The care economy collapse: There is no care system, so what is it?

When speaking about care workers, we’re talking about early childhood care and education, adult medical/quality-of-life care, and end-of-life care (adult care can be in-home or in a facility). There is also a portion of unpaid care workers who are people typically caring for a family member. Not only are most paid care workers women, but so are most unpaid care workers, with women disproportionately staying home to provide child care or to care for an aging parent.

Like many social and economic ills of the United States, this is a gender and race issue with a significant financial and human footprint dovetailing into many other affairs—being a caregiver puts a lot of mental strain on those providing care.

The work is strenuous 

Published in the American Journal of Nursing in 2008, “Physical and Mental Health Effects of Family Caregivingpresented research on the ill effects of being a family caregiver. The study found that the type of care they needed to give a care recipient corresponds to the caregiver’s physical and mental health. For example, a person with Alzheimer’s has more physical and psychological demands for the caregiver than a care recipient without dementia. They also “found that two types of patient suffering—emotional and existential distress—were significantly associated with caregiver depression and use of antidepressant medication.” Even the perception of how much a care recipient suffers can affect a caregiver’s health.

When asked about the emotional toll on care workers, specifically with COVID-19 in mind, Chelsea Holmes Rector, director of clinical services at Brighton Hospice in Indianapolis, Indiana, told Daily Kos, “With the pandemic, it was pretty traumatizing; I think people don’t talk about the trauma health care workers go through. [There are] no resources available to the people who went through this. There’s no actual support or changes in resources available to people that went through this. […] Some of that trauma lingers.”

COVID’s impact on this failed system has only emphasized the failure—the Kaiser Family Foundation (a national nonprofit focused on health policy) found that as of February 2022, over 200,000 residents and staff of long-term care facilities have died of COVID. The Bureau of Labor Statistics has found that 20% of health care workers have left the industry, with nursing facilities facing shortages nationwide. And 28 states have over 30% of their care facilities facing staffing shortages, with eight (Alaska, Iowa, Kansas, Minnesota, Maine, Washington, Wisconsin, and Wyoming) having staffing shortages in over 50% of their facilities. And now, as we’re just starting to understand the human and economic effects of long COVID, we can presuppose, based upon the disproportionate number of COVID infections, the care industry will be found to be hit hard by long COVID.

RELATED: A mass disabling event: The effects of long COVID don’t stop at the individual

The impacts on health for caregivers go beyond COVID. The Family Care Giver Alliance provides services and resources to family caregivers and has collected resources detailing the health effects of being a family caregiver. Family caregiving, especially for adults, often happens in an emergency. If a family hasn’t planned for the care, or doesn’t have the financial resources, it quickly becomes taxing. The Family Care Giver Alliance shows that the gender disparities continue in the health of family caregivers, with women, who are two-thirds of family caregivers, facing worse health outcomes than male family caregivers: increased heart disease, diabetes, and high blood pressure risk are notable adverse health outcomes. Alarmingly, elderly family caregivers face a higher mortality rate, 63% higher, than elderly non-caregivers.

Providing adequate mental and physical health support to family caregivers must be a part of any policy solution to this crisis. According to Rector, care facilities being understaffed ripples out. “I know my team feels a lot of stress from the fact that they go into these nursing homes that are totally understaffed. So they are taking extra time doing things that aren’t within their roles to try to help that person out, and they don’t have time for their families at home, and they don’t know what will happen when they leave that person.”

As Rector further elaborates, especially in finding balance, the emotional toll comes through. Rector is on maternity leave and will return to work sooner than later, leaving her two young children in another care worker’s hands, saying, “I will lose a lot of time with them. And I have lost a lot of time with them. But it’s for good purpose. Because it’s something that I love and I’m passionate about. But it doesn’t make it any easier. It’s really hard because you’re choosing not to provide in one area or another, because there’s not enough time.” And her company can fully staff, but because burnout is so high, it makes turnover high, so when they are done training one group, they need to come back around and replace another group that just left.

An invisible, unpaid working class 

The adverse outcomes of burnout and mental health issues don’t stop at family time or staffing shortages. The individual and social-wide economic effects are just as significant, with unpaid care workers propping up an already failed system. Bank of America, whose global research team released a report, estimates unpaid care workers provide labor worth $11 trillion—with women providing 76.2% of that care work.

The Institute for Women’s Policy Research (IWPR) January 2020 brief “Providing Unpaid Household and Care Work in the United States: Uncovering Inequality” explores the depths of the gendered impacts. In it, they argue that U.S. policies toward unpaid caregiver labor harm the social value of paid caregivers. “This failure to include unpaid care services when estimating the nation’s economic productivity and well-being contributes to the relatively low societal value placed on unpaid (as well as paid) care work.”

Laura Dresser, an economist and associate director of COWS, an aptly named think and do tank housed at the University of Wisconsin-Madison, (disclosure: the author was previously employed by COWS), believes the “system” has already collapsed, and the extent of unpaid care work is a result of it. She tells Daily Kos, “The problem has been clear for quite some time but is more intense right now—we accept this as the reality and kludge together solutions all the time. [And it’s] generally on the shoulders of women, witnessed during the pandemic with at-home learning. This is where the informal edges of the care economy come in to back it up, people have their grandparents live near them, people make arrangements with neighbors, people work from home because the care is impossible to get—work distractedly, or their kids on a device, all day. … The ‘system’ is so underinvested and chaotic already that you can find all sorts of edges that suggest a failure.”

PFUNGSTADT, GERMANY - JULY 11:  Kindergarten teacher Stefanie Wagner helps Mathilda, who celebrates her third birthday, in a Kindergarten on July 11, 2013 in Pfungstadt, Germany. According to numbers which were published by German Family minister Kristina Schroeder, the country reached a family-friendly milestone in boosting the number of child care places. More than 800,000 creche spots for under-three-year-olds would be available in the year starting August 1, surpassing a government target by about 30,000.  (Photo by Thomas Lohnes/Getty Images)

This failure and evolving disaster are further demonstrated by child care and home health care employment numbers lagging behind other industries. Additionally, 16,000 child care programs have closed throughout the U.S. since the start of the COVID-19 pandemic. But this was a problem long before COVID-19 caused havoc.

Jenn Stowe, executive director of the National Domestic Workers Alliance (NDWA), explained, “What is happening now is that you have hundreds of thousands of families on a waitlist to get funding to ensure that their loved ones can be cared for. You also have a care workforce that is one of the fastest-growing workforces, but a workforce that is suffering from poverty, wages, and lack of investments. So I think we have a real opportunity to pour money into the home- and community-based services program to make sure that we can expand access for older folks and for people with disabilities to get care.”

Those paid for their care work tend to make poverty wages, earning a median annual income of $20,200. For some, pay is rising to $15 an hour, which is still far from the middle class. NDWA’s, “HomeEconomics: The Invisible and Unregulated World of Domestic Workreport states, “Caregivers have an even more compressed wage distribution [compared to other domestic workers]: the median hourly wage is $10, 27 percent earn less than the minimum wage, and just 7 percent are paid more than $18 an hour.” This intersects with issues of immigration as well: “Caregivers who are US citizens are paid a median hourly wage of $10.19, while for undocumented immigrant caregivers it is $8.33 (an 18% wage penalty).”

Boomers and babies

The problem will grow with 73 million baby boomers and currently 12 million parents with children younger than six years old. Stowe sees an extra “generation” because of increased lifespans. “We’re in an age wave in our country, so every eight seconds someone is turning 65, retirement age, we’re living longer. So essentially, we’ve added a generation to our lifespans. And that means that we’re going to need to be taken care of.”

Workers from the fast-food, home care and child care industries protest outside a McDonald's restaurant as they demand a nationwide $15-an-hour minimum wage, in Los Angeles, California on April 14, 2016. / AFP / Mark Ralston        (Photo credit should read MARK RALSTON/AFP/Getty Images)

But costs for care are not becoming cheaper. The cost of child and adult care is growing with the need for them—58% of Americans are planning on spending $10,000 on child care a year, and the median cost for in-home adult care/health aid is over $60,000 a year unless you qualify for Medicaid—which is difficult to navigate and makes obtaining home health care services a challenge. For some states, like Massachusetts, child care costs can reach upward of $20,000 a year. For long-term adult care, you’re looking at costs ranging from $50,000 to $90,000 a year. Care work is prohibitively expensive and care workers are underpaid, overworked, and undervalued.

The industry’s meltdown has forced parents and workers to leave employment to come home and take care of a child or parents, or sometimes both. And 700,000 parents have left the workforce due to the lack of not just affordable child care but child care in general. And again, most of the parents leaving the workforce are women. The 19th News reporter Chabeli Carrazana wrote, “Mothers in 2020’s pandemic have reduced their work hours four to five times more than fathers to care for children in a nation that hasn’t created a strong caregiving foundation. …This year (2020), female unemployment reached double digits for the first time since 1948, when the Bureau of Labor Statistics started tracking women’s joblessness.” This is a gendered and racial economic crisis, not just a care worker crisis.

Care is critical public infrastructure

The equation of this crisis keeps growing: low wages and poor conditions for workers, high prices for those who need care, and now people are leaving the workforce to provide unpaid family care. Dresser says the reason for this is the cost of providing care and how care is funded, especially for child care—the “system” is funded by individuals, and while individual costs may be high, when spread out across an agency, nonprofit, or co-op, the cost is quickly thinned. Dresser compares it to school funding and why it isn’t an individualized cost: “What you’re buying is a really expensive thing. It would be like buying school, right? And we know that school is really expensive. And that’s why we make it a public good.”


A report by COWS, “At the Wage Floor: Covering Homecare and Early Care and Education Workers in the New Generation of Minimum Wage Laws” states, “Overall, public funding pays for 70 percent of paid homecare (PHI 2017). The majority of government funding comes from Medicaid,” additionally the report states “that by 2026, the United States will need an additional 1.2 million homecare workers.”

So what can be done? Dresser believes this must be addressed at the federal level, injecting more money into the care economy and making it effectively a publicly funded good. But the danger is ensuring the increased funding creates higher wages and benefits for the workers. She believes this could be done by setting a wage standard for entities that receive funding through Medicare and Medicaid.

Rector would love to see more investment in care workers, focusing on addressing staffing and patient ratios, increased benefits, and, quite importantly, more access to mental health resources for care workers, adding, “It’s expensive to get counseling, but how do we care for others if we aren’t healthy ourselves, and we aren’t emotionally recovered from some of the things that we’re facing, even on a day-to-day basis.”

Stowe believes the COVID-19 pandemic has opened a window for change, even though funding for care and domestic workers didn’t end up in the Inflation Reduction Act. “But I will say that, you know, three years ago, $0, was on the table for care investments. And we fought in a coalition to ensure that $1 trillion was on the table. So I don’t think that should be overlooked.” She also believes in advocating for funding, helping people think back to the early shutdown, what life was like, and how much care families had to take on is important in increasing the social value of care work and workers.

An essential part of NDWA work is raising care workers’ value among society, and labor organizing comes with that. They launched a campaign for a National Domestic Workers Bill of Rights, a bill co-sponsored by Sens. Kirsten Gillibrand and Ben Ray Luján and Rep. Pramila Jayapal. It’s about worker dignity, extending full benefits to domestic workers, worker protections, and raising the floor on wages and working conditions.  

There are other ways to help address this issue, such as universal health care that includes robust adult care investments and universal pre-K, lifting the financial burden of child care for millions of families. Access to pre-K is one of the best ways to increase educational performance for children; it would also lift the current economic weight strengthening the financial standings for millions of Americans.

This urgency and crisis are emphasized by Stowe, that home care will become the fourth-largest occupation in the U.S., saying, “For us not to pour investments into that workforce, we’re not going to be able to build it up like we need to. So many people have loved ones with medical needs. So many folks are trying to care for their children and people with disabilities or seniors; we’re going to need that help. It’s critical and urgent that we pay attention to that workforce […] we’re already in crisis mode and at a critical moment.”

And for this crisis to have such gendered disparities, it’s all the more important for men to take a more active role in caregiving—especially unpaid care work. Men should sit down and talk about how they can better help provide care work and domestic labor within their family. We must also become more vocal advocates for wages, working conditions, and investments for paid care workers. This all wraps into issues of reproductive choices and abortion.

The National Domestic Workers Alliance has many different ways to get involved. You can engage with NDWA directly or with their Care in Action campaign. You can also get involved with Care Across Generations, building a multigenerational care movement.

If you are a caregiver and need mental health or other resources, you can visit the Family Care Alliance or Mental Health America.

This story was produced through the Daily Kos Emerging Fellows (DKEF) Program. Read more about DKEF (and meet the author, and other Emerging Fellows) here.

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