Seizing the Moment to Make Our Care Systems More Equitable
By Sanjay Pinto, Patricia Campos-Medina, Rakeen Mabud & KC Wagner | May 27, 2021
The Biden administration’s $600 billion in proposed federal funding for childcare and long-term care is rightly being framed as an investment in the nation’s core “infrastructure.” Indeed, a robust and equitable care infrastructure is as necessary for generating economic activity as roads and bridges, with important spillover effects to the rest of the labor market.
Beyond boosting the economy as a whole, investments in care can also be configured in ways that directly address deeply rooted racial and gender inequities within our society. The Just Recovery Survey, which polled 3,100 working people nationally in late 2020, illuminates the exploitation and lack of protection that women of color experience as direct care workers, the disparate impact of unpaid caregiving on their economic security, and the barriers they confront accessing healthcare when seriously ill.
Building on existing frameworks such as this one developed by Caring Across Generations, we draw on these survey findings to reinforce key principles that should guide investments in our childcare, long-term care, and healthcare systems, helping to advance equity and laying the groundwork for our collective economic security.
Challenges Confronting Frontline Direct Care Workers
Black and Latinx women, who were oversampled in the Just Recovery Survey, are highly overrepresented among low-paid frontline healthcare occupations and comprise an outsized share of the lowest-paid segments within the childcare workforce. The strong presence of women of color in these jobs reflects patterns of occupational segregation that are partly rooted in legacies of slavery and imperialism. It is also an important reason why the work is undervalued and lacking in basic protections.
History is replete with examples of how the toxic confluence of racism and sexism shapes the fortunes and agency of direct care workers. For example, white Southern politicians excluded farm and domestic service occupations (the latter often involving childcare and eldercare) from labor, employment, and social security protections enacted during the New Deal era to undercut the power of Black workers. And within the publicly funded home care system, policymakers have long set reimbursement rates at low levels based in part on the assumption that women of color can supply these services cheaply.
Within the publicly funded home care system, policymakers have long set reimbursement rates at low levels based in part on the assumption that women of color can supply these services cheaply.
With data from the Just Recovery Survey, we compared the experience of frontline “healthcare support occupations” (e.g., home health aides and certified nursing assistants) versus “healthcare practitioners and technical occupations” (e.g., doctors and nurses). U.S. government data for 2020 shows that the former category of workers is more heavily comprised of women (85% v. 74%), with a much higher concentration of Black workers (25% v. 12%) and Latinx workers (20% v. 9%).
Despite the rhetoric around valuing all essential workers, we found that frontline workers were more likely to report losing income during the pandemic, fear employer retaliation for reporting unsafe conditions, and report not being able to afford healthcare if they were to fall seriously ill—differences that remained statistically significant even after we controlled for the varying educational profiles of the two groups.
Disparate Impacts of Unpaid Caregiving on Economic Security
Even while playing an essential role providing paid care, women of color have long faced steep structural barriers to squaring their own unpaid caregiving roles with basic economic security for themselves and their families. Starting in the early 20th century, “maternalist” reformers advanced government policies enabling mothers—particularly single mothers—to support their families financially. But caseworkers denied benefits to women of color at substantially higher rates, leading to powerful “welfare rights” organizing spearheaded by Black women.
Today, following welfare reform in the 1990s, policy and organizing turns around questions of childcare access for working parents. Especially in politically conservative states, women of color bear the brunt of high administrative barriers to accessing benefits, while stringent thresholds for benefits eligibility force many working women into impossible choices between maximizing earnings and obtaining needed childcare support.
Among workers reporting family caregiving duties, women overall were more likely than men to report increases in unpaid family caregiving, with minimal differences along racial lines. However, the impact of these shifts was felt most acutely by Black and Latinx women.
The Just Recovery Survey showed that among workers reporting family caregiving duties, women overall (57%) were more likely than men (48%) to report increases in unpaid family caregiving, with minimal differences along racial lines. However, the impact of these shifts was felt most acutely by Black and Latinx women. And taking time off for family caregiving held serious implications for economic security, with those taking time off almost twice as likely to report increased difficulties paying for household bills during the pandemic than those who did not.
Health Inequities and Barriers to Healthcare Access
In late 2020, Dr. Susan Moore provided video documentation of her experience while gravely ill with COVID-19, noting the failure of a white physician to respond appropriately to the severe pain and discomfort she expressed, and how that shaped her own capacity to ask for what she needed in the last days of her life. Moore’s tragic testimony called up a long and particular history of medical racism experienced by Black women, including racist experimentation in the field of obstetrics.
For Black women, Black men, and other people of color, different forms of racist treatment within healthcare systems have combined with other social determinants of health to produce differential health outcomes. Racial wealth and income inequalities, along with residential segregation, are two historically rooted social determinants that reinforce and reproduce racial health disparities, including disparate rates of illness and death due to COVID-19.
The Just Recovery Survey captured significant disparities in healthcare access concerns during the pandemic. Black women were most likely express concerns about substandard treatment due to race/ethnicity in the event they became seriously ill, followed by Black men, Latinx men and women, and white women and men—disparities that remained consistent across the income spectrum.
Latinx men and women were most likely to say that they would not be able afford healthcare if they became seriously ill, followed by Black women and men.
Meanwhile, Latinx men and women were most likely to say that they would not be able afford healthcare if they became seriously ill, followed by Black women and men, and white women and men. Racial disparities in income were a significant determinant of these affordability concerns.
Creating Stronger and More Equitable Care Systems
Together, these survey results point to deep disparities at the heart of the nation’s care systems, and a fundamental contradiction. Women of color help form the backbone of the frontline direct care workforce. Yet, they confront particular challenges accessing the care they need for themselves and their families.
The current moment provides a chance to pivot. The Just Recovery Survey showed strong public support for racial and gender justice movements, and recent polling indicates broad approval for proposed federal care investments. The following measures and principles should be built into any new childcare, long-term care, and healthcare investments, ensuring that they press firmly in the direction of greater equity.
Raise Pay and Other Standards for Direct Care Workers
- Substantially raise the floor on reimbursement/pay rates for frontline workers in publicly funded care services.
- End carve-outs that deprive domestic workers (including nannies, housecleaners, and many home care workers) from basic labor and employment rights and social security protections, and ensure that all direct care workers have a meaningful right to organize.
- Create paths to upward mobility for frontline care workers—e.g., through training linked to updated wage tiers and opportunities to move into new job titles.
Create Universal and Equitable Access to Childcare and Long-Term Care
- Lower thresholds for benefits eligibility nationally and reduce administrative barriers that disproportionately impact women of color.
- Create stronger and more equitable national standards around how federal dollars are spent (e.g., on extending benefits rather than surveilling benefits recipients).
Advance Health Equity and Create Universal and Equitable Access to Healthcare
- Lower health insurance premiums and close coverage gaps, which should include ending state opt-outs of healthcare expansion that disproportionately affect Black and brown communities.
- Leverage value-based payment systems to incentivize racial equity within publicly funded healthcare institutions.
- Address social determinants of health inequities—e.g., by reducing racial pay and wealth gaps.
Historically, race and gender have been used as political wedges to undermine investments in care systems and other collective goods, despite the clear benefits for the overall health of our economy. Now is the time to turn the page on this cynical and divisive politics. Congress must invest in ways that lift up care workers and make childcare, long-term care, and healthcare more accessible. Together, the kinds of policies outlined above would shore up our precarious care infrastructure and help lay the foundations for a strong and inclusive post-pandemic recovery.