The Caring Infrastructure

Covid-19 has exposed social problems that existed long before the pandemic. For one, Covid-19 has exacerbated long-ignored challenges we face in caring for the elderly, the disabled, and younger children. Nursing homes became foci of infection and death during the past 18 months. Group homes, day-care, and home-care services for the disabled and elderly disappeared. Schools closed. Caregivers clearly rose to the top of the list of our most essential workers. And this essential workforce, itself sickened, further reduced the substructure holding up our infection-shaken economy.

Backlogs for home and community-based care were already impossibly long for hundreds of thousands of people before Covid-19. Back then, inadequate services challenged predominantly low-income Americans who had to rely on government subsidized caregiving. During Covid-19 the shortage became an issue for everyone. Fifty-three million family members were already providing most of the care for vulnerable seniors and people with disabilities before Covid-19. As caregiving shortages became rampant, the burden of caregiving fell to all, making it next to impossible for families with two working adults to also juggle caregiving responsibilities. Without care options, many adults, most often women, left the workforce.

Essential work, as is now abundantly understood, has historically been underpaid. Covid-19 has exposed a caregiver workforce earning substandard salaries. Caregivers, such as nursing assistants and home health and personal care aides, earn on average, $12 an hour. Most are women of color; about one-third of those working for agencies do not receive health insurance from their employers. By the end of this decade, an extra one million workers will be needed for home-based care.

The problem is not going away. By 2030, we will have 74 million citizens over the age of 65, and before the end of life, 70% of them will require help with dressing, hygiene, moving around, taking medications, cooking, or housekeeping, usually for two to four years.

Pre-Covid-19, our system of caring was broken, unfixed by the market economy, and has now essentially failed. In large part the challenge is that we have no investment in caregiving as a public good. The current administration plans to devote 20 percent of its $2 trillion infrastructure strategy on home and community-based services over eight years. A larger, better paid, better trained workforce of aides will indeed take years to organize, even with the political will. The pandemic has changed our politics but can government spending really expand services, eliminate waiting lists and increase salaries? We shall see.


Michael Stein & Sandro Galea

As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.

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