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Family Care for All

Supporting the work that makes all other work possible

Once the coronavirus pandemic began to shut down American businesses earlier this year, it wasn’t long before Congress passed a massive stimulus package to prop up major industries and extend loans to small businesses. By the end of March, well over ten million people filed for unemployment compensation. At the same time, entire segments of the labor force went untouched by emergency bailouts and social insurance. One of the largest such groups consists of domestic care laborers: home health care workers, disability aides, nannies, housekeepers, and cleaners.

They are the workers who scrub our toilets, fold our laundry, and care for our children and aging parents. They are often paid in cash and for the most part work without basic labor protections. There are, according to the National Domestic Workers Alliance, about two million of these workers in the United States, and even in “good” economic times, they struggle to support their families. (By comparison, there are more than three million farmworkers—another group mostly written out of the protections of labor law.) Many face ever-expanding job descriptions: nannies doing laundry and cleaning, home health aides picking up groceries for their patients. Some experience chronic discrimination or sexual assault; trafficking is a known problem. They have no sick leave, no job security, no health insurance. Now they face joblessness or else the risk of contagion if they continue to work during the pandemic.

Few organizations focus on the rights of these workers[*]. Many maids, nannies, and cleaners work for individual families instead of companies, so they are not in a position to join a union or bargain collectively for better wages and benefits.

Even before the pandemic, domestic workers subsisted in an economic system showing multiple stresses: a rapidly growing elder population; childcare that may be barely affordable for middle-class families, let alone for the workers who serve them; a bloated and byzantine health care industry that is inaccessible to at least thirty million Americans; immigration policies that penalize the very people who are holding our families and households together. Now we face a reckoning: some of the most invisible workers in America are, in fact, essential. If we are going to rebuild the economy, it will take more than corporate bailouts. It will require visionary changes to labor law—and social insurance—that recognize how important domestic care workers are to a functioning and humane society.

I Really Do Care, Don’t U?

Such a vision has been taking shape over the last thirteen years at the National Domestic Workers Alliance, which advocates for the rights of those who care for our homes and children and parents, striving to make domestic jobs into quality jobs, with the pay and protections necessary to support those who are getting a foothold on the economic ladder. With four local chapters, sixty affiliate organizations, and a presence in nineteen states, their movement is driven by the idea that our social and health challenges can be solved with innovative social policies that bring care workers out of the dark and make the care we need affordable.

I met with the NDWA’s director, Ai-jen Poo, in mid-February when the dire urgency of the coronavirus was still a few weeks away. We spotted each other in the lobby of a workspace in lower Manhattan and had a brief hug. Poo seemed unchanged since the time we first met as co-presenters at a New York University event about a decade ago. She is steady, direct, and in all likelihood one of the most informed persons in America about the real-life concerns of domestic workers, who she has been organizing for nearly two decades. In 2014 she won a MacArthur Genius Grant and used it to write a book, The Age of Dignity: Preparing for the Elder Boom in a Changing America, which came out a year before my own book on end-of-life care.

Exceptionally few Americans can actually afford the care that they need. So the challenge is two-fold: we have to help families pay for their care and we have to support the workforce with sustainable jobs that offer fair wages.

Poo and I talked about how the NDWA has grown, the challenges of advocacy in the Trump era, and a sweeping, practical solution to the care crisis in the United States—one that is even more compelling now that the old jerry-rigged system seems to be crumbling. For several years, she has been imagining such a plan: “Our solution is called Universal Family Care,” Poo tells me—a social insurance fund that we all contribute to but also benefit from, one that provides childcare, long-term care, and paid family leave. “It will totally revolutionize how we take care of each other,” she says. “It’s like putting a new infrastructure in place to support family life in the twenty-first century.”

Many Americans assume that Medicare covers long-term care, but it does not. So it’s frustratingly common for elders to arrive at the point of crisis without a plan. “It’s a tragedy,” Poo says. “Most people have nothing in place, and they end up spending down their resources, completely impoverishing themselves, to be eligible for Medicaid.” While Medicare covers health care for all older Americans, Medicaid was created for those in poverty—and it was never intended as a long-term care program.

By socializing the costs of care, a Universal Family Care fund would prove durable enough to even out the risks and expenses. Social insurance works best when you have a massive pool and, as Poo notes, “there’s no bigger pool than American families.”

The Caretaker Diaries

In my years as a hospice volunteer, I met many women who care for elders in their final days. Maria, with her long nails and quick laugh, was paid so little that she would often stay overnight in the abandoned nanny’s room at our patient’s house so she wouldn’t have to pay for transportation from the Upper West Side to Brooklyn. Maxi had chronic back pain from hoisting our patient out of a chair and out of the shower. Both were hired for a limited job—assisting the patient with daily activities—that over time began to include cooking, cleaning, and picking up groceries on their way to work. When our patient died, Maria and Maxi were out of work and grieving.

The cost of this kind of round-the-clock care is enormously expensive, even for elders who have savings and other resources, which presents the immediate challenge—absent the national fund envisioned by the NDWA—of providing caregivers with a living wage without bankrupting families.

This necessitates changing our culture to view domestic labor as deserving of all the protections and benefits other kinds of labor enjoy. “The cultural devaluing of domestic work is a reflection of a hierarchy of human value that defines everything in our world,” Poo once said in a TED Talk, “a hierarchy that values the lives and contributions of some groups of people over others, based on race, gender, class, immigration status—any number of categories.” When I ask her how this hierarchy specifically devalues care, she evokes the words of actor and caregiving advocate David Hyde Pierce, who opened his moderation of a panel at the White House a few years ago with the reminder that “to age is to live, and to care is to be human.”

It’s a truth that is nonetheless warped by prejudice, Poo says, by “hierarchies that value the lives and contributions of men over women, of white people over people of color.” Because domestic work and caregiving have for so long been associated with women, the work has been discredited, its importance denied or made invisible. “It’s seen as not having any real value in the economy or culture,” Poo notes. NDWA is hoping to change that by bringing these workers out of the dark as part of a concerted push for a federal Domestic Workers’ Bill of Rights that will codify the value of these essential laborers and grant them the necessary protections.

Central to Ai-jen Poo’s work is remaking caregiving as a social challenge rather than a private shame.

“We are bringing all the tools and all the creativity we have to do this work,” Poo told The New York Times Magazine last year. “We are in a moment where we can either shape the future and be part of how this whole thing unfolds, or we can be victims of it, the way that we have been for generations.”

In 2010, three years after the NDWA was founded, the organization and its affiliates celebrated the passage of the first Domestic Workers’ Bill of Rights in New York State. It provides protection under the New York State Human Rights Law, overtime pay after forty hours, and three paid days off per year. Through the efforts of the NDWA and other organizations like Hand in Hand, an association of domestic employers who advocate for sustainable jobs for the workers they employ, eight other states have signed similar legislation—as have the cities of Seattle and Philadelphia. With support from Senator Kamala Harris, Representative Pramila Jayapal, and others, the NDWA is now working to enshrine the protections of the Bill of Rights in federal law.

Poo sees this federal legislation as a foundation from which we can revolutionize the way care is provided in the United States. “Caregiving today is still seen as a personal burden or responsibility,” she tells me, “and if you can’t figure it out and you can’t afford it and you can’t manage it, it’s your personal failure.” Central to Poo’s work is remaking caregiving as a social challenge rather than a private shame; to articulate how vital care work is, she has called it the work that makes all other work possible. “This is a problem that the market can’t solve; this requires a collective solution, a public policy solution,” she says.

Alongside these efforts to enact policy at the state and federal level, the NDWA has launched several programs to directly improve domestic workers’ lives. They’ve set up an online service called Alia, for instance, that gives the existing clients of domestic workers a way to contribute to an affordable benefits program. For a mere five dollars per cleaning, Alia enables workers to purchase affordable insurance and access paid time off.

Priced Out

The Trump era presents a fresh challenge: the NDWA is advocating for a sector of the economy with one of the largest populations of undocumented workers during a time of mass incarceration at the border. But Poo doesn’t blanch when I ask her about advancing workers’ rights under an administration that seems hell bent on punishment and carnage. “Trump ran on building a wall and targeting immigrants,” Poo says, “blaming immigrants for the jobs crisis and crime. We knew it was going to be a very hard time for our workforce, and it has been.” But as she points out, the administration’s punitive efforts have only made the injustice more obvious and increased awareness of how border issues are connected to each of our personal lives.

At the start of the current border crisis, the NDWA helped launch Families Belong Together, a network of nearly two hundred fifty organizations working to end family separation and detention through direct action, organizing, and fundraising. Such endeavors are predicated on the interconnectedness of workers, caregivers, and families—and on building a movement that will meet everyone’s needs by making care affordable and making caregiving a sustainable job.

What’s innovative about the work Poo directs is how it orients a number of pressing issues—immigration, labor rights, the rights of women and women of color, health care quality—around the issue of domestic care. Caregiving is a core issue, not a private matter of the domestic sphere—and it is increasingly a source of crisis for families.

Exceptionally few Americans can actually afford the care that they need. So the challenge is two-fold: we have to help families pay for their care and we have to support the workforce with sustainable jobs that offer fair wages. The challenge continues to expand, but perhaps a window of opportunity is opening as well. “We have a once-in-several-generations chance to revolutionize how we support families and how we take care of the people we love,” Poo says.

One of Poo’s data points is that Baby Boomers are turning sixty-five at the rate of approximately ten thousand per day, and because they’re living longer, we will soon have the largest elder population in our country’s history. On top of that, millennial women gave birth to more than three million babies in 2018. “We need more care than ever before,” Poo notes, “and we have nothing in place, no infrastructure, no systems to support that care.” While women once provided all of the uncompensated care that elders and children needed, that hasn’t been our reality in decades.

Another factor in the care crisis is the general erosion of livable salaries; there’s no way people can afford the care they need. Nearly 40 percent of American households make less than $50,000 a year. Poo does the math for me: if the average cost of childcare is $11,000 a year and a private room in a nursing home costs more than $100,000, the numbers just don’t add up.

Fuller House

The first women who did this in-home care work as a profession in the United States were enslaved Africans. Since then, women of color, immigrant women, women of marginalized social status have been the workers in our homes, with our children, and with our elders. “And that is not an accident,” Poo notes. “In fact, it was codified into law in the 1930s.”

She’s referring to the New Deal. As Congress debated the labor laws embedded in this suite of progressive policies, Southern members refused to support any laws that included protections for domestic workers and farm workers, who were predominantly African American. Southern congressmen won out, and these two sectors were excluded. “It was an explicitly racial exclusion,” Poo says, “that has really shaped domestic work and care work in America. It’s a very concrete manifestation of the hierarchy of human value and how it gets codified into law.”

Yet what work is more fundamental to family life and social reproduction in this country? Care workers are in our homes, wiping the chins of our toddlers and parents. It is the fastest growing work force in the economy. And it’s the sector that supports every other working family. “If every domestic worker in New York decided not to go to work one day, imagine the chaos,” Poo says. “Even though that work is invisible, it is central to the operation of so many industries.”

The pandemic has rendered care work not only visible but “essential,” the linchpin in our social structure.

What happens if caregivers don’t go to work one day is strikingly easy to imagine now, as New York State has decreed that all nonessential employees must work from home to prevent spread of the coronavirus. Social media reverberates with tales of mothers and fathers who are struggling with work, childcare, home schooling, and elder care all at once. And yet many caregivers continue to go to their jobs because their charges require assistance for everyday activities; the pandemic has rendered this work not only visible but “essential,” the linchpin in our social structure.

Today, domestic workers struggle to feed their own children, they suffer burn-out and experience physical and mental exhaustion, harassment and racism. And because their wages are so low, the care sector has often lost talented caregivers to better paying work like fast food or retail. But Poo sees yet another opportunity here. “There’s a tremendous amount of waste in our health care system right now,” she observes, “and a lot of it is concentrated at end of life.” I know this from my own work. As much as 25 percent of Medicare’s annual budget goes to the last year of life. Which wouldn’t be so bad if we were providing the kind of care elders needed.

“The very best prevention,” Poo tells me, “is good caregiving.” Workers who are well-paid and well-trained, workers we recognize and invest in, could be an asset to the health care system and a solution to many of its current problems—from unnecessary institutionalizations and re-hospitalizations to management of chronic illnesses and better quality of care.

The Road We’re On

You might think that the partisanship of the current political climate bodes ill for Poo and the NDWA’s vision for Universal Family Care, but caregiving is what Poo calls a “trans-partisan” issue. A recent poll conducted by Maria Shriver’s Women’s Alzheimer’s Movement and Caring Across Generations found that 71 percent of Republican voters would support a federal program to help cover the costs of caregiving. The poll focused mainly on long-term care, but support for a new government program is strong.

In March, in an op-ed for the New York Times, Poo wrote that “domestic workers and caregivers are too often asked to put the needs of the families who employ them over their own and those of their families.” Poo argues that the Centers for Disease Control and Prevention “should direct more of their resources toward the front-line care professionals” who work in our homes and neighborhoods because they serve as our first bulwark against damages to public health. Providing these workers, predominantly women of color, with safety equipment, testing, and information in multiple languages should have been our first step in preventing the spread of coronavirus.

“What you’re doing, because it is so big, is imaginative, it’s a creative act,” I tell Poo at the end of our conversation. “How can we envision this better future?”

“For me, it’s not hard,” Poo says. “I want people to get excited about the idea of Universal Family Care, the idea that care for families is a part of the infrastructure of the twenty-first century—like roads and bridges and tunnels are now an expected expense because they enable everything else.”


[*] Correction: A previous version of this article incorrectly stated that the Service Employees International Union (SEIU) 1199 does not represent home health aides. This is not the case; the SEIU represents a large number of home health workers.