Introduction

“Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks, and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.” —Arundathi Roy¹

Of the many things the COVID-19 pandemic revealed about our society, it showed us clearly how we care for people and who we care about. It also showed us how urgently and how much needs to change about how we care for everyone—especially the most vulnerable.

Over one million Americans died in the worst public health crisis we’ve seen in more than a century—a tragedy that disproportionately fell upon older people, people from marginalized communities, and disabled people. COVID-19 highlighted the horrific conditions in long-term care facilities, whereas of 2022, resident and staff losses made up around 23 percent of all of the deaths in the United States.²

“The pandemic really put into a much sharper perspective—for the broader public—the life and death consequences of being able to live and age in your own home and community,” said Jaimie Worker, Director of Public Policy at Caring Across Generations. “For most people, having that option to choose care at home rather than being forced into an institutional care setting is critical for maintaining dignity and independence.”

“The pandemic really put into a much sharper perspective—for the broader public—the life and death consequences of being able to live and age in your own home and community.”

Beyond the death toll, millions—especially women and people in hard-hit industries—lost jobs or were forced out of the workforce due to caregiving responsibilities. Schools went virtual in some areas for over a year. As child care facilities shut down or went out of business, parents were left to figure out on their own how to teach and supervise children, often while trying to maintain employment themselves.³ The result was learning losses that will likely take years to overcome.

Even though the worst of the global health emergency had passed by the fall of 2023, and prime-age women’s labor force participation rate was at record high levels, the United States is still struggling with the direct fallout of the pandemic and a deeply battered care infrastructure, in addition to political and social unrest, inflation, labor shortages, and mental health crises.⁴

At the beginning of the pandemic, there was some hopeful public policy progress around care issues. In an emergency where quarantining was the central mitigation strategy, a spotlight was quickly shone on America’s patchwork of paid family and medical leave and paid sick time policies. The U.S. is the only high-wealth country that offers no guaranteed paid leave at the national level. But in the early days of lockdown, quickly overcoming long-standing political resistance, the federal government sprung into action on a bi-partisan, emergency basis, instituting a wave of safety net measures that many Americans never had access to before, like paid sick leave and family leave.⁵

In March 2021, President Joe Biden (D) allocated over $152 billion in the American Rescue Plan Act (ARPA) for child care relief funding, child tax credits, Medicaid home- and community-based services, and Medicaid funding, creating tangible examples of what a more robustly funded care infrastructure could look like.⁶ ARPA expanded the Child Tax Credit and changed its structure to allow for direct monthly payments to go to families at a much higher rate. It was a far-reaching, nearly universal payment program for families with young children, which proved to be the most effective program in U.S. history at reducing child poverty.⁷ It cut the poverty rate for 2021 to 5.2 percent, a nearly 50 percent decrease and the biggest single-year drop on record. Parents Together Action, an advocacy organization, found that 90 percent of parents surveyed said the payments were “helpful” or made a “huge difference” for their family.⁸ Advocates of family-supportive policies had high hopes that decades of advocacy were paying off, and once these measures were put into place, they’d eventually become long term or permanent.

But policies that held broad political support during the tumultuous early stages of the pandemic were allowed to expire without more permanent measures being put in place. President Joe Biden’s signature social legislation, Build Back Better (BBB), which would have devoted $750 billion to funding universal child care and pre-K, child tax and earned income tax credits, and home and community-based care, failed to pass. This means that from the perspective of our care infrastructure, we aren’t just back where we were in 2019: We’re much worse off. Despite federal efforts to support the child care industry during the pandemic, 16,000 child care centers closed nationwide, and 100,000 workers left the industry, often in favor of higher paying jobs in other fields, like retail.⁹ As the original ARPA money for child care stabilization has already begun running out without reinvestment, states are facing a $48 billion cliff in federal dollars.¹⁰ The Century Foundation estimates that the loss of these funds could result in 70,000 child care centers closing and over three million children losing their spots.¹¹ Child care policy experts predict that steep fee increases will occur to make up for the shortfalls at centers that remain open, making child care even more unaffordable for families.¹² We’re also sitting on a demographic time bomb; our current weakened elder care infrastructure is egregiously underprepared for the approximately 73 million aging baby boomers, all of whom will be over 65 by 2030.¹³ But before this wave fully arrives, there are already national shortages of home health and personal care aides, which is no surprise given that their median hourly wage in 2020 was $12.98.¹⁴

The disappointment that Build Back Better didn’t pass is warranted, and the care challenges this country faces are daunting. Dawn Huckelbridge, the Director of Paid Leave for All, said: “There were some people who thought, ‘You had this chance with Build Back Better and that's it, and it's over.’ But that's not how policies get passed or how movements get built.” Many activists and funders believe the window is still very much open in the short, medium, and longer term to create transformational social change in how we care for people in America. Policy and practice advances in states and cities across the country show that the groundwork to build that change is already well underway. There’s also a time-sensitive opportunity to get extensions in federal pandemic-related care funding through a program called State and Local Fiscal Recovery Funds (SLFRF). The New Practice Lab at New America has identified over 500 programs using $2.8 billion in SLFRF funds for care infrastructure. If advocates are well organized, they may have an opportunity to influence how uncommitted funds are spent before the end of 2024, which could be a meaningful stopgap measure for care programs in some communities.¹⁵ The next few years will be crucial for organizing broad and diverse coalitions and building even more meaningful political power around care issues.

Some past legislative failures, like when former President Richard Nixon (R) vetoed a universal child care bill in 1971, took the wind out of the sails of future efforts for decades.¹⁶ This isn’t what’s happening right now to the care movement. In fact, there are hundreds, if not thousands, of new and reinvigorated voices and efforts that are now plotting a path toward better care infrastructure that will benefit everyone. “The pandemic did a lot of work for us in terms of realizing the breadth of who could be organized in this movement,” said Ai-jen Poo, President of the National Domestic Workers Alliance. Part of the work of advocates in keeping people inspired means tuning to personal or collective ideas of a “north star,” a big, inspiring goal to work toward. Reaching this vision often takes incremental steps over an extended period, but articulating what the movement is actually fighting for can be meaningful in keeping people committed.

“The pandemic did a lot of work for us in terms of realizing the breadth of who could be organized in this movement.”

A few highlights of promising advances in the last three and half years include Biden’s 2023 Executive Order on care, which included more than 50 directives to Cabinet agencies to support care workers and make child care and long-term care more affordable.¹⁷ The U.S. Department of Commerce now requires computer chip manufacturers who apply for more than $150 million in federal funding to submit plans to make child care available to their workers.¹⁸ We saw rare bi-partisan federal victories with the passage of the Pregnant Worker’s Fairness Act (PWFA) and Providing Urgent Maternal Protections for Nursing Mothers Act (PUMP) in 2022.¹⁹ Congressional dads with young children formed the Dad’s Caucus in 2021, and Congress created a new bi-partisan working group on child care. The last three years have marked a wave of successes at the local ballot box for child care funding in Portland, Oregon; New Mexico; and the Florida panhandle.²⁰ We’ve seen increases in pay for unionized care workers through collective bargaining, and the first public long-term care state insurance program take effect.²¹ By fall 2023, new paid family and medical leave laws had passed in five new states since 2020,²² bringing the total number of states with their own paid leave programs to 14, including the District of Columbia. New groups and gatherings are organizing energized activists around care issues like the Careworkers Can’t Wait Summit, the Chamber of Mothers, and Moms First. The Holding Co., a lab created to redesign care in the twenty-first century, has created the Care Guild, a wide-ranging list of people reimagining care systems to highlight creative thinkers and their great work to a larger audience. The Fair Play Policy Institute hosts the CareForce, a multidisciplinary network of professionals interested in care issues. There are newer campaigns and coalitions like Care Can’t Wait, Paid Leave for All, and the Child Care for Every Family Network uniting organizations that have been working on care issues, sometimes for decades, to collaborate in new ways. And finally, the ambitious political goals have money to match: A new group, Care Can’t Wait Action, has announced their goal to raise $50 million to make care a central issue during the 2024 election cycle.²³ This is a big, ambitious play for the care movement’s political influence. This amount of money far exceeds previous election spending from separate care groups.

Anna Wadia, Executive Director of Care for All with Respect and Equity (CARE) Fund, a donor collaborative, describes both culture shifts and the collaboration she’s seeing as, “a sea change in the alignment among groups working across the different pillars of the care agenda….I've been in this field for decades now and never seen this before.”

Care advocates’ hopes were very high when Joe Biden introduced his signature piece of social legislation in 2021 after Democrats won both chambers of Congress and the presidency in 2020. The American Jobs Plan and the American Families Plan, from which Congress pulled to craft The Build Back Better Act (BBB, contained a long wish list of programs to robustly build America’s care infrastructure.²⁴ Paid family and medical leave; universal pre-K; federally funded and subsidized child care programs; funds for long-term, home, and community-based care with living wages; and better benefits for care workers were all included in the original framework. BBB would have springboarded off of the short-term funding infusions of emergency ARPA funds and gotten a long-term, New Deal-level expansion of the social safety net. A Democratic legislative branch trifecta during a once-in-a-century crisis seemed like the perfect condition to get this major legislation through Congress.

The House passed BBB in November 2021, but it never made it to the Senate floor. Two Democrats—one opposed to new taxes and the other concerned about the creation of new safety net programs—complicated negotiations. The objections of Sen. Joe Manchin, (D-WV), one of these lawmakers, ultimately tanked the bill, which Democrats were attempting to move through the legislative process via budget reconciliation. This way, BBB would have required fewer votes than other types of legislation—a necessary political maneuver considering united Republican opposition to the bill.

Still, coming so close to historic, once-in-a-generation care and family sustaining policy change was a crushing blow for both the advocates who worked hard for it and the millions of Americans who would have directly benefited from the policies. It was also a missed opportunity for policymakers looking for levers for long-term economic growth and competitiveness. The data is clear on what not having a robust system of care costs us: The Blue Cross Blue Shield Association has found that unpaid caregiving has a $264 billion per year cost through decreased productivity, absenteeism, and poorer health outcomes for caregivers themselves.²⁵ And there’s plenty of data on what we’d gain. For example, James Heckman, Ph.D., a University of Chicago professor and a Nobel prize winner in economics, has found that investing in high-quality birth-to-five education has a 13 percent per year return on investment in social, health, and professional metrics for the child and improved economic outcomes for their mothers.²⁶

While the outcome of BBB is widely known, how hard care advocates fought for the bill, how well they worked together, and how much progress they made given their minuscule financial resources is a big success story that deserves more attention. In 2020, groups like Caring Across Generations, Paid Leave for All, National Women’s Law Center, MomsRising, and many others came together to form Care Can’t Wait, a coalition “committed to building a comprehensive, 21st-century care infrastructure.”²⁷ The groups worked together throughout the BBB fight and have continued to work closely together to win new care policies as a result of building that movement’s connective tissue. This energized collaboration is exciting because it suggests the movement can be much larger than the sum of its parts. “In the past, groups focused on aging, disability, labor, child care, or paid leave were often pitted against each other for very small pots of [funding],” both philanthropic and government money for programs, explained Nicole Jorwic, Chief of Advocacy and Campaigns at Caring Across Generations. “We are now getting outside of the scarcity mentality and seeing that when we break down silos, we could actually fight for a bigger pie. That's obviously a really good thing. We are all continuing to work together to elevate each other’s issues leading to more power.”

“We are all continuing to work together to elevate each other’s issues leading to more power.”

The difference in capital and political infrastructure between care advocates and other causes within the progressive movement is stark, to say nothing of the well-connected and lavishly funded business opposition that opposed the tax increases on corporations that would have paid for BBB. “What is the difference between the climate change movement and the care movement?” Kristin Rowe-Finkbeiner, CEO of MomsRising asked, rhetorically, referring to the climate package that was able to pass separately as the Inflation Reduction Act after BBB’s social agenda failed.²⁸ “Tens of million dollars and several decades [of concerted organizing]. I bring that up not to be bitter, but to show how much we were able to accomplish relative to the environmental movement with less time and less money. That shows true momentum for these care policies.”

Ai-jen Poo believes how far BBB got is a testament to the power and popularity of care infrastructure ideas. “A group of determined, mostly women, all running underfunded organizations with very little real political capacity, has seriously punched above our weight and is making generational historic progress on an issue that no one saw was even an issue five years ago,” she said.

Based on lessons learned, these care movement leaders are refusing to be politically sidelined again. Many are using and investing in the tactics outlined in this playbook for different outcomes in the future.