President-elect Joseph R. Biden Jr. has no shortage of ideas about how to transform caregiving. One striking feature of his team’s plan: It does not address elder care separately from child care, or divide plans to support family caregivers from those for paid caregivers. Rather, it takes on Medicaid benefits for older and disabled adults, preschool for toddlers and better jobs for home care workers, all in one ambitious, $775 billion-over-a-decade package.
“It approaches the care economy in a holistic way, across the age spectrum,” said Ai-jen Poo, executive director of the National Domestic Workers Alliance, which has long pushed many of those measures. “It’s a big breakthrough.”
The same families who need child care in order to stay employed are often responsible for aging relatives, she pointed out, and many work as paid caregivers themselves.
Elements of the Biden plan, announced last summer, will sound familiar. The campaign for paid family leave, whether for childbirth or for care of older parents, goes back decades. So does the ongoing effort to rebalance Medicaid, making it more able to cover caregiving at home, where most older adults hope to stay, rather than in the nursing homes they dread.
But the coronavirus pandemic and the accompanying economic crisis have spotlighted the halting, fragmented way the United States approaches these issues, compared with other industrialized democracies.
Advocates see this emergency as both ruinous for families and workers, and as an opportunity to tackle long-deferred needs. Policies like converting the anemic federal Family and Medical Leave Act, which mandates only unpaid leave, into 12 weeks of paid leave, as Mr. Biden has proposed, could help propel the nation’s labor force back to work.
“Working adults are buckling under the pressure of addressing child care on one hand and care for elders on the others,” Ms. Poo said. “Women are leaving the labor market because they have impossible choices.”
“What was important to people became urgent,” added Fatima Goss Graves, president and C.E.O. of the National Women’s Law Center. “There are periods where acceleration feels possible, and this is one of them.”
Despite its integrated approach, the Biden plan does call for certain programs most likely to benefit older people and their caregivers. For example, it proposes a tax credit for as much as $5,000 to reimburse families for expenses associated with unpaid caregiving.
“It helps the people in the middle, stuck between Medicaid” — which primarily benefits the very low-income — “and those with the resources to pay for long-term care,” said C. Grace Whiting, president and C.E.O. of the National Alliance for Caregiving.
An AARP survey last year found that families spent about $7,400 out of pocket annually, and close to $13,000 if the caregivers lived an hour or more away from the relatives they helped. In another AARP study, about one-quarter of family caregivers reported taking on more debt and depleting their savings.
Ms. Whiting ticked off some costs the credit might cover: “Household expenses. Paid help. Home modifications. Remote devices to monitor safety. Equipment like hearing aids. Medical expenses not covered by other payers.”
The Biden plan would also give family members Social Security credits for the time they spend out of the work force caring for loved ones.
An Urban Institute analysis found that this change would most benefit lower-income workers, by crediting them with earnings equal to half the average national monthly wage, in addition to their other earnings, for every month in which they provided 80 or more hours of unpaid care.
One of the Biden plan’s most far-reaching components for seniors concerns Medicaid. This state and federal program underwrites most long-term care, but it has historically spent more on nursing homes than on so-called home and community-based services. About 800,000 people linger on state waiting lists for home care, sometimes for years, the Biden team has said.
The shift to home services, which now represents more than half of Medicaid spending on long-term care, has been “vastly inadequate,” Ms. Poo said. “It’s still not mandatory for states to offer home and community-based services as an option.”
The Biden plan vows to eliminate the wait list, then enhance federal contributions to allow states to develop more community alternatives, which are generally less expensive than nursing home care.
Finally, it tackles the issues that have led to persistent churn in the mostly female work force that provides elder care and child care, including low wages, lack of benefits like health insurance and sick leave, and the need for further training.
That effort, the plan notes, will support unionization and collective bargaining. “The solution cannot be caregivers at poverty levels with unfair working conditions,” Ms. Goss Graves said.
The Biden team asserts that the nation can pay the tab for this vast undertaking over 10 years, by rolling back tax breaks for real estate investors with incomes over $400,000 and increasing tax compliance for other high earners.
It also argues that the plan will create three million new caregiving and education jobs, and increase employment by five million by allowing unpaid caregivers (most of them women, again) to re-enter the work force.
Debate is certain to ensue over the price tag nonetheless, given a fragile economy, and over whether these plans represent the best solutions to the nation’s child care and elder care needs.
As Ms. Whiting pointed out, “the tax credit puts money back in caregivers’ pockets, improving their well-being.” But it won’t benefit lower income families who don’t pay much income tax, or any, unless it’s made “refundable,” so that a caregiver could receive a reimbursement check for more than she paid the I.R.S.
Social Security credits would most likely have greater impact, said Richard Johnson, an economist who directs the Urban Institute Program on Retirement Policy. One drawback, however, is that “it doesn’t help caregivers until they begin collecting Social Security,” he said. “The tax credit could provide immediate help.”
Of course, the political odds of realizing all these ideas, or any of them, remain highly uncertain, even if the Senate acquires a slender Democratic majority. “The question will be, ‘Do we have the political will to make it happen?’” Ms. Whiting said. Some Medicaid changes will also require agreement from state governments.
The plan does not delve into details about how the administration would carry out all these policies, and the Biden transition team did not make a policy adviser available to discuss the president-elect’s goals and strategies. But some aspects of the plan — efforts to pass a caregiver tax credit, for instance — have previously drawn congressional sponsors from both parties.
“There’s growing recognition of the essential help provided by family caregivers, and an emerging consensus among both Democrats and Republicans that they need more support,” Dr. Johnson said. “So the time might be right to enact meaningful federal legislation.”
Supporters of the plan see Mr. Biden as a president with an unusually personal understanding of caregiving. He has been a single father and a caregiver both to injured children and to a grown son with terminal cancer. In announcing his caregiving plan, he also mentioned caring for his parents, when they were hospice patients, in his home.
Vice-president-elect Kamala Harris was the principal sponsor of the National Domestic Workers Bill of Rights last year. “They’re the right people to lead the conversation,” Ms. Whiting said.
But as veterans of the effort to promote a more expansive federal approach to caregiving, advocates like Ms. Goss Graves have also developed a well-honed realism. “Things don’t happen on their own,” she said. “I’d feel hopeful, but I’d also be preparing to get to work.”