Why A Transformation Of Caregiving Could Be Biden's B.F.D.

It would cost a lot of money. But there's a reason for that.
Getty Photos / Illustration by Rebecca Zisser

Democrats in Congress are feverishly putting together what could be the most ambitious piece of domestic legislation in several decades. But you probably haven’t heard much about what the bill would actually do, except maybe that it would require a lot of new government spending.

That’s partly because it feels like such a collection of disconnected elements. But some of the proposals are connected in an important, potentially transformative way. They would create a new pillar of the welfare state that could alter everyday life in the same way that the core pieces of the New Deal and Great Society did.

It would be a “big f***ing deal,” as Joe Biden famously described the Affordable Care Act in 2010 when he was vice president. But this time, the B.F.D. would be a revolution in federal support of caregiving.

It’s got three main components. One is an initiative to provide up to three months of paid leave to take care of family members, including newborns. Another is a proposal to make child care and prekindergarten available to any family that wants it, and to improve the quality of that care for everyone. The third piece is a proposal to fund what are known as “home- and community-based services,” a clunky piece of policy-speak that refers to programs that allow disabled and elderly Americans to live on their own rather than in nursing homes and other institutions.

Americans need these programs desperately. Paid leave is available to only 1 in 5 private-sector workers. Child care costs more than in-state college tuition these days, and studies suggest that half of American families live in child care “deserts,” which means they live somewhere where there is less than one licensed provider for every three young children. Home and community services are difficult to get, with more than 800,000 people on waiting lists, because Medicaid funding for them is so limited.

“The work itself is associated with work that women do and that we’ve taken for granted.”

- Ai-Jen Poo, executive director of the National Domestic Workers Alliance

The reforms Democrats propose would give the federal government partial responsibility for them, in the same way it now provides pensions through Social Security and health insurance through Medicare, Medicaid and the Affordable Care Act. The ideas are extremely popular, if the polls are correct. But together they would cost the federal government around a trillion dollars over 10 years. And that’s creating a major political problem.

Democrats have ultra-thin margins in Congress and a handful of their more conservative members, led by Sens. Joe Manchin of West Virginia and Kyrsten Sinema of Arizona, have said the overall spending bill costs way too much. Democratic leaders have already scaled back parts of the caregiving agenda in response, cutting proposed funding for home and community services in half. More cutbacks could follow and, of course, the whole legislative effort could fall apart altogether.

Manchin, Sinema and their supporters haven’t criticized any of these proposals specifically, at least in public. They just argue the government needs to spend less. But there’s a reason these three initiatives cost so much, and it’s why they would have such far-reaching effects: They would recognize the value that caregiving provides to society and, critically, the value of the people who provide it.

A History Of Undervaluing Care ― And Caregivers

Responsibility for caregiving has historically fallen disproportionately on women ― who, in turn, were expected to provide it for little or no pay. That was possible, in part, because until relatively recently in history most women didn’t have alternatives in the paid workforce. That was especially true for women of color, who were subject to discrimination (and, at one time, enslavement).

“The work itself is associated with work that women do and that we’ve taken for granted,” Ai-Jen Poo, executive director of the National Domestic Workers Alliance, told HuffPost. “And as a profession, it’s always been associated with women of color, especially Black and brown women.”

Later in the 20th century, campaigns for gender and racial equality helped to open up more work opportunities. But the shift of so many women into the paid labor force created new demands for child care. Somebody still had to watch the kids, after all, and it’s not like men were leaving the workforce to pick up the slack.

Demand for care of older Americans has increased too, thanks to advances in medicine that have prolonged life expectancy and the aging of the baby boomer generation. For a while, boomers served as caregivers to their own elders. Now they’re the ones who need care, which is why the ratio of caregivers to the elderly population, which peaked around 2010, is falling.

Caring for children, the elderly and people with disabilities require different skills, obviously, but they have historically drawn from the same general pool of workers. And in a properly functioning market, the increasing demand for these workers would have pushed their wages up, in order to attract more of them.

But wages for both child care workers and direct-care workers have remained nearly stagnant ― and near the bottom of the income scale, with both making roughly what retail workers do. Today, roughly 1 in 5 home care workers have incomes below the poverty level, while more than half are on some form of public assistance. The numbers for child care workers are similar, as studies from the Economic Policy Institute have shown.

A big reason for this low compensation, according to University of Michigan economist Betsey Stevenson, is that individual families don’t have the resources to pay more.

“People can’t pay more for child care than their own take-home earnings. That puts a limit on how much families are able to pay,” Stevenson told HuffPost. “The result is low wages for workers who aren’t sufficiently rewarded for developing skills in child development.”

What’s true of child care is true of care for elderly and disabled Americans: Low pay makes it tough to attract and then hold on to the most talented workers, because they quickly discover they can make more money doing something else. Half the home care workforce turns over every year, PHI, a research and advocacy group, concluded in a 2015 report.

A Political Movement ― And A Policy Opportunity

The care situation in other countries isn’t necessarily easy. But it’s certainly easier, thanks to national programs governments put in place long ago.

Literally every other economically advanced country on the planet has a paid-leave program, making it possible for working adults to take time off without giving up their incomes in order to care for a newborn or relative. Most also have some combination of child care and preschool that is either cheap or free, and pays well enough to attract caregivers who have formal training in child development.

Coverage of home care for elderly and disabled people tends to be more inconsistent, but in general Europeans don’t have to pay as much out of pocket for long-term care because their comprehensive, seamless social insurance programs pick up so much of the cost.

The U.S., characteristically, has dealt with these needs in fits and starts. A series of narrowly targeted federal programs, including Head Start, subsidize care for less than 1 million children. Medicaid finances home care for elderly and disabled Americans, but it doesn’t come close to meeting the demand, which is why the waiting lists are so long. A few states have paid-leave laws, but there’s nothing at all on the national level, which is why the majority of workers don’t have access to it.

In the past decade or so, Congress has started to pay a lot more attention to these issues, driven by women lawmakers who have firsthand experience as caregivers. The most visible champions for child care include Sen. Patty Murray (D-Wash.), a former preschool teacher, and Sen. Elizabeth Warren (D-Mass.), a former special education instructor. Both were working moms who had a hard time finding care for their kids.

Among the leading advocates for paid leave is Sen. Kirsten Gillibrand (D-N.Y.), who first introduced her version of legislation a few years after having a baby. Rep. Debbie Dingell (D-Mich.), who is leading the charge on the home care bill, learned about the system’s dysfunctions while arranging care for her husband, former Rep. John Dingell, in the years before he died.

“People can’t pay more for child care than their own take-home earnings.”

- Betsey Stevenson, University of Michigan economist

But it’s not just these lawmakers who have made caregiving a priority. Advocacy groups have worked tirelessly to publicize the need for federal investment and make a case that it could be successful. And especially in the last few years, they’ve been coordinating with each other in order to present a united front. That’s a change from the past, when groups working on child care had very little to do with groups working on elder care ― and, more generally, when groups representing the people receiving services kept their distance from groups representing the people who provided them.

An example of the new coalitions is “Caring Across Generations,” a coalition that Poo helped establish in 2011 with support from labor unions, among other groups. The whole point of the organization was to emphasize the common needs of both providers and receivers of care, during all parts of the life cycle ― and to make sure lawmakers did something to address those needs.

Advocates made a big push on their agenda in the lead-up to the 2016 election, in the hopes that Hillary Clinton, who had her own long history of advocacy on care issues, would use her presidency to push legislation through Congress. That didn’t happen. And although Republicans during the Trump era showed some interest in paid leave specifically, mostly they were uninterested in the caregiving agenda ― precisely because serious plans all involved creating or expanding social welfare programs, which is something conservatives have generally opposed.

That shifted the focus to the 2020 election, when advocates pushed all of the Democratic presidential candidates to lay out a caregiving agenda. They succeeded. Every major Democratic candidate, including Biden, ended up proposing plans addressing some combination of paid leave, child care and home care. Then the pandemic hit, making the value of caregiving and the burden on women more obvious than ever.

The Democratic Agenda ― And Democratic Resistance

None of this guaranteed that caregiving would be a focus once Biden got elected and Congress got to work. It’s easy to imagine a scenario where Biden dropped his commitments, or at least made them a much lower priority, citing a need to make tough choices.

But that didn’t happen. Unlike most men of his generation, Biden has years of experience as a primary caregiver for young children after his first wife died in a car accident. He also has a long history of advocating for the working class, which consists less and less of factory workers and more and more of care workers.

That likely helps explain why raising wages for caregivers has been as much a focus of Biden’s agenda as has making caregiving more affordable for families. Both the child care and home care proposals do this by giving extra federal money to the states, and making that money conditional on paying care workers more than they make today. (Paid leave arguably has the same effect, as it compensates people caring for their own loved ones.)

This is also a big reason advocates worry so much about reductions in proposed funding as leaders try to accommodate more conservative members in Congress: There might not be enough money to help both the caregivers and those getting the care. “There doesn’t seem to be an understanding that this is a policy that ... can’t be cut down to the extent that we are hearing is being considered,” Nicole Jorwic, senior director for public policy at The Arc, a disability rights organization, told HuffPost after learning about the cuts to home and community services.

The concern is especially acute because even the money that Biden and Democratic leaders initially sought for the care agenda represented a compromise, with less spending, in order to accommodate more conservative members of the caucus who were wary of too much government expansion (or, in some cases, opposed to tax increases on the rich that would have paid for the initiatives).

The child care proposal, for example, would only cover children up through age 5, even though older children frequently need care before or after school, and during summer months. And instead of simply funding programs that would be affordable to all families, the new program would involve a complex set of subsidies sure to confuse both providers and parents, and it wouldn’t be available to higher-income families.

The paid-leave program would offer only 12 weeks of leave, which is much less than most European countries offer, and rely on a similarly confusing system. The money in the home care program could raise salaries incrementally, but maybe not enough to attract as many workers as it would take to meet the exploding demand.

“This is a policy that ... can’t be cut down to the extent that we are hearing is being considered.”

- Nicole Jorwic, senior director for public policy at The Arc

Still, the reforms under consideration would make a difference. More than 8 million kids would end up using the new child care system, according to one estimate. At its original funding level, the home care proposal was expected to wipe out waiting lists. These sorts of gains would have secondary effects on the economy too ― by freeing up unpaid family caregivers to seek or hold paid jobs when they want, raising wages at the lower end of the income scale and giving young children the kind of start that increases their odds of success later in life.

And however incomplete these initiatives might be, they would create a policy infrastructure that future generations of lawmakers could strengthen ― which is precisely how the American welfare state has evolved in the past. The original Social Security benefits were too meager and left out whole swaths of workers. Medicare didn’t initially have a drug benefit. But lawmakers kept working at it, which is why poverty among the elderly has fallen dramatically and access to prescriptions has significantly improved.

Enacting the caregiving agenda wouldn’t mean that every working parent finds quality child care they can afford, or that every disabled and elderly person who needs home assistance will get it. But many would. And that would be a B.F.D.

CORRECTION: A previous version of this article misidentified Joe Manchin as a senator from Arizona. He represents West Virginia.

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