Jandos Rothstein
The United States is an outlier in family care policies. It is one of the few wealthy democracies without national provision of paid parental or sick leave. It devotes fewer public resources than its international peers to early-childhood education and care. And it has failed to join a growing number of countries with broad-based programs for care in old age.
A long history of missed opportunities lies behind this pattern. At critical moments of choice over the past century, the United States could have adopted family care policies of the kind that are now well established in Europe and other parts of the world. Part of the explanation for those missed opportunities lies in the difficulty of moving social legislation through America’s governing institutions, with their multiple “veto points.” When advocates for reform have succeeded in putting change on the political agenda, they have also often been outmatched by well-funded antagonists, who have told Americans that family care policies are a threat to free enterprise and a step on the road to socialism. With each moment of frustrated change, a hodgepodge of public and private arrangements has partially filled the void. As a result, instead of universal policies, Americans today confront a confusing array of means-tested programs, employer-provided supports (for some), and private services that are often prohibitively expensive for people with moderate incomes.
The history of America’s missed opportunities begins in the early 20th century. Between 1915 and 1919, Progressive reformers campaigned in the major industrial states for publicly financed health insurance plans that included compulsory maternity benefits and sickness pay. Indeed, their proposals were intended as much to cover the cost of lost wages during illness as they were to pay for medical bills. No private health insurance business existed at that time, but insurers nonetheless didn’t want government intruding in their industry (and the proposals did include a funeral benefit that threatened part of their life insurance business). Business groups objected to sick pay on the ground that it would encourage malingering, and although the American Medical Association initially favored the proposals, it turned sharply against them as the legislation came up in the states and physicians worried about government regulating their incomes. By the 1930s, New Deal reformers left out health insurance and sick pay from the Social Security Act for fear of arousing the insurers, employers, and physicians and endangering the entire legislation.
Other attempts to expand federal supports for children and families proved short-lived. The 1921 Sheppard Towner Act directed federal funds to state governments for programs intended to help combat the country’s comparatively high rates of infant and maternal mortality. Although opposed by the AMA and conservative groups who decried the bill as Bolshevism, the act squeezed through the legislative gauntlet because members of Congress feared newly enfranchised female voters would throw them out of office if they voted against it. By the late 1920s, however, politicians decided they had more to fear from an enraged AMA than female voters, and they repealed the law. In the 1930s, the FDR administration used federal funds for nursery schools that could create employment for teachers, nurses, janitors, and others thrown out of work during the Great Depression. The 1940 Lanham Act then spent the equivalent today of $1 billion to support these and other child care programs that helped women work in support of the wartime economy. Yet, the centers were quickly shut down as men returned from the war and women were expected to retreat back to the domestic sphere.
Another opening came at the start of the 1970s, spurred by rising rates of employment among women with young children and growing attention to early child development. The 1971 Child Development Act (CDA) sought to create a network of federally funded child care centers that would be free to parents with low incomes but available to others on a sliding fee scale. Sponsored by two Democrats, Rep. John Brademas and Sen. Walter Mondale, the bill began with wide bipartisan support as many in Congress agreed that working women needed help and that children would benefit from enriching early-education programs. Yet, as the bill wended its way through the legislative process, it became caught up in racially inflected struggles over who would run the centers. By the time the bill passed both chambers of Congress, many Republican backers reversed course and voted against it.
Waning Republican support enabled President Richard Nixon to veto the bill. He did so with a vitriolic message, authored by White House staffer Pat Buchanan, which claimed the law “would commit the vast moral authority of the National Government to the side of communal approaches to child-rearing over the family-centered approach.” The veto message’s sharp rhetoric reflected Nixon’s sympathy with right-wing critics who claimed the bill was socialistic overreach. Nixon’s and future administrations would, however, support means-tested funds for programs aimed at those on public assistance, as well as tax breaks for families’ child care costs. The day after Nixon vetoed the CDA, in fact, he signed a bill expanding middle-class access to child care tax breaks. But the United States has never again come so close to enacting a universal federal child care initiative.
Advocates for reform often have been outmatched by well-funded antagonists, such as business groups and other private interests.
Such reforms have been off the table largely as a result of a conservative mobilization that took shape in the 1970s combining free-market opposition to expanded public programs with social conservatives’ antipathy toward policies that encourage mothers’ employment. These forces helped obstruct campaigns for federally mandated paid parental leave, which Phyllis Schlafly famously derided as a “windfall for yuppies” that was of little use for traditional families. Business opposition to paid leave was particularly fierce, especially given expectations that employers should not only allow their employees relief from work but also help pay for those days off.
After a decade-long effort, a broad coalition of advocates finally got the Family and Medical Leave Act through Congress in 1993; Bill Clinton signed it only two weeks after taking office. The legislation was a compromise measure, however, that guarantees up to 12 weeks of unpaid leave and, due to various limitations, covers only 60 percent of workers. For instance, those who have worked for less than a year or are employed in establishments with fewer than 50 employees are ineligible for the leave the law is supposed to guarantee. Decades of painstaking advocacy work since 1993 have thus far managed to get paid leave on the books in eight states and the District of Columbia, as well as a new measure giving federal employees paid leave rights as of October 2020. Democrats and Republicans in Congress also have sponsored recent paid leave measures: Rep. Rosa DeLauro and Sen. Kirsten Gillibrand, both Democrats, have sponsored the FAMILY Act, which would use a new payroll tax to pay workers 66 percent of wages during their 12 weeks of family and medical leave, while Republican Sens. Marco Rubio and Mitt Romney have advocated a voluntary system allowing employees to draw on future Social Security benefits to pay for family and medical leave.
THE FINANCING OF LONG-TERM services and supports—care for older adults and people with disabilities—has come chiefly from two sources: Medicaid and private long-term care insurance. Both are limited, especially from the standpoint of middle-class Americans. Since Medicaid covers only individuals in poverty, people have to spend down nearly all of their personal resources before they can gain access to it. Private long-term care insurance is expensive, and the market suffers from “adverse selection”: The main people willing to buy coverage tend to have health problems and anticipate needing to use the policy. Not only does the high cost deter the healthy from buying a policy; the higher that cost rises over time, the fewer healthy people buy it, until the insurer abandons the market altogether, the result of a relentless “death spiral.”
Social insurance alone can create a large enough pool of participants to share the risks and costs of long-term care. In recognition of that reality, some countries have added long-term care to their systems of social insurance, but such efforts have been stymied in the United States. During the 1980s, Sen. Claude Pepper led one such effort, only to see it fail for lack of public support for the necessary taxes. Policymakers have instead sought to subsidize private long-term care insurance policies, but subsidies for voluntary purchases of coverage do not overcome adverse selection, as illustrated by the experience of the CLASS Act.
Enacted as part of the Affordable Care Act in 2010, the CLASS Act sought to create a long-term care insurance program that beneficiaries could use to help cover institutional and home-based care and support. Yet the benefit was to be purely voluntary and financed entirely by beneficiary premiums, with no federal subsidies to support it. Soon after the bill was passed, however, the Obama administration concluded that the program was unsustainable, and in 2011 it was repealed.
AP Photo
Richard Nixon vetoed a national child care system in 1971, condemning “communal approaches to child-rearing.”
THIS HISTORY OF NON-REFORM has left a void in family care that has been filled by an array of partial solutions marked by unequal access. Employer-provided paid sick leave is a clear case in point. As of 2019, only 51 percent of workers in the lowest-paid 25 percent have paid sick leave, compared to 92 percent of those whose earnings put them in the top 25 percent. Thirteen states plus the District of Columbia also now require that employers provide paid sick leave, but the specific mandates vary considerably.
The situation with parental leave is far worse. Access to paid parental leave in 2019 was limited to a mere 9 percent of those in the lowest 25 percent of wages, compared to 30 percent in the top 25 percent. In the past year, Congress enacted a temporary measure that has allowed people in firms with fewer than 500 employees up to two weeks of paid sick leave (or ten more weeks paid at two-thirds pay). To qualify, workers must have reasons related to the pandemic, such as the closure of schools or child care centers. This mandate, however, is set to expire at the end of 2020.
Child care takes a big bite out of the annual income of parents with small children, and it is especially tough on moderate-income families. Taking into account tax breaks and other subsidies, middle-income and low-income two-earner and single-parent families in 2018 had to pay 30 percent of their earnings to keep two children in full-time centers, compared to an average of 17 percent for two-earner middle-income families and 11 percent for low-income single-parent households in 35 member countries of the Organisation for Economic Co-operation and Development.
Public-opinion surveys show that majorities favor family care. But public sentiment has not easily translated into political change.
Why do Americans appear to tolerate this situation? In fact, public-opinion surveys show that majorities favor expanded federal spending on child care, mandated family leave, and long-term care. But public sentiment has not easily translated into political change. Not only do the proposals face the usual conservative and business opposition; the current patchwork of provisions fragments constituencies for reform. Many people find a way to muddle through during times of need, and Americans with higher incomes (and thus likely more political power) tend also to have employer-provided benefits and the means to pay for care services.
The pandemic may create an opening for change, as many people have become aware of how much our economy depends on the provision of child care and how little we have done to protect seniors in nursing homes. The pandemic has also made clear that paid sick leave serves the interest of the whole community by enabling workers who are ill to stay home. We have had enough missed chances in the past to address the needs for family care. The lessons of the pandemic give us another opportunity, and we ought to seize it.
