John Hersey
Most families cobble together caregiving arrangements for children, elders, and loved ones with disabilities through some mix of free care from relatives, modest home care options, or pricey institutional settings. Paying for these arrangements when necessary is one of the greatest trials facing American workers. The national caregiving crisis has been magnified by the COVID-19 pandemic and the weak federal Family and Medical Leave Act of 1993, a dubious bargain of limited, unpaid time off.
In the face of federal neglect, states have begun to step up to lighten the burden, offering assistance to families struggling with child care, elder care, and paid leave. But nowhere has the care infrastructure been built as comprehensively as in Washington state.
In 2019, Washington catapulted into the vanguard of the social-insurance movement, becoming the first state to provide residents with a comprehensive long-term care program. Combined with a paid family and medical leave system that went into effect this year, a cap on child care expenses for low-income workers (with a goal of universal access by 2025), and a home care workforce training operation run through SEIU Local 775, Washington policymakers have inched closer to a vision of supporting families through all stages of life.
“When you have a state where a critical mass of voters values care in its policy and its priorities, I think that you see progress,” says Ai-jen Poo of Caring Across Generations, which has worked on policy issues in Washington. But the state’s trailblazing family care agenda forced several tough choices, revealing the need for federal support to supplement the vision.
For example, eight states and the District of Columbia have instituted paid family and medical leave programs, usually with complex, hybrid payment mechanisms based on payroll contributions from both employers and employees. So far, the District of Columbia is the only entirely employer-funded paid leave program in the country, providing 90 percent of wages for two to eight weeks through a 0.62 percent payroll tax.
In 2017, Washington state lawmakers crafted a bipartisan consensus on medical leave as a shared contribution, with family leave costs borne by employees. The family and medical leave program provides between 12 and 18 weeks of paid leave to employees who work a minimum number of hours in a 12-month period. Designed to keep low-wage workers in the program, Washington’s program is generous. Employees can receive up to 90 percent of weekly wages, capped at $1,000 per week.
The maximum benefit period of 16 weeks is far less than California’s 52-week maximum, but California workers recoup only 60 to 70 percent of their wages. Many low-wage workers who cannot afford a 30 to 40 percent pay cut forgo taking leave. “Subsequent policies in other states have really increased the progressivity of those benefit formulas, so that everybody actually can take the leave,” says Kathleen Romig, a Center on Budget and Policy Priorities senior policy analyst.
On the flip side, Washington’s 16-week cap keeps the cost of financing down: A payroll tax of 0.4 percent funds the program. Self-employed and tribal members are exempt, but can choose to opt in. Employers with fewer than 50 employees also are not required to pay the employer portion of the premium, though they still must collect it from workers. To encourage participation, these employers are eligible for small-business grants if they contribute.
Long-term care services and supports present similar challenges for program design: how to keep it cost-effective and also meet the significant needs of Washingtonians. A 0.58 percent payroll tax funds the Washington Long-Term Services and Supports (LTSS) Trust that will begin collecting payments in 2022 and paying out benefits in 2025. Individuals receive up to $100 a day toward a maximum lifetime benefit of $36,500 for services like in-home personal care, adult family home care, and nursing home care. The state auditor will monitor the program’s operations and finances, and assess recommendations for improvements.
With more people able to afford long-term care, the new program increases employment opportunities for home health care workers. SEIU Local 775 Benefits Group, a labor-management partnership that trains and supports home care workers, is Washington’s second-largest educational institution after the University of Washington, serving nearly 50,000 caregivers across the state. State home care workers must complete 75 hours of training and pass a certification exam, requirements similar to the federal certified nursing assistant standard, according to Adam Glickman, SEIU Local 775’s secretary-treasurer. An LTSS Trust Commission will determine if additional workforce training requirements should be implemented for home care workers and family members.
“You can get money for professional care supports and also money to pay a family member to compensate for their work for taking care of [another] family member, so they can afford to leave the workforce for a couple of years and do that,” says Benjamin Veghte, director of the LTSS Trust and a lead author on the National Academy of Social Insurance’s 2019 “Designing Universal Family Care” report. “The desire to age in place with family supports is sharpening right now and increasing,” Veghte adds. “Nursing homes are no one’s utopia for how they want to spend their final years.”
Nowhere has the care infrastructure been built as comprehensively as Washington state.
The program may seem like a boon to families, and compared to the lack of basic support for needs like elder care in every other state in the union, it is. But given the high costs of medical and in-home care professionals, equipment, and supplies, it’s actually a modest benefit, conceived more as a supplement to existing or future resources to tide over families. Medicaid-funded in-home care in Washington runs $24,000 per year; nursing home care is $65,000 per year. In most cases, the funding will provide one to two years of support, giving families the time to apply for Medicaid or develop alternative funding sources, according to Veghte.
Washington officials say that the state has the fiscal resources to sustain the LTSS Trust. “We have worked hard to build a strong safety net in our state that is truly responsive to the many threats to economic stability that working families face,” says Mike Faulk, press secretary for Washington Gov. Jay Inslee, a former Democratic presidential candidate. “Building social insurance of this kind, with the flexibility it provides to choose the care arrangement that best fits a family’s needs, is a big deal.”
Early child care and education (ECCE) throws up another set of hurdles, being both prohibitively expensive for families and low-wage work for providers. Today, parents and guardians pay more than half of these costs out of pocket. There are federal dollars available, through programs like Head Start and the Child Care and Development Block Grant. But these are means-tested and fail to reach even eligible families. No state has fully addressed how to pay for ECCE programs.
Washington passed the Child Care Access Now Act in 2019. For those families that meet income-based eligibility thresholds, the law caps child care expenses at 7 percent of household income, subsidizing the balance. The subsidy scheme, implemented through two state programs, Working Connections Child Care (for low-income families) and Seasonal Child Care (for seasonal agricultural workers), is subject to available appropriations, and so some families do end up on a wait list. The bill establishes a goal of universal child care access for the entire state by 2025, but of course, access does not equal affordability.
Ted S. Warren/AP Photo
Under Gov. Jay Inslee’s tenure, Washington has passed a paid family and medical leave program and a long-term care social-insurance benefit.
But after the advances in paid leave and long-term care, early education stands to be the next big issue for debate in Olympia. Through its Early Childhood Education and Assistance Program, Washington provided pre-kindergarten for the 14,000 at-risk children “furthest from opportunity” in the 2019-2020 school year, and recently expanded income eligibility for the program, with a goal to enroll 90 percent of children entitled to qualify by 2022-2023.
Only a handful of other states have attempted universal pre-kindergarten coverage. Just 22 percent of four-year-olds are in state-funded pre-kindergarten programs, and just 3 percent of three-year-olds. Only Florida, Georgia, and Oklahoma have statewide programs for four-year-olds. Of the six jurisdictions that plan to implement pre-K, only the District of Columbia and Illinois include programs for three-year-olds.
Absent ECCE programs that untangle the knot of federal and state programs and dollars, progress toward a true Universal Family Care insurance fund mechanism may leave states concentrating on family and medical leave and long-term support and services care programs. According to Veghte, ECCE could be constructed in such a way to require a small family contribution with the remainder paid by a social-insurance framework. But Veghte stresses that the way forward is one fund that provides payments for all three social-insurance components.
The Washington social-insurance programs approach that goal. But even the most robust state approaches are ultimately piecemeal solutions to fill the void left by the federal government’s failure to move on social insurance, despite long-running worker and employer interest in a taxpayer-funded caregiving program.
A 2018 National Partnership for Women & Families poll found that majorities of Democrats, Republicans, and independents support a national paid leave program. The COVID-19 crisis has only intensified this demand: A Lake Research Partners poll conducted in June for Paid Leave for All Action found that majorities of Americans across party lines, gender, age, race, income, and other metrics believe that having a national paid leave program would have been “helpful” during the pandemic.
Partisanship, of course, stands in the way of movement toward national social insurance. Conservatives typically disdain creating risk pools, preferring families to provide care or pay for their own stopgap measures if they can’t get leave from their jobs, if care arrangements fall through, or if a family wants a certain type of early child care—a sort of rugged individualism, family style.
This mindset forms the basis for perverse Republican family leave proposals predicated on notions like using advances on employees’ own earned benefits, such as Social Security (which can expose workers to cuts in their own retirement support), rather than creating new programs with dedicated funding streams. Most Americans would prefer paying into a national fund that benefits all workers and families, rather than tapping into already meager public retirement options.
“All families have to pay for this anyway,” says Veghte. “We either have to pay for it on our own or we pitch in to a risk pool where we all pay a little bit out of every paycheck and then draw down as we need, like health insurance or Social Security.”
California, with a paid family and medical leave system in place for nearly two decades, is the closest to joining Washington state with two prongs of Universal Family Care set. State officials and long-term care specialists and advocates have been working on devising specifics. In November, Colorado voters will weigh in on a $1.3 billion social-insurance ballot initiative that would establish a family and medical leave program of up to 12 to 16 weeks, funded by payroll taxes split equally between workers and employers, a similar model to Washington state’s. With little productive debate on Capitol Hill, the Washington state model is likely to steer progress on designing social-insurance programs for the foreseeable future.
