majorities of Americans across party lines, gender, age, race, income, and other metrics believe that having a national paid leave program would have been “helpful” during the pandemic.

Partisanship, of course, stands in the way of movement toward national social insurance. Conservatives

typically disdain creating risk pools, preferring families to provide care or pay for their own stopgap measures if they can’t get leave from their jobs, if care arrangements fall through, or if a family wants a certain type of early child care—a sort of rugged individualism, family style.

This mindset forms the basis for perverse Republican family leave proposals predicated on notions like using advances on employees’ own earned benefits, such as Social Security (which can expose workers to cuts in their own retirement support), rather than creating new programs with dedicated funding streams. Most Americans would prefer paying into a national fund that benefits all workers and families, rather than tapping into already meager public retirement options.

“All families have to pay for this anyway,” says Veghte. “We either have to pay for it on our own or we pitch in to a risk pool where we all pay a little bit out of every paycheck and then draw down as we need, like health insurance or Social Security.”

California, with a paid family and medical leave system in place for nearly two decades, is the closest to joining Washington state with two prongs of Universal Family Care set. State officials and longterm care specialists and advocates have been working on devising specifics. In November, Colorado voters will weigh in on a $1.3 billion social-insurance ballot initiative that would establish a family and medical leave program of up to 12 to 16 weeks, funded by payroll taxes split equally between workers and employers, a similar model to Washington state’s. With little productive debate on Capitol Hill, the Washington state model is likely to steer progress on designing socialinsurance programs for the foreseeable future. n

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Building Movements Around the Care Economy The case study of child care politics over the past five years offers lessons for how to build a movement around Universal Family Care.

By Dorian T. Warren and Seth Borgos Access to affordable child care and early learning is an urgent practical concern to millions of American families. Voter support for investing public resources in the education and care of young children routinely polls at 70 percent or higher, cutting across ideological and partisan lines.

And popular sentiment is backed by science; there is abundant evidence that providing high-quality care early in life pays large dividends for society as a whole.

Nonetheless, for more than 40 years the issue languished in the political wilderness. Since the Nixon administration spiked the creation of a national child care system in 1971, indicative of the lost possibilities of that ill-starred decade, Washington

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has accomplished very little to remedy what has become a broken system.

The Child Care and Development Block Grant provides vouchers to lowincome parents, but only 1 in 6 eligible families get it. Programs like Head Start and TANF also subsidize care, but this patchwork fails to address the dearth of affordable care across America, the scandalously underpaid labor force doing critical work, and the severe stresses this causes, only magnified by the pandemic.

If Social Security was the third rail of American politics, then child care was a sleepy branch line, receiving little attention from candidates and only fitful notice from policymakers.

Even in the progressive community, the conventional wisdom was that child care was a worthy cause but one that few voters really cared about, a second-tier issue at best.

Rather suddenly, the wheel has turned. Universal child care legislation is getting traction in Congress.

Governors and presidential candidates have made it a major theme in their campaigns. Media attention has exploded, and recent polling suggests that voters not only favor public action but view it as a political priority. Even the Trump family has joined the debate, offering proposals with little substance but which are symptomatic of the new climate.

Child care, in short, has moved from branch status to the main line.

The story of how this transformation occurred is worth unraveling. It tells us something about how issues acquire salience and momentum in the current political environment.

It speaks to the role of community organizing in creating effective constituencies for change. And it illuminates the opportunity to make family care a defining issue in the coming era, as voters feel growing apprehension about the intensifying stresses on American families, the

lack of progress on racial and gender equality, and the future of care in a market-driven economy.

From Stepchild to Poster Child Five years ago, our organization, Community Change, convened a cohort of organizers and asked what it would take to fix those flaws and create a genuinely comprehensive and equitable early-learning and child care system. No one doubted that it would be a heavy lift.

Despite the high social value placed on caring for young children, many Americans view care as a private responsibility rather than a public good. Resistance to government spending on child care is amplified by sentiment among many white Americans that these are “other people’s children,� and the low earnings of early educators and child care providers are clearly tied to the gender, race, and class composition of the workforce. Unlike health care, there is little waste or profit that can be wrung out of the child care sector to pay for improvements in access, quality, and compensation, meaning that the cost will be borne by the larger public.

But the biggest challenge organizers identified was the absence of a broad-based constituency that could mobilize the public will. The fragmentation of child care providers, not just between public and private or in-home and center-based care but including informal and uncompensated caregivers, often creates competition for limited resources rather than expanding the pie. And the different perspectives of advocates for children, parents, and providers made it difficult to engage the larger community.

But these organizers were also hearing a torrent of concerns about child care from their members. The problem of affordability and access was reaching a crisis in communities across class lines. Related fam-

ily care policies like paid family leave and earned sick time were also getting traction, and the Fight for $15 was generating a national debate about the exploitation of low-wage workers. Even in some deep-red cities and states, bipartisan coalitions were mobilizing a broad range of civic elites to expand preschool and early learning. The seeds of a national child care movement were discernible, but they had to be cultivated in order to grow.

That cultivation began in earnest in 2015, when community organizations in New Mexico, Minnesota, California, Michigan, and other states launched new efforts to engage those most directly affected by the child care crisis. These local projects were supported by a growing network of national organizations, including grassroots parent groups like MomsRising and ParentsTogether; unions like SEIU and the American Federation of Teachers; policy centers like the National Women’s Law Center and the Center for American Progress; and organizing hubs like Community Change. In response to agitation, early-childhood funders that had historically focused on research and demonstration proj-

ects began to provide some grants for base-building and community-organizing strategies.

The local campaigns aimed at a variety of goals: expanded pre-K programs, more child care subsidies for low-income families, higher wages and benefits for early educators, and new sources of revenue for early learning and care. These ideas had been discussed in policy circles for decades. But this time, the choices were being framed not just by civic elites and professional advocates, but by leaders from directly affected constituencies, primarily women of color. For these emerging leaders, debates over policy design—sources of revenue, allocation of subsidies, the definition of “quality care”—were not wonky technical disputes but fights about values, tests of whether government was truly committed to helping their struggling families and advancing gender and racial equality.

Political leaders took notice. In the 2016 presidential primaries, both Hillary Clinton and Bernie Sanders embraced universal child care programs. Although neither lifted it to a major theme, it was the most explicit

Most Americans agree, in principle, that the government should invest more resources in families, and give peace of mind to those who need care.

advocacy by presidential candidates in many years. Early in 2017, community organizations made a concerted push to increase funding for child care in state budgets. Running barebones campaigns in a challenging fiscal environment, they won budget increases in a half-dozen states with support from both Democratic and Republican leaders.

These gains, tenuous as they were, encouraged local organizations and their national partners to launch new state and municipal policy campaigns, and to increase the presence and visibility of grassroots leaders at the national level. Those efforts have borne fruit. Over the past two years, the child care issue has gotten political traction through a number of pathways.

In 2018, Congress doubled discretionary funding for the Child Care and Development Block Grant, the largest increase in the history of the program. With Republicans controlling both houses of Congress and the White House, Democrats had few cards to play in budget negotiations, but they chose to make child care a priority at the urging of Sanders, Patty Murray, Elizabeth Warren, and other progressive senators.

The same year, gubernatorial candidates from a disparate set of states—including Gavin Newsom (CA), Michelle Lujan Grisham (NM), Stacey Abrams (GA), Tim Walz (MN), Gretchen Whitmer (MI), and J.B. Pritzker (IL)—made early care and learning a major theme in their campaigns. After the election, this continued to be a political priority. A study by the Center for American Progress showed that nearly two-thirds of the nation’s governors were proposing increases in funding for early care and education in their 2019 budgets.

California led the way this year, allocating more than $600 million in new funding for child care and early-learning programs. New Mex-

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 77

BUILDING UNIVERSAL FAMILY CARE: THE SOCIAL INSURANCE SOLUTION ico raised the eligibility ceiling for child care subsidies; Illinois raised wages for 14,000 child care providers; and Oregon and Washington created high-level task forces to find solutions to the child care crisis. Even the deepred Ohio legislature coughed up $10 million to fund wage incentives and other measures to enhance the quality of early-childhood education.

As Marcia Brown has noted in this issue, our affiliated grassroots organizations OLÉ in New Mexico and SPACES in Action in D.C. have won emergency COVID-related funding for child care.

Parent Voices Action, another partner, was the driving force behind a successful ballot measure in Alameda County, California, generating $150 million each year that will increase access to child care, raise wages for providers, and fund Northern California’s only level-one pediatric trauma center. More than 6 out of 10 voters chose to raise their taxes so East Bay kids can get the best start possible.

Arguably the highlight of the past year was the attention given in the presidential campaign to an advanced solution, a universal child

care proposal. Elizabeth Warren’s rollout was striking not only for the ambitious substance of the plan, but because she was candid about the $70 billion annual price tag, tied directly to her signature tax on wealth, and explicitly framed as a critical tool for gender and racial justice. She would tell crowds that, with revenue from the wealth tax, “we can provide universal child care for every baby in this country and raise the wages of every child care worker and preschool teacher in America.” Other presidential candidates, like Sanders, echoed Warren’s call for a universal program, and most recently, Democratic nominee Joe Biden has made greater investment in early learning and care a pillar of his Build Back Better agenda. Child care is now a central element of the progressive agenda.

Taking Stock Creating a universal entitlement on child care, and even expanding it to a full family care agenda where paid family leave and long-term elder care are combined in a social-insurance

Child Care Rising

2016: Hillary Clinton and Bernie Sanders embrace universal child care programs 2017: Increases in funding for child care in six states 2018: Congress doubles funding for the Child Care and Development Block Grant 2020: California adds $600 million in new funding for child care and earlylearning programs 2020: Illinois raises wages for 14,000 child care providers 2020: Ohio appropriates $10 million to fund wage incentives for earlychildhood educators 2020: New Mexico and Washington, D.C., grant emergency COVID-related child care funding 2020: Elizabeth Warren proposes $70 billion/year universal child care plan

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program, may seem like a long shot in the next few years. But a post2020 Congress could make a significant down payment through the existing patchwork of programs, by increasing access to the Child Care and Development Block Grant, by joining the community of nations in mandating paid leave, and by using health care programs to benefit access to and compensation for long-term care. That would improve the lives of millions of Americans, and lay the foundation for a comprehensive solution to the care crisis.

What lessons can we take from the journey on child care to apply to family care?

First, organizing can transform a social problem into a political issue.

Child care has been a perpetual topic of research and analysis, but it only became a focus of public debate when a broad-based constituency pushed it to the fore. The women’s movement and welfare rights movement provided much of that base during their heydays in the late ’60s and ’70s. Now a new movement is emerging, spearheaded by women of color, rooted in Black, Brown, immigrant, low-income, and faith communities. The rise of this “mother’s movement” did not occur spontaneously. It is the product of decisions by community leaders, organizers, national institutions, and funders who committed time and resources to the hard labor of base-building.

While an energized constituency is essential to change, it is not sufficient.

Major advances in public policy don’t happen without the support of voters and elected officials. Child care, and family care in general, was ripe for that coalition-building, because it speaks to both mainstream “persuadable” voters and to constituencies at the heart of the progressive base. The issue is not highly polarized like health care or immigration; most Americans agree, in principle,

that the government should invest more resources in families, and give peace of mind to those who need care.

In addition, for many women, especially women of color, our failure to help those struggling with care needs or provide living wages to caregivers is not just callous and foolish, but emblematic of a system that devalues their work and their lives.

Politic a l lea ders who have embraced early care and learning— Elizabeth Warren, Nancy Pelosi, Patty Murray, Stacey Abrams, Gavin Newsom—recognize that support for child care spans the divide between universalistic economics and identity-based politics that is a recurring fracture point in the Democratic coalition. Like child care in isolation, family care is an issue that can unite the base and serve as a stepping stone to an electoral majority.

We shouldn’t underestimate the challenges of converting political momentum into substantive change.

Family care is a complex ecosystem that doesn’t compress readily into sound bites. The optimal policy solutions—an integrated, universal program with sliding-scale contributions, a wage floor and training ladder for providers, local management with national standards—are difficult to express in a succinct way.

The new coalition must make room for and build a coherent narrative out of all of the disparate benefits of family care: educational development, improved health outcomes, job growth, racial and gender justice.

Finally, as policy proposals become more concrete and the price tag comes into focus, opposition will crystallize, as it did with Nixon in 1971. Among progressives, there is likely to be sentiment—some is already surfacing—that scarce resources and scarce political capital should be spent on other priorities like health care or climate change.

The seeds of a national childcare movement were discernible, but they had to be cultivated in order to grow.

The danger is that leaders will respond to this resistance by retreating to an incremental posture, tinkering at the edges of the system while adding small bits of cash to the pot.

It’s the wrong move from both a policy and political standpoint. This is the moment to go big, not small. It will take a powerful social movement to overcome the compound of structural racism, sexism, and privatism that is the root of our family care crisis. Only a generous vision of change—a narrative of hope and aspiration anchored in shared values—can inspire people to join such a movement. And only an ample investment in organizing and political mobilization can sustain it over the long haul.

This type of transformative, bold vision is only possible when we organize and work together, just like when we won better wages, safer workplaces, and civil rights. This is how we passed the Social Security Act in 1935—with a social movement powering it via “Townsend clubs,” through millions of people signing petitions in the pre-internet age and organizing to demand a response from the political system. Over the last few years, women—providers, early-childhood educators, and mothers—have fought across the nation for a new child care system that could become the heart of the Third Reconstruction in America. The family care coalition mirrors

that movement in terms of race and gender. Led by women of color, this is an intersectional social movement in action—with real, tangible wins beneath its wings and a bold vision for the future.

Family care is more than an issue of deep practical concern to millions of Americans; it is a point of entry for debate about some of the most fundamental questions we face as a society. Why is care so devalued in our economy? What is the line between private responsibility and public good? What do we owe to every child as a birthright, and to everyone for dignity in their working lives and their final years?

What will it take—and how long can we wait—to achieve genuine equality? The emergence of family care as a salient political issue reflects the growing urgency of these questions, a collective recognition that they can no longer be deferred but need to be addressed head-on. We hold the high ground right now. It would be a historic mistake to abandon that opportunity for another generation. n Dorian T. Warren is president of Community Change.

Seth Borgos is director of research and program development at Community Change.

BONUS ISSUE, 2020 THE AMERICAN PROSPECT 79

THE FAMILY CARE ISSUE: AN INTERVIEW WITH ELIZABETH WARREN Sen. Elizabeth Warren could have made her Democratic National Convention speech about anything. She spoke from a school in Massachusetts, talking about child care. We asked her about the importance of ensuring affordable child care for everyone and better wages for care providers.

Sen. Elizabeth Warren speaking from a school in Massachusetts to the Democratic National Convention in August

The American Prospect: Sen. Warren, your proposed Universal Child Care and Early Learning Act seems like a slam dunk. With so many families unable to afford reliable care and so many care workers underpaid, this is a rendezvous waiting to happen. Yet it has been impossible to achieve politically, even as we have expanded other areas of social provision such as health care. Why is this one so hard?

Sen. Warren: Before the coronavirus out-

break, there was already a child care crisis in America, but I think a lot of people thought it wasn’t their problem. The COVID-19 crisis is exposing the major holes in our economy and our society, including the giant boulder of unaffordable child care crushing too many families right now. Tens of millions of Americans are losing their jobs or worried they will. Schools are shuttered and kids are at home trying to keep on learning.

And child care providers are closing left and right, with many saying they may never be able to reopen. So the challenge of finding affordable child care has gone from hard to darn near impossible. So families get it.

And more and more people without children are realizing that child care is a core part of our infrastructure. We build infrastructure like roads, bridges, and communications systems so that people can work.

That infrastructure helps us all because it keeps our economy going, and child care is infrastructure for families. Without reliable, safe, and affordable child care, parents simply will not be able to get back to work.

And that’s like dropping a giant anchor behind our struggling economy.

That’s why I am working with my colleagues in Congress to save our child care system from collapsing with a $50 billion child care bailout. But we need to build this broken system back better than before. We

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can’t just go back. We need to make a longterm investment in child care and early learning for all our kids. We can do this if everyone gets in this fight and calls on their member of Congress to act.

Do you think the pandemic and the progressive hopes for the Biden administration to deliver policies that make a palpable difference in people’s lives provide an opening for real progress that has been denied up until now?

I believe this is a pivot point in modern American history. And Joe Biden and Kamala Harris have committed to big solutions to shrink our economic and racial gaps, like canceling billions in student loan debt, investing in universal, high-quality child care and pre-K, creating new union jobs in clean energy, increasing Social Security and disability benefits, making the wealthy pay their fair share, repairing racial inequities, and fighting corruption in Washington.

I believe government can be a powerful force for good when it actually works for people. We can save lives, support families, and also make big, structural changes to make our economy and our country work for every person, not just the wealthy and well-connected.

What about the challenge of existing child

care and pre-K workers in family day care or other facilities that are not up to par?

On the one hand, we need to professionalize and upgrade quality. On the other hand, we don’t want to displace the large force of existing workers.

The way I see it, this comes down to how we pay and value child care workers—who are often women and often women of color.

Joe Biden and Kamala Harris have committed to something I’ve also fought for: treat child care workers and educators with the respect and dignity they deserve by paying them what they deserve.

And they sure deserve a raise. Under the universal child care bill that I introduced and under Joe Biden’s plan, child care workers’ wages and benefits would be similar to those of local public elementary school teachers with similar credentials and experience, and child care workers would have the training and development they deserve with the ability to join a union.

And we need to invest in the child care supply, which has collapsed during this pandemic, and build more safe child care facilities. We can’t leave family and homebased child care providers out of this. They may be small, but a lot of them are anchors of their communities. They deserve support and fair pay, too. n

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Trump’s COVID-19 School Crisis

By Randi Weingarten, President AMERICAN FEDERATION OF TEACHERS

hen a Georgia student posted a photo of her packed school hallway with virtually no one wearing masks, it went viral. Officials reacted by suspending her rather than figuring out how to keep kids and educators safe during a pandemic. Later, of course, they had to take the coronavirus seriously when 35 people at the school tested positive.

That behavior has been the norm in far too many places, and nobody has modeled it more than President Donald Trump. He has spent the entirety of the COVID-19 crisis downplaying the virus and distorting reality, jeopardizing the physical and economic health of Americans.

The facts are clear: We’re in the midst of a public health crisis the likes of which we’ve never experienced in our lifetimes. In the last two weeks of August, there were 70,000 new child cases of COVID-19 and today the United States has more than 6 million confirmed cases amid a continuing surge.

But Trump, Senate Majority Leader Mitch McConnell, Education Secretary Betsy DeVos and other leaders continue to push fiction over facts.

Trump has dismissed the report of growing cases among children, saying only a “tiny fraction” result in deaths. He and DeVos finally, begrudgingly, acknowledged that safeguards were needed, yet they still won’t find the resources needed to put them in place.

pretending COVID-19 doesn’t matter rather than fighting it. At every turn, Trump chooses himself, his politics and the rich, at everyone else’s expense.

With record unemployment and 1.5 million more hungry children since the start of the pandemic, U.S. billionaires added $584 billion to their own wealth.

Trump’s rhetoric on reopening schools echoes the kind of recklessness we saw earlier this year, when he accused nurses of stealing PPE rather than getting them the equipment they desperately needed. And now, ironically, when everyone would have wanted to start the school year in person if it were safe, we are barreling toward the most chaotic and confusing back-to-school in modern history.

Educators, parents and children are angry and scared about schools being forced to reopen without adequate resources for safety protocols. They’ve seen what happened in another Georgia district, where more than 1,000 students and educators are now quarantined days after reopening. Or in places like Florida, where the governor demanded schools reopen despite the state having one of the biggest COVID-19 surges—and where our state affiliate successfully sued to protect the health and safety of students and educators. At one Florida school, an entire class had to be quarantined the day after reopening, yet the teacher is being required to lead remote learning from that same classroom. Educators, students and parents alike feel abandoned by their government,

whose leaders, for the most part, have had months to come up with plans and resources and have failed.

There are some bright spots, where science and safety are the standards, not politics. In New York City, the start of in-person classes has been pushed back, after the teachers union raised concerns about safety. In Los Angeles, educators and school officials developed a plan to make distance learning work. But in most of the country, virtually everywhere you look there is chaos and confusion, which is why polls show 59 percent of Americans now oppose fully reopening schools.

When it comes to the health and safety of our children, we must spare no expense, put politics aside and act immediately. In-school instruction is important, but safety is more important. Educators and kids should not be bargaining chips or have their health jeopardized. Reopening schools should be based on science, not on spin, which is what we tried to do with the reopening plan the AFT developed in April. That’s why we’ve been mobilizing to get the Senate to act to fund schools. And why, at our convention, we supported educators employing safety strikes as a last resort if the health and safety needs of their students and themselves are not being met.

As educators and health professionals, we are guided by facts and helping those we serve. It would be nice if the president of the United States were guided by the same moral compass.

Educators and kids should not be bargaining chips.

Trump turned the wearing of masks into a partisan fight. His administration forced states to compete against each other for personal protective equipment.

And with record numbers of people still unemployed, and essential services threatened because of the toll the virus has taken on state and local budgets, Trump bypassed Congress by issuing several executive orders he hoped would play well but that do little to help people. DeVos has refused to testify before Congress on reopening schools; she has been working remotely from her Michigan mansion while saying we should go back to school in person.

The New York Times recently reported that the White House’s plan all along was to pass blame and responsibility on to the states, instead of helping people. Trump and his administration have viewed this entire crisis as a political issue, not a human or a moral one. Their focus remains on

Photo: AFT

Weingarten delivers her keynote address at the AFT’s 2020 convention.

Follow AFT President Randi Weingarten: www.twitter.com/RWeingarten

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