America Might Finally Get a Comprehensive Care System

In building up care infrastructure under the American Jobs Plan and American Families Plan, the U.S. would start the critical work of reversing decades and decades of underinvestment in the care sector.

America Might Finally Get a Comprehensive Care infrastructure System
President Biden signing the American Rescue Plan into law on March 11. (@POTUS / Twitter)

This article was originally published by the Century Foundation. It is reposted here with permission.

It is really quite a moment for American families and care workers. After years of meetings, calls, letters, tweets and texts to Congress from exhausted mothers, overwhelmed fathers, struggling child care small business owners, family caregivers, people with disabilities, employers, early educators, union members, child development experts, advocates and more, the U.S. has a genuine opportunity to build the care infrastructure we have long needed.

The Biden–Harris administration’s American Jobs Plan and American Families Plan taken together would lay the foundation for building comprehensive child care and early learning, creating greater access to home- and community-based services with a well paid workforce, and paid family and medical leave for everyone that would bolster women’s workforce participation, support healthy child development and learning, ensure people with disabilities can live independently, support aging with dignity, and ensure a flourishing economic future for everyone. In building up our care infrastructure under these plans, the United States would start the critical work of reversing decades and decades of underinvestment in the care sector.

Taken together, the president’s plans would provide:

  • $450 billion for child care and early learning,
  • $225 billion for paid family and medical leave, and
  • $400 billion for home and community-based services.

The plans also include direct support for nutrition assistance and extend the December child tax credit expansion, which would reduce child poverty and help millions of families meet the high costs of raising children. The expansions of the earned income tax credit (EITC) and the child and dependent tax credit would also make it easier for families to make ends meet and improve child academic performance and lifetime earnings.

Care workers and family advocates have been working toward policy change like this literally for decades, and the moment is finally here.

Child Care and Early Learning

Fifty years after President Nixon vetoed the last comprehensive child care and early learning proposal—one that had passed Congress on a bipartisan basis—elected officials are once again stepping up to lead and move forward this “win for all” issue. Decades after President Nixon’s veto left parents to fend for themselves, early educators to rely on public assistance because their pay is so low, and children without the stable, nurturing care they need, progress is long overdue. A comprehensive child care and early learning policy is the pathway to progress on gender, racial, and income equality; healthy child development and family well-being; educational outcomes; and economic growth and prosperity.

President Biden’s plans would at long last begin to build a comprehensive child care and early learning system by providing direct support to children and families through guaranteed child care assistance and universal preschool. The plans focus includes:

  • Affordability: The plans would make child care for young children ages 0–5 more affordable by ensuring that families spend no more than 7 percent of their income on child care, with an income eligibility cap at one-and-a-half times the state median income and providing free preschool for all three- and four-year-olds.

  • High-quality programs: The plans would build the supply of high-quality child care and early learning options that promote children’s social, emotional and cognitive development through developmentally and culturally appropriate curriculum and small class sizes that are inclusive of children with disabilities.

  • Diverse providers: The plans ensure families can choose among diverse child care and early learning settings, including child care centers, family child care providers, home-based care, Early Head Start and public schools.

  • High-quality jobs: The plans call for a wage floor of $15 an hour for early educators and child care staff and require that they receive comparable compensation and benefits with kindergarten teachers that have matching credentials. The plans also envision coaching, professional development and additional training opportunities.

In April, activity from members of Congress demonstrated their commitment to moving forward on these and related proposals.

  • Sens. Elizabeth Warren (D-Mass.), Tina Smith (D-Minn.), Ron Wyden (D-Ore.) and Alex Padilla (D-Calif.), along with Rep. Katherine Clark (D-Mass.) and others called on the administration to invest $700 billion over ten years in child care and early learning.

  • Sen. Warren and Rep. Mondaire Jones (D-N.Y.) reintroduced the Universal Child Care and Early Learning Act.

  • House Ways and Means Committee Chairman Richard Neal (D-Mass.) held a hearing on child care and paid leave and announced his plans for the Building the Economy for Families Act, which includes investments in child care and paid leave as well as tax reforms to help build families’ economic security.

Ideally, the next step would be for Congress to decide to move forward with a jobs and families package that included $700 billion over ten years for child care and early learning (which is more than what the president has called for). This would allow policymakers to build a high quality child care and early learning system that is affordable; is available when and where families need it; is diverse and culturally responsive; is supportive of children’s healthy social, emotional and cognitive development; pays early educators and child care staff well; and provides additional supports for their valuable and complex work.

If the total budget approved by Congress reflects only the president’s plan, policymakers will still be able to build the foundation for the system, but the tradeoffs will be more challenging, including making decisions about what ages to include, eligibility criteria, the phase-in period and more.

Paid Leave for All

Twenty-eight years ago, in 1993, the Family and Medical Leave Act (FMLA) was the first bill that President Clinton signed into law. It provides workers up to 12 weeks of unpaid, job-protected leave to care for a newborn or newly adopted child, manage a serious illness, or care for a seriously ill loved one; starting in 2009, it also includes unpaid, job protected leave of up to 26 weeks for workers caring for a wounded service member and up to twelve weeks for certain circumstances accompanying a family member’s deployment.

The push to expand the FMLA to reach more families and provide paid leave has been ongoing since the FMLA’s passage. While 10 states have enacted paid leave policies and the federal government recently began offering 12 weeks of paid parental leave to its own employees, this past March, in response to the pandemic, Congress adopted a limited, temporary paid leave policy. The emergency paid leave provisions in the Families First Coronavirus Response Act (FFCRA) guaranteed 12 work weeks of emergency paid family leave for parents working in businesses with fewer than 500 employees who had to care for children whose school or child care was closed, as well as for other pandemic-related purposes. Private and nonprofit employers that were required to provide paid leave under the FFCRA were also eligible for tax credit reimbursement from the federal government.

These provisions helped those who were able to use them, but the requirement that employers provide emergency paid sick and family leave expired in December 2020, replaced only by tax credits to incentivize employers to continue to provide these benefits.

President Biden’s plans prioritize creating a sustainable and more comprehensive paid family and medical leave program—because, as he said in his address to the joint session of Congress: “No one should have to choose between a job and paycheck or taking care of themselves and their loved ones—a parent, a spouse, or child.”

President Biden’s plans call for a paid leave program that is:

  • Guaranteed: The plans will guarantee 12 weeks of paid parental, family and personal illness/safe leave by year 10 of the program, and also ensure that workers get three days of bereavement leave per year starting in year one. The paid leave would be available as a direct benefit to workers, so that it covers all working people no matter where they live, their employer or the nature of their job.

  • Inclusive: The plans would support paid time for workers to bond with a new child; care for a seriously ill loved one; adjust to a loved one’s military deployment; find safety from sexual assault, stalking or domestic violence; heal from serious illness; or take time to deal with the death of a loved one. It would also acknowledge that family caregiving responsibilities can extend to a workers’ grandparent, grandchild, sibling, adult child or chosen family.

  • Meaningful: The plans provide progressive wage replacement, including 80 percent of wages for the lowest-wage workers and two-thirds of average weekly wages replaced for those paid higher wages.

Since 2013, in every Congress, Sen. Kirsten Gillibrand (D-N.Y.) and Rep. Rosa DeLauro (D-Conn.) have introduced the FAMILY (Family and Medical Insurance Leave) Act, which would provide 12 weeks of paid leave. The House Ways and Means Committee and the Senate Finance Committee are the committees of jurisdiction, and in order to prepare to move the policy through a reconciliation process, Ways and Means Committee Chairman Richard E. Neal (D-Mass.) recently released a discussion draft for a new bill, the Building an Economy for Families Act. Like the FAMILY Act, the proposal would create a new guarantee of up to twelve weeks of paid family and medical leave for all workers. The program would be administered by the U.S. Department of the Treasury in combination with existing state paid leave programs. The proposal would create progressive wage replacement, as has been done in a number of states, so that every worker taking leave would receive at least two-thirds of their wages, and those with the lowest pay would receive more of their pay to cover their leave time.

As Congress moves forward, they most will likely look at the president’s proposal, the Neal proposal, the FAMILY Act, as well as lessons from the states, to design a national policy that would cover all working people in the United States, as each of these approaches would do. These policies would boost women’s labor force participation, contribute to children’s healthy development, improve maternal health, support gender equitable care, enhance family economic security and individual retirement and income security, and support small businesses.

As New America senior fellow Vicki Shabo points out: “National paid leave would touch virtually every household in America at some point in workers’ lives.” While it is too late for a paid leave bill to be the first that President Biden signs into law, it is definitely not too late to enact this much-needed policy.

Home and Community-Based Services

Fifty-six years ago, Medicaid and Medicare were established to provide health insurance to low-income families, people with disabilities, and people aged 65 and over, respectively. Most people have limited understanding of Medicaid, and think of it only as a health care program. Many people also believe that Medicare will cover any long-term care needs they may have when they age. But the main program that pays for long-term services and supports (LTSS) is Medicaid. Medicare only pays for short-term nursing home stays, health care in a home following a hospital stay, or home hospice care.

Medicaid is mandated to pay for nursing home care for those who qualify (with strict income limits, causing many to spend down assets). Yet, home and community-based services (HCBS)—paid support to help seniors and people with disabilities live independently in the community by assisting with daily self-care and household activities—are considered an optional service and the number of families who receive this support is extremely limited. That institutional bias in Medicaid, making HCBS optional, means states can have waiting lists, with over 850,000 people with disabilities and aging adults are waiting all over the country—and that is only for those who know that there are waiting lists to be on.

Most families are left on their own to find solutions, and if they do receive federal support, it is for congregate care settings like nursing homes because of that institutional bias. And those who work in direct care—primarily Black, Latinx and immigrant women—are underpaid, which can lead to high turnover and burnout rates. Yet, as the population ages, these supports will be even more essential and families will struggle on their own to provide solutions. An LTSS plan that includes significant support for access to home and community-based services will not only support the aging population and people with disabilities, but also increase the economic, physical and emotional well-being of family caregivers and paid home care workers and personal care attendants.

President Biden’s plans call for $400 billion to expand access to quality, affordable home- or community-based services for people with disabilities and aging adults and investments in the wages for the direct care workforce. These efforts build on the American Rescue Plan Act, which provides a 10 percentage point increase in federal matching funds for Medicaid home and community-based services (HCBS) to states from April 1, 2021 through March 30, 2022. President Biden’s plans would:

  • Serve aging adults and people with disabilities: The newly proposed funding would expand access to LTSS under Medicaid for HCBS, make the Money Follows the Person program permanent, a program that supports transitioning people out of congregate care into their communities.

  • Create good care jobs: The plans would establish an infrastructure to create good, family-sustaining jobs, provide the direct care workforce—currently paid an average of $12 an hour—a raise, benefits and an opportunity to organize or join a union and collectively bargain.

  • Support family caregivers: The plans would support the more than 50 million family caregivers who are managing or providing care for their loved ones, allowing them to have more ease in their work and family responsibilities, increase their workforce participation, and build their economic and retirement security.

Congressional leadership needs to include the full $400 billion outlined by President Biden to build access to HCBS and to build and strengthen the direct care workforce as they work with the House Energy and Commerce Committee and Senate Finance Committee to develop the final legislative language. The need for this policy solution has grown tremendously over the past half a century. Half of all adults turning age 65 today will need LTSS, and about two in five people who need LTSS today are under 65 years old—including many people with disabilities—and many may require the support over their lifetimes. This policy cannot wait.

The Time to Build Care Infrastructure Is Now

Throughout the pandemic, Black, Latinx, Indigenous and immigrant women in particular—all of whom have long faced intersecting oppressions—experienced the multiple effects of being more likely to have lost their jobs, to be on the front lines as essential workers, and to be solving their care challenges on their own. Today, years of organizing and advocacy are coming together with the right leadership to put the needs of these women—and indeed all caregivers—front and center and build the care infrastructure we have needed all along.

The American Jobs Plan and the American Families Plan will not only pave the way to progress on gender, racial and income equality; they will also create and support millions of jobs, helping to advance an inclusive and equitable economic recovery.

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Julie Kashen is director of women’s economic justice and a senior fellow at The Century Foundation, a leading progressive think tank. She is one of the nation’s leading experts on the issues affecting working families, having authored numerous studies on childcare, paid leave, equal pay and other topics.