4

Exploring Policy Strategies and Innovations

Before introducing the final panel, Debbie Chang, president and chief executive officer of the Blue Shield of California Foundation, explained why a panel that focuses on population health would examine the topic of care work. Economic security and mobility are a determinant of health, but they are precarious for care workers who contribute to healthy child development and improve quality of life for aging adults and people with disabilities. The work of care workers makes all other work possible, and caregiving touches everyone. Chang shared how she could not do her work or provide for her own family without caregivers, adding, “they are essential workers and they need essential benefits.” Chang added two data points to facts and figures highlighted in earlier panels: the median salary for child care workers is just over $11 per hour, and for home care workers, it is just over $12 per hour. This underinvestment, Chang asserted, “has led to workers sacrificing their own health and economic security while they support and are the backbone for families and communities. We know that these workers are primarily women of color, immigrants, and undocumented women. This is a health equity issue.”

Chang shared two examples from her foundation’s work to improve the lives of care workers: support for programs to strengthen child care entrepreneurship and a partnership with the California Domestic Workers Coalition, which organizes workers to advocate for policy change. As an example, she shared that San Francisco recently passed an ordinance, the first of its kind in the country, that creates a portable paid sick leave benefit for domestic workers.

Chang introduced Julie Kashen, senior fellow and director for Women’s Economic Justice at the Century Foundation; Josie Kalipeni, executive director of Family Values @ Work; Melissa Boteach, vice president for Income Security and Child Care and Early Learning for the National Women’s Law Center; and April Sims, secretary treasurer of Washington State Labor Council.

Kashen began by sharing her own care story, of how early during the pandemic, family child care and older adult care needs collided. “We know,” Kashen said, that “at some point, every one of us will need care or need to provide care” as family members are born and grow up, and others fall ill and age. This explains one reason why Americans need to care about care work, but another important aspect is that care work is important to the economic recovery and to prosperity and the ability to build wealth, Kashen added. The care crisis is not new but is the result of the nation never having had a comprehensive care infrastructure. Families juggle caregiving and work without “common sense protections like paid leave, high-quality child care, and home and community-based services.”

Kashen provided several data points to illustrate the relationship between the care crisis, the economic well-being of families, and the nation as a whole: greater than 35 percent of income being spent on child care by low-income families, more than $12 billion annually lost by U.S. businesses due to child care issues, and $300,000 in lost lifetime wages and Social Security benefits of those who care for adult family members. And the effects of the care crisis are not felt in just one moment in time, but continue across generations, and also affect women and especially women of color more profoundly. The pandemic has caused 1.4 million mothers to leave the workforce, and has affected Black, Latin, and Indigenous families the most, Kashen continued. She stated that the Build Back Better Act provides an opportunity to make progress on these issues by addressing the need for affordable child care, paid family and medical leave, universal pre-K, and home- and community-based services.

Kalipeni briefly described the Family Values @ Work network, which works in 27 states conducting grassroots organizing to change the culture of how Americans care for one another, and reiterated the theme that care work is not simply an individual responsibility, but requires societal attention. Echoing earlier presentations, she emphasized that the conversation about care work must be grounded in an acknowledgment of the “sexist and anti-Black racist history that has long undervalued and erased and ignored and hidden behind closed doors the work of Black and Brown and immigrant women in this country who make up the core of our care infrastructure.” Kalipeni also made the link between the extractive nature of the care economy—wealth that is built on the free or undervalued work of women of color—that relegates the care workers to a cycle of genera-

tional poverty manifested in the very places where they live, which are underinvested, under-resourced, and lacking opportunity.

Early December 2021 marked the 50th anniversary of President Nixon’s veto of universal child care legislation, said Boteach. She added that women’s labor force participation rate in 2021 was the same as that in 1989, and went on to describe the many connections between economic security and health, from health insurance being linked to jobs, to the relationship between mental illness and stress and financial instability. Extensive research about the effects of the child tax credit, for example, illustrate its multiple and far-reaching benefits, given the deep interconnections among health, work, and economic well-being. Boteach stated that the care workforce has been decimated since February 2020, with 1 in 10 fewer child care workers, and 1 in 8 fewer nursing and residential care facility workers than in pre-pandemic times. The workforce crisis is being exacerbated by somewhat higher or rising wages in retail, as well, with growing numbers of care workers leaving the field for better paying, but less societally important work. Echoing the earlier presentation by the historian Edward Baptist, Boteach stated that:

Reflecting on the Build Back Better legislation, Boteach noted that it includes provisions for child care assistance for most working families, four weeks of paid leave, which, while not enough, would allow more than 3.7 million women caregivers to return to the workforce, and support for home care that would provide better quality care jobs. Care is a public good, Boteach added, and not an individual responsibility each family must figure out on its own. Although other nations in the Organisation for Economic Co-operation and Development recognize this and act accordingly to varying degrees, the United States has been slow to invest in families, children, and the care infrastructure.

April Sims began her remarks with an acknowledgment that she was speaking from the traditional lands of the first people of Tacoma, the Puyallup Tribe. Sims stated that the Washington State Labor Council American Federation of Labor and Congress of Industrial Organizations (AFL-CIO) is the largest umbrella labor organization in Washington state, representing 600 locals and more than half a million union members. The Council has been focusing on child care policy since before the pandemic.

Child care workers in Washington State earn $24,000 per year, and lead teachers in a center earn $31,000—exemplifying the low pay of workers in one of the fastest growing occupations. As a result of the inadequate pay for this workforce composed of largely women, people of color, and immigrants, half of child care workers live in families that use public assistance.¹ The annual cost of child care in Washington State is just over $18,000, and a majority of workers live in child care deserts. In addition to the issue of access, because the cost is too high but the pay is too low in the care economy, a holistic approach is needed to find a solution, said Sims. Dialogue with workers in their state has surfaced potential solutions such as tax credits and state subsidies, but there also are structural solutions that need to be addressed through policy change. From their polling, the Council has learned that changing the narrative to talk about child care as an infrastructure issue resonates. If workers need child care in order to go to work, Sims added, then child care requires infrastructure investments.

Chang asked why investing in care workers’ economic security and mobility and their overall health and well-being is critical to improving health overall, and how health sector leaders could further the policies that would help achieve those linked goals. Kalipeni shared how the lack of valuing care and caregiving leads to intergenerational cycles of poverty, where a parent works double shifts to make ends meet and care for their own children while being unable to save for retirement, and in turn presenting an economic challenge to their adult children. If care work is one of the fastest growing fields but also among the lowest paid, Kalipeni noted, that means that care workers do not earn family-sustaining wages and that has implications for their housing, educating their children, and accumulating wealth toward economic security. If workers fall ill and cannot afford their health care, that further shapes the cyclical and health-affecting nature of these challenges. Kalipeni spoke about the importance of viewing the relationships among people needing care and their paid and unpaid caregivers as an ecosystem, and said that the people closest to the problem are the most important to finding the best solutions. She added that the connections between health and everything else should be evident to the workshop audience. Kashen added to Kalipeni’s answer by using the analogy of a doctor or nurse whose ability to provide quality care may be affected if they are stressed about not making ends meet, and about having children being cared for by a neighbor who might call at any moment that they need to take on an errand. She emphasized that a systemic perspective is necessary, because not having a care infrastructure:

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¹ See https://cscce.berkeley.edu/workforce-index-2020/2021/02/19/state-by-state-analysisshows-u-s-child-care-workforce-struggling-to-survive/ (accessed May 18, 2022).

Sims agreed with all previous remarks and added that in her family’s experience, it was her mother’s union job that ended the need for public assistance and contributed to economic dignity and stability that allowed her mother to become engaged in school and other civic activities.

Responding to the question about how the health sector could support care workers, Boteach noted that the Build Back Better Act had health care advocates at the table with housing, economic, and racial and gender justice advocates. She also reflected on the implementation of potential legislation, including the regulatory changes that would be needed to support access to new services, including informing families how to enroll in child care and providers how to get licensed, and the need for systems that communicate with each other.

Chang relayed a question from a viewer, who asked about how these policies and strategies could be sustainably funded. Boteach first highlighted the scarcity mindset that pits urgent needs against each other, despite the extraordinary wealth being accumulated at the top of the income spectrum during the pandemic. Research on inflation inequality also shows that goods and services purchased by lower income people rise at a faster rate compared to yachts and other luxury goods. The tax system embeds patriarchy and racism, as demonstrated by the scholarship of Dorothy Brown in The Whiteness of Wealth,² but a range of policy solutions are available to ensure that the wealthiest individuals and corporations pay their fair share. Kashen added her observation that when military spending is on the table, decision makers do not debate which branch to fund (e.g., the Army or the Air Force) because they are all important. Similarly, she said, American families need a system that comprises child care, and paid family and medical leave, and home and community-based services, and paid sick days and does not force prioritizing and leaving something out. “We have wealth in this country. We can afford to do all these things. We just have to have the political will,” Kashen noted, and Boteach shared a personal anecdote. When asked how she would choose between preschool and child care, she said, “I am not sure you quite understand that if my 4-year-old is in school, but I do not have care for

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² See https://www.penguinrandomhouse.com/books/591671/the-whiteness-of-wealthby-dorothy-a-brown/ (accessed May 18, 2022).

my 2-year-old, I still cannot work,” and added that in so many cases the parent in this situation is a woman of color or an immigrant.

Sims also criticized the scarcity mentality³ that she said is not serving the American people well in policy conversations. One idea being considered in Washington State is the creation of apprenticeships for child care work, along with creating a wage progression that provides workers opportunities for growth and a path to the middle class. Union membership gives workers a voice on the job, Sims said, but domestic workers were left out of the National Labor Relations (or Wagner) Act of 1935. Child care workers in Washington State have become unionized, she added. Sims also mentioned that the licensing requirements for child care providers pose financial and other barriers to child care providers opening centers or homes to provide services, so her organization is reviewing those barriers.

The conversation about sustainability sometimes misses the important point that care economy policies have broad support across the country, Kalipeni asserted. Small businesses, for example, support them because they understand that affordable care and paid leave are good human resources and retention strategies. She added that the federal and state governments need to partner with small businesses and tax-paying workers to support these policies, and that if the public understands what they could get for the taxes they are paying, they support these policies.

Chang asked the panelists to comment on the interplay of federal and state policies. Kashen said that several states had been making progress in enacting policies that support care workers and families. A report she co-authored for The Century Foundation graded states on their care policies—child care, paid leave, paid sick days, and support for home and community-based services—and no state got an A (Kashen and Novello, 2021).⁴ The majority of states received a D or lower, despite the fact that there are many advocates and strategists on these topics. The reasons for slow progress are entrenched opposition, a lack of resources, and a lack of political will. Chang asked about how these issues can be framed most effectively. Kashen said that a strong economic case can be made about improving the care economy so that workers can go back to work and help in the economic recovery. Sims asserted that it is important to frame care needs as not merely a women’s issue, but a worker issue, in order to garner wide support and investment. Boteach shared that she and Kalipeni participate in the Care Can’t Wait coalition, which is

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³ As referred to elsewhere at the workshop, a sense that there are not enough financial resources to support all identified priorities in a given domain.

⁴ See https://tcf.org/content/report/old-care-matters-report-card-care-policies-states/?agreed=1 (accessed May 18, 2022).

premised on organizations representing the different dimensions of the care economy standing together and not allowing anyone to divide them or to pit groups against each other, following a long historical tradition of white supremacy and patriarchy to divide and conquer. The coalition has refused to drop any component of the package or to compromise on the mix of policies it is advocating. Family Values @ Work, Kalipeni stated, has worked to gain paid family and medical leave in nine states and the District of Columbia, and their work has included developing state models and research (e.g., on child care, wages, paid leave, and union access) to inform federal policy on what works, e.g., number of weeks of leave that increases uptake for working women of color, the thresholds of income or wage replacement that make it worthwhile to take leave. Enacting good policies is not enough if they are not implemented or implementation is ineffective or delayed, Kalipeni said, and having workers, labor, and other partners at the table in advocacy, design, and implementation is critical.

Chang shared an audience question on countering the scarcity narrative. Sims said that the success in Washington State’s increase of the state minimum wage was later used to help pass paid family medical leave. Having a tight coalition was important to these successes. Boteach added that forming a coalition, a base of support, can gradually shift the narrative. For example, the work of the Service Employees International Union and Jobs With Justice and their many union partners so changed the narrative about minimum wage, that any conversation about a national minimum wage could never go below a $15 target. Narrative is not the end goal, Kalipeni asserted. Narrative work is about changing the cultural posture by telling the story in a way that sparks understanding and empathy, and on an issue to mobilize people to take action. Kalipeni added that narrative must be customized to fit the audience, and that communities of color, for example, need the least amount of convincing about policies to support care workers, because they understand “how communal and generational it is and how important it is and how we have to think about it.” Chang agreed that culture change and narrative change are hard work, and asked about the cost of such changes. Kashen reflected on the funds spent on advertising to persuade people about acquiring material things like a car and said she would like to see comparable resources invested in furthering the care agenda. Sims said that she could gather information about the cost of past campaigns, but those figures do not reflect the totality of the effort, including a variety of resources contributed by partner organization. The role of funders must be carefully considered, said Sims, because it is community organizations that are grounded in the community. Boteach added that changing the narrative, and enacting a policy is just the beginning—implementation

and continuing to grow the power of the workers and organizations that advocated for the policy are ongoing.

Chang mentioned the innovative work in San Francisco to enact paid family and medical leave and asked about other examples of innovation. Kashen answered that the reality is that this work has been ongoing for decades, and the victories, like gaining paid leave in nine states and DC, are hard won. Chang asked whether COVID-19, by shining a bright light on the care crisis, has made things possible that were not possible before. Kalipeni offered two answers: (1) several temporary policies emerged around the country for family and medical leave, for protective equipment, for worker training, etc., and these demonstrated that these policies can be enacted and paid for at a moment of crisis, and (2) a unique experiment in universal basic income (UBI) is unfolding around the country, providing a monthly stipend to primarily women of color. The evidence on UBI has debunked the narrative that when people are given greater flexibility with their time and given more money, they become lazy, unemployed, etc. The evidence indicates that UBI can change the economic trajectory and stability of families. Sims added that in Washington State, the governor approved $300 million in unemployment benefits for undocumented workers generally left out of safety net programs, as an example of an innovative approach to protect the most vulnerable workers. In her answer, Boteach shared research her organization is conducting to explore the relationship between women and work over the past year, and the ways in which workplace rules about remote work have shifted, the opportunities and challenges associated with formal and informal care work, and what is suddenly acceptable compared to two years ago.

Chang called on panelists to share a key takeaway and a key resource for the audience. Responding to both questions, Sims invited viewers to look for the Washington State Labor Council timeline of labor history that is instructive about the scope of what is possible. She asserted that allowing child care workers to unionize is the best approach to moving toward a sustainable public investment in child care and care work. Boteach said that people’s imagination seems to stop at the status quo, but the pandemic opened a unique window to accelerate work that has been in development for a long time, and the key realization is that what is being built in this space created by the pandemic is power—“power across multiple movements with women of color at the center.” She added that nwlc.org provides a range of resources about women’s employment status and the care economy, but there are scores of other websites of partner organizations, from the National Association for the Education of Young Children (on the licensed care workforce) to Homegrown for friend, family, neighbor, and home-based child care. The key takeaway

for Kalipeni was “that everyone has a role to play in shaping and winning the care economy that we all deserve as individuals, as families, as communities,” and people working in the health sector can play an important role in shaping and sharing data and stories—and a key piece of the narrative is that the trajectory of the care economy will have an impact on generational poverty for decades to come. Kashen shared the tcf.org website of her organization and said that the pandemic has shown people that their lives touch each other in so many ways and expressed the hope that people can join in the fight for policies that will support a vibrant care economy.

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