Well, welcome to the Economic Policy Institute. I'm so glad you're here with us today. And I am Elise Gould. I'm a senior economist here at the Economic Policy Institute. I've been here for 16 years. I do research mostly on labor markets, so wages, employment. I do a lot of work on gender wage gaps and racial wage gaps. I do, obviously, also some work in the care space on early care and education. So you are so happy. I'm going to tell you you're going to be so happy to hear. There's this giant report, and there are copies of it in the back. And instead of reading it, although you could, and you should read it, you're going to get to hear a really great detailed summary from some of the authors of the report of the panel doing this really important work on designing universal family care. What this report does, it explores strategies that states could pursue to better support families. You're supporting families in meeting their evolving care needs over the lifespan. What they do in the report is they provide a discussion of the challenges that families face in on all ends of the spectrum, affording early care and education, the need for paid family medical leave, and the importance of long-term services and supports. In each area, the report highlights policy options within the context of assuring universal access, affordability, and financial stability. In the end, they propose an integrated approach to care policy, one offering families a single point of access to early care and education, paid family and medical leave, and long-term services and supports under an umbrella called the Universal Family Care. And that's what you'll find in this report. So we're fortunate, again, to have with us expert contributors to this report. First, we have Benjamin Vickty, is a research director at Caring Cross Generations. From 2015 to 2019, he led policy work at the National Academy of Social Insurance as vice president for policy. There, he directed the study panel on universal family care chaired by Mark Cohen and Heidi Hartman and was lead author and editor of the study panel report, Designing Universal Family Care. This report that you can get again at the back. Alexandra Bradley will be up next. She is the lead policy analyst for the National Academy of Social Insurance's study panel on universal family care. She spent three years at the National Academy of Social Insurance as a lead policy analyst on health and caregiving and remains a consultant for the project. We're also privileged to have with us today Robert Espinoza. He's the vice president of policy at PHI, where he directs the national policy advocacy and research program focused on the direct care workforce. For more than 20 years, he has spearheaded high-profile advocacy campaigns and written similar reports on aging and long-term care, LGBT rights, racial justice, and immigration, among other topics. He also serves on the board of directors for the American Society on Aging and the Forum on Aging, Disability, and Independence for the National Academies of Sciences, Engineering, and Medicine. I'm going to give you a little outline of what we're going to be doing here. Ben is going to begin by presenting the case for action and the rationale for the study panel and provide a brief overview of its work. Alexander will then discuss early care and education and paid family and medical leave policy options from the study panel report. Then Ben will come back up and outline long-term, the part of the report discussing long-term services and supports and universal family care policy options from the report. Then I'm going to discuss some of the EPI's research on early care and education with a focus on creating high-quality ECE that works for parents, children, and workers alike. And then last, Robert will present his research on the workforce implications of any new long-term services and support social insurance programs. At that point, we will open it up for questions. There will be plenty of time. Without further ado, let me introduce Ben. Thank you so much, Elise. And Elise just came back from a trip late last night with flight delays and was kind enough to moderate this panel this morning. I'm very little sleep and short notice, so thank you so much. I'd like to start by saying a few things that may make you feel unsettled. Think of your own extended family from the youngest generation to the oldest. Think about people in your family or people in our families who need care, whether that's day care or long-term care. And think about your own fears of growing older and maybe needing long-term care one day and the financial and psychological demands that that could place on your relationship with your spouse and your children. Think of the tremendous inequality of opportunity we have in this country and the fact that millions of children don't get a decent start in life. Now think about the people in our families who provide care to a loved one. We know that most of us can't afford to take a big reduction in our work hours or a big cut in pay in order to provide such care. And we know that hiring professional care supports, whether it's day care or long-term care, is expensive and out of reach for many of us. Finally, think of the care workforce and the substandard quality of the jobs in the day care sector and in the long-term care sector and the racial and gender equity implications that that has. I'd like to tell you that there's good news on all of these fronts as challenging as these issues are. The study panel from the National Academy of Social Insurance came up with vetted viable policy options that could address all of these challenges both individually and in a unified, integrated way. And we're gonna be talking about those today. The study panel met for 18 months, was funded by the Ford Foundation and Caring Across Generations. And did not seek to come up with a recommended policy approach to care challenges, but rather sought to evaluate policy options for policy makers at the state level, although there are implications for the federal level as well. And it talked about, the study panel report talks about trade-offs among those policy options. Some of the people in this room were on the panel. Obviously, Alexandra was and I staffed the panel. Robert served on the panel. Jeff Hayes in the back is here. He served on the panel. Are there any other panel members in the room? So thank you to them. Here's a full list of the panel members. So caring for loved ones can create some of those meaningful experiences in our lives. But gaps in the care infrastructure leave many of us struggling to balance work and care. One of the dark sides of the liberal public sphere, all the political scientists in the room will know what that means. The liberal public sphere that John Locke and others elaborated in the 18th century, it's the foundation of our economic and political system. One of the dark sides is the assumptions that it makes in a couple of areas. So one assumption is that if we all work hard, we can earn enough money to satisfy our care needs through the market, that we can purchase goods and services to satisfy our needs. Another assumption that the liberal public sphere made was that invisible populations provide the social reproduction of families, provide care, mostly women and people of color and those two groups overlap strongly. And those women and people of color weren't citizens at the time with this approach to government and the economy was developed. Well those assumptions no longer apply today. Let's look at some data points. There are four trends that have made revolution, switching our paradigm over the guard to care and revolutionizing our care infrastructure necessary today. First of all, there's been four decades of wage stagnation and growing income and equality. There's been a lot of fantastic work done here at EPI on that. Seventy-one percent of the workforce earns less than $50,000 a year. So many of us can't afford to purchase goods and services to hire professional care supports to meet our caregiving needs. Second, families today need all adults' earnings, most families need all adult earnings to make ends meet. So in other words, if it's a husband and wife or a husband and a husband or wife, two spouses of any kind, they need all adults working in order to pay their bills, meet their obligations. Sixty-four percent of mothers today bring in at least one quarter of family earnings, and 41 percent bring in half or more of family earnings. So there is no more stay-at-home family caregiver in most families to address care needs. Furthermore, boomers are aging, and the ratio of people of prime caregiving age, 45 to 64, to people who are over the age of 80 is declining from seven to one in 2015 to three to one by 2050. That decline is already taking place. So this means that there are fewer people to take care of elders who need long-term care. This applies both to family caregivers and to professional caregivers. There's gonna be a shortage in both domains. And finally, care is unaffordable at both ends of the lifespan. The average cost of daycare is $10,000 a year in this country. The average cost of a home healthcare aid is $50,000 a year. It's expensive. There's a patchwork of disparate programs addressing these needs today, all based on the sort of liberal public sphere assumption that most of us can set as far as needs to the market or through a stay-at-home caregiver. Those who can't because they didn't work hard or whatever the theory goes, the government steps in for them, the residual welfare state. The government steps in to help those who can't fend for themselves. That's what we have today, and it's not suited to the nature of our society and economy and family structure today. We have Medicaid long-term services and supports in place, which makes long-term care primarily institutional care to some extent home care available to those who have become impoverished. We have an array of programs that Alexandria will talk about to help in the daycare space, but they're both targeted programs and the broad middle class is largely left unprotected. Finally, the number of paid caregivers won't meet demand and care jobs are probably compensated, limiting the quality of the childcare and long-term care workforce as Elise and Robert will be talking about. And finally, families bear the burden of this insufficient infrastructure, and it's mainly women who bear this burden, many of whom are sandwiched in between caring for parents and caring for children. So the Academy took on this project because the Academy believed that they'd improve the care infrastructure is possible through social insurance. The risks that involved here are long-term services and support, the need for long-term care, the need for paid family medical leave, the need for affordable childcare are insurable risks. Families experience these needs in interrelated fashion, so a holistic integrated approach makes sense. If you're a family caregiver, the risk of taking care of your child or your parent is it's the same set of risks that you're facing, so an integrated approach we thought would make sense to study. There are synergies to addressing these challenges together, and we also believe that states have an important role to play. So for those reasons, the Academy took on this project and worked on this report. With that, I'd like to pass it to Alexandra. All right, so I'm here to talk to you about early childcare and education as well as paid family leave. So I'm gonna start with early childcare and education because for some I think this is the most little confusing piece of the puzzle. We haven't really taken a social insurance approach to early childcare and education in the past. It's something we've looked at paid family and medical leave as a social insurance program. We've seen states taking action in that way. We've seen it in the long-term services space for a long time, but why early childcare and education? A more social insurance program is something that we all pull our money into together to protect against a certain risk and that we might experience and then we all pay out, get our payout when we have a risk that transpires. So thinking about children may not seem quite like a fit because children are not a risk. They're the future of our society. But I'd like us to maybe think about what the implications are for a lack of an early childcare and education structure because the way we have it right now, there's a very little investment on the future of our workforce, of our future caregivers, on our citizens. Anything that those children is gonna become is affected by those earliest five years.  Right now, zero to five is not treated on par with K through 12 public education. We've decided that K through 12 education is worth the investment, but not so much our youngest children. I think that that's where we're starting to make some maybe missteps. This is one of the highest developmental values for the future and also a high cost benefit for families and society alike. And unfortunately, the existing patchwork of programs because we all hear about Head Start or the childcare and development block grant, but these programs don't actually reach all the children that even are eligible, no less all the children that actually experience need. Only one in six children who are eligible for the childcare and development block grant actually receive benefits, only about a third eligible for Head Start actually are participating and only 7% for early Head Start, which is that zero to three. So we're really not even seeing the federal programs that are supposed to be taken care of, the folks in even the lowest income families getting cared for, no less everybody in the middle or the upper lower end who wouldn't even qualify for those programs who still have a tremendous amount of need and could not possibly fill in the gap between the programs that come from the federal government and those that cost $10,000 out of pocket. What are some other reasons why we might wanna invest in early childcare and education holistically? Well, improving the quality of care and investment in infusion of money into the care infrastructure, and I know at least it's gonna talk a lot about the care workforce, so I'm gonna table that. But an investment in the future of children also means an investment in the workforce and the quality of care. And when we see an improvement in the quality of care, we're gonna see long-term societal benefits from those children going up with higher quality education. And there's also going to be effects on lessening inequity in access to care. So we see a lot of regional distribution and also a lot of lack of competence or quality in areas that experience more adversity. And so infusions of money that are kind of across the board may help to elevate all ships up to the same level or at least a closer to the same level. So what were some of the policy options? Because we haven't thought about early childcare and education as a social insurance program, what are some of the ways that we can look at it in that light? Well, one would be a truly comprehensive universal program, much like our K through 12 public education system. So a state might choose this option so that all children are eligible. And it's essentially an expansion of K through 12 down to younger levels. You could either go straight down to zero, you can progress over time. So a state might start with four-year-olds. In fact, many have, the District of Columbia has a universal pre-K program for four-year-olds. Some states have extended that to three as well and you could work your way down over time if you wanted to phase this in. It is a high upfront public investment, but I also want us to think about the payoff of how much that would do for society. That investment is an investment, so it is bettering our future. There is the second option, which is an employment-based contributory program. So a lot of states have wanted to talk about tying benefits for early childcare and education with family members' employment. So say a parent was working, they would then be eligible for benefits. This is certainly a way to target working families and make sure that folks can maintain labor force attachment. But unfortunately when coverage is not universal, that also means that there's gonna be a lot of gaps and a lot of folks are going to not only be left out, but also rotate in and out of coverage. Because if you think about especially lower wage jobs, part-time jobs, seasonal jobs, temp jobs, many of the jobs that especially mothers and parents in general are required to hold in order to provide care for their children, they're often churning in and out of the workforce and what happens to a child when they are in early childcare and education one moment and then out the next? And what is that gonna look like on a practical level? It's not only a problem for families, but it's also a high administrative burden for the state and very complex. And finally, the last option, which is kind of a middle, maybe a lighter version of the first option is the universal subsidy or voucher program. So all children would still be eligible for some benefit, but rather than the state covering the entire cost of care through the program, families would receive a certain amount in terms of a subsidy and might have to fill in the gaps. Now, that may or may not actually cover the full cost of care for families. Some families will be able to fill that gap and some families will not. So we have to look at whether or not that amount is actually going to be adequate for the families at the margins and whether or not that's gonna increase or decrease in equality. Because if only the families with the most likelihood to be able to fill that gap are going to be able to do so, then we're not really actually seeing a decrease in inequity, we're seeing an increase. But it does provide some flexibility for states and maybe a way for states to easing to a program like this. So as I said, programs that are universal are a better position to improve equity across all children. Programs that are employment based may leave many children out. And all programs I should emphasize because I've gotten this question in the past, we are not gonna overnight see a public education system on part, like exactly the same as K through 12 education where suddenly public providers are gonna pop up out of the woodwork and start providing four year old education on day one. We're gonna have to take a look at the existing private care space, engage those folks, bring them in, bring them up to par for what the community needs to provide those services. And many of them will probably be involved in providing the services for early care and education. And just to reiterate, especially in the subsidy program, the generosity of benefits is really going to determine whether or not families are actually experiencing a decrease in equity because of higher earners are the only people able to pay the gap between what the state provides and what is left for them to pay, then we're not looking at an actual decrease in inequality. Okay, on to paid family and medical leave. So this is an issue that we've definitely thought about in terms of social insurance. And in fact, many states have already done it. So when I say paid family and medical leave, just in case folks aren't familiar, I'm talking about time that you take away from work in order to either provide care for a family member or receive it for a medical concern of your own. So that might look like someone who had an acute medical condition, such as a heart attack or a cancer diagnosis and needed to take some time off for their own personal care or someone who gave birth to a child or whose spouse had a stroke. These are some of the reasons why you might need to take time off. So we have five states that have a long-term temporary disability program, which is the paid medical leave portion. And four have added paid family leave on since then. And another five states are in the process of implementing a new program that's combined paid family and medical leave since they didn't have that existing paid medical leave program in place. The District of Columbia is one of them and they're about to come live next year. I won't go into detail on the different decision points for the sake of time and also because it's in great detail in your report. But some of the things that I wanna flag in some points that states have actually dispersed on are things like the qualifying events. So what counts as a qualified family member to receive this benefit? So in some states you might see only children and parents and very close family members. And some states are making decisions to include more chosen family or broader definitions of family. Those are decisions that states will have to make in terms of who's eligible. Also the generosity of benefits is going to greatly affect whether or not families are actually able to take that time off. In some of the very early states the benefit amounts were very low and lower income families who are making minimum wage could not possibly afford to take say 60% of their regular pay when their regular pay was already barely making men's meat. So the policy options that we looked at there were two substantial policy options. The contributory social insurance program which is what the vast majority of states have selected. This simplifies administration because everybody's in one risk pool and everybody gets paid out of one risk pool. It spreads risk across the entire workforce in the state. So especially for smaller states that's gonna be a big benefit and it reduces the potential for employer involvement or discrimination. The second option which we saw mostly happening in New York but with some kind of small representation in like California and New Jersey is that there is a hybrid social insurance program that either regulated private options or the option for certain employers to opt out. The only state that actually has a robust private market right now is New York. But what the issues that we've seen with this is that it's just an increase on the administrative complexity on states. So rather than having one program to monitor you have one program and 200 employers to monitor each with a unique individual program or an entire private market like the workers compensation program that you have to monitor every policy on the bucket. So it is a higher administrative complexity, requires robust regulatory mechanisms to make sure that employers and private providers are actually doing what they're saying that they're doing. But on the flip side, we have seen this model work with workers compensation and it does increase employer choice. So it has been appealing it to some states. We talk about the trade-offs a lot more in the report. And finally, we just wanna think about the funding source for paid family and medical leave. So states have done different things. The vast majority have done the social insurance model so that either is a shared employer and employee or an employee or employer-only cost. The only state that has taken employer-only is DC and that is for very complicated reasons because we don't have self-rule. But the most states have either chosen an employee-only model in terms of the contributions or a shared cost and most have chosen the shared cost. And that is it for me. I'm gonna turn it back to Ben for long-term services and supports. So I know this is a lot. If anyone wants to stand up and stretch, feel free. So we're gonna switch now to long-term services and supports, long-term care. First of all, what's the rationale for a social insurance approach to long-term care? As I mentioned at the outset, the low-income populations or people who become impoverished over the life course have potentially access to Medicaid on long-term care. Although that is not easy to qualify for. Anybody who's applied for it on behalf of themselves or their parents knows how challenging that can be. Every state is different. It's a 20-page form, a lot of documentation required, and it's not guaranteed that you'll get it. If you do get it, depending on your state, you may only have access to nursing home care. You may or may not be able to get home aid. The top 10% of households can probably afford to pay either out of pocket or have private long-term care insurance. 7% of households 50 or over have, or 7% of individuals age 50 or older have private long-term care insurance. Probably another few percent could afford to pay out of pocket. But so that leaves the broad middle-class unprotected against the risks associated with needing long-term services and support. So that's a rationale for a social insurance approach. Another reason why social insurance makes sense rather than trying to fortify the private insurance market is that social insurance contributions are much more affordable in the long-term care space than private insurance premiums for a variety of reasons.  Maybe I should buy long-term care insurance at which point the premiums are much higher because you're paying over a shorter period of time. Secondly, there's no adverse selection in social insurance because everyone's a mandatory program with private insurance. People who think they're going to need long-term care because their mom or dad needed it are the ones who are more likely to try to purchase it which is adverse selection which drives up the premiums. There are sales and marketing costs associated with a private long-term care insurance. So those are all reasons why a social insurance approach is more affordable for families. Furthermore, there is up to 30% of people apply for private long-term care insurance, get denied coverage because they're considered a bad risk. So even if you wanted to buy a long-term care insurance, you might not be able to. If a state were to try to set up a social insurance program for long-term care, what are the key decision points they would need to evaluate? The first major one is what would be the population covered? And now the first question there is do you only cover people who have pay into the program? In other words, is it a classic social insurance approach where you need to pay and invest or are you going to try to cover everyone? A second coverage eligible population issue relates is the generational one. Do you only cover, do you cover everyone who has a disability immediately upon passage as almost every other country has done when they pass these programs? Or do you only cover people who have the opportunity to pay and over time invest in the program? That overlaps with the previous issue, but it's not identical to it, it's a separate question. So for example, Washington State in 2019 passed a long-term care social insurance program, but they chose, in order to keep the contribution rate low, they chose to only cover people who invest and therefore boomers are completely uncovered by the program. So that was a hard choice that they had to make to keep the contribution rate under 0.6%, for example. Another issue is the timing and duration of coverage. Here's data from Melissa Feveiro and Judith Day on the projected duration of LTS need among seniors with need, this is just among seniors. You see about half, about half of us who end up needing long-term services and supports need it for two years or less, about half of us need it for more than two years. One approach is to have, in a public program, would be to have a front-end coverage model where you get coverage for the first two years, for example, or up to a certain lifetime maximum benefit that it's designed to equate to one year of need or two years of need. This is what Washington State chose to do. The idea there is that that covers like the most immediate problem and then if you have a longer duration of need, the long-term services and supports program can kick in to help you at that point. A separate approach, a distinct approach would be to have a back-end catastrophic approach where the assumption there being that that's the most expensive and hardest to manage and most unpredictable tail of the risk. So you let families cope somehow with the first couple of years of need and you help them out on the back-end. That would be another approach. Both of those approaches cost about the same in terms of what the cost of the program would be. A third approach would be to have a temporarily unlimited duration of coverage, so comprehensive coverage in terms of time. That is what every other country has done. That's why there's six social insurance programs and four other programs in Scandinavia that offer this that are tax-funded. That's what they do, but in this country, the debate is between front-end and back-end. Medicaid is essentially a back-end program. Okay, financing considerations. There, so if you're going to structure this as social insurance, you have to figure out what tax base to use and what rate of contribution to apply to the tax base. When Social Security was created in 1935, we had a certain economy and income distribution and the assumption was that you could have a cap on the income subject to the contribution and ensure wages under the cap. There's been tremendous growth in income inequality in the last four decades and for that reason, newer programs tend to not have a cap on, well, Washington State, for example, does not put a cap on the tax base subject to the contribution. Furthermore, because of this tremendous growth in inequality, many experts are considering a progressive approach to the payroll tax base. We have that in Medicare Part A already where there was one rate charged on earnings under the threshold of $200,000 for an individual, $250,000 for a household, and an additional rate on, which is about a quarter of the total, on earnings above those thresholds. So if I make 200, if my wife and I have $251,000 of household income, which would be fantastic, we would pay the base rate on our first $250,000 and we pay an additional rate on the last $1,000, right? So the additional rate, it's not that higher income households pay the entire, both together, higher rate, they simply pay a base rate on our first chunk of income and a higher rate on the income above that. Another policy option to make a payroll tax progressive in this area would be to expand EITC at the same time as you're enacting the program. That's a consideration, that's a policy option that's been considered in the social security space and it could be considered here as well. So there's, so one thing, one point I wanna drive home here is that there is a myth that payroll taxes are regressive. It's not true. They can be regressive, they can be progressive, they can be proportional, depends how you structure them. So there's a variety of ways you can structure them. They don't have to be regressive. One final note here that, again, Washington State's payroll tax rate is 0.58%, that's the rate that they have used in their program. Payment, I won't cover these issues, but we could cover them in Q&A if you wish. There are more detailed policy design questions. The ultimate goals of a program are, the first of course is approving access to care so that more people have access to the care they need so people aren't forced to go into a nursing home prematurely or suffer at home without the adequate care they need. Reduce out-of-pocket spending for families. It's a tremendous burden. Most of us don't have nearly enough money to maintain our living standards in retirement, much less pay for long-term care needs out of that limited retirement income. A twin goal there is to reduce the burden on family caregivers, because if people can't afford to pay for private, for professional supports, then they and family caregivers ended up having to provide that care, which has drastic consequences. Peter Arnaud has looked into this on lifetime savings, lifetime earnings, savings, and social security benefits for family caregivers. Obviously, any program should be designed so that it's fiscally sustainable. You do that through annual actuarial evaluation of the program, and it should be designed in a way that's politically sustainable as well. Obviously, we've seen with the Affordable Care Act what kind of chaos it can cause in a program. From year to year it's unclear if it's gonna survive long-term. Some key takeaways on this issue of long-term services and supports is that one, a universal social insurance approach would fill the gap in the current system, which is the broad middle class. LTSS programs can be tailored to a state's needs, so every state's different. Iowa is different from Massachusetts, but there are a lot of decision points here that you can dial up or down to be more expansive in your coverage, more expansive in the benefit design, et cetera, to meet a state's climate or needs. And the cost of a social insurance program that's sort of middle of the road front end, like Washington State, would be about 0.6% of earnings. And with that, I'd like to switch to a broader concept, which is universal family care, which the study panel also looked at. Universal family care would be a new social insurance program that provides integrated access for families to all three needs that Alexandra talked about and I've talked about, child care, long-term care, and paid family medical leave. So what is the case for an integrated universal approach? First of all, we all juggle work and care. The assumption of the residual welfare state that only kicks in when people don't work hard or can't fend for themselves, that ideology of the 18th century, the assumption there is that only those only low-income families struggle with this. While all of us in this room, I'm sure struggle with this issue, right? And if you don't, God bless you, I'm happy for you, but most of us struggle dealing with these issues. So it's not a anti-poverty issue, it's a social insurance issue that affects all of us. Social insurance is also a more efficient way to pay for the care. So rather than waiting till a care episode strikes, my mom needs long-term care, which did happen in the last 15 years. And do I, and I'm trying to pay for my child's education, do I reduce my work hours and care for her? Do I affect his education in a negative way? Do I, how do I deal with all these? Do I wanna face the care challenges and the financial challenges at the same point in time in my life? And the answer is no. I mean, much more efficient for me if I could pay into a system while I'm working before the care episode strikes and have that protection available when the care episode strikes. That's what social insurance does. And so that's, it's a more efficient way for families to support families. It's more family friendly because it means during care episodes, I'm not worrying about money, I'm worrying about caring for my child or my parent or my spouse. Finally, an integrated approach, if you approach all these, you could always, of course, design and implement these three programs in parallel, right? Or only two of them or one of them, which is, these are also options obviously. But an integrated approach through universal family care would provide a one-stop shop for busy family caregivers. All of us know if we're dealing with childcare issues and parent issues, elder care issues or disability supports for family members, that each of them entails their own bureaucracy, their own time consuming challenges. If there were one simple way to one integrated program that we could go turn to, like Social Security is there, for example, for retirement, disability and survivors benefits. It's not three separate programs, right? Medicare provides pharmaceutical benefits and doctors benefits and hospital benefits. We don't have three separate programs for that. If you had one integrated approach, a busy family caregivers would have a much easier time. So we've been talking about public policy this whole time. Let's do a paradigm shift here of our own or perspective switch from the macro level to the micro level to look at the family perspective. What does this look like for families trying to navigate their own care challenges? To understand this, at Caring Across Generations, we conducted interviews with family caregivers, with dozens of family caregivers in the Bay Area and San Francisco Bay Area, of all different income levels and family structures to get a sense of what their care challenges were and how we could design a program that would work for them in terms of, because of course it would Silicon Valley, we decided to develop a web app that would not in order to have the app because the program hasn't been enacted yet. The idea is to simulate the experience of a family claiming benefits. How could a program be designed so that it not only works for the policy walks in this room and makes sense for all the things that we think are important in terms of policy design, but also works for what families think are important in their daily lives. So this is one of the families that we interviewed. Leah on the right is a 30-year-old pregnant mother of a two-year-old son and a part-time caregiver for her 78-year-old father. I actually did interview this family, that's a real family. Her father has serious health issues and she's worried that if her dad has an incident, he might require a home health care aid which could require her to quit her job and make it unaffordable for her to meet her care challenges. So let's imagine that a web app exists for claiming universal family care. And we, in fact, designed one earlier this year. So rather than apply for programs like paid family leave benefits, well-term care benefits and childcare benefits, Leah would turn to this program, universal family care, whether it's a door you knock on or whether it's a web app. And the program would ask her what her needs are and try to provide integrated supports that make sense for her. So using the web app as a metaphor for understanding this, it would welcome her, again, this could also be a program obviously she would turn to, it doesn't have to be the app. It would first, it would assess her needs, it would ask her questions. Who are you looking for benefits for? For yourself, as you would with paid medical leave or for a family member, which family member? Ask their name, what their challenges are? Are they enrolled in other benefit programs? And then it would offer a tailored system of supports for that family caregiver, for Leah in this case. So Leah, for example, would probably need paid family leave to care for her dad. And she might need childcare supports and she might need a home health care aid for her father at some point. So the program would then offer her a dashboard, for example, like this where her different family members would be represented and she could monitor the care that they're all receiving, the professional supports that they have access to in one integrated fashion. So we think that there's a case to be made that an integrated approach could be easier for family caregivers as well as make sense from a public policy perspective. The pillars of a universal family care program would be that work is the foundation, it would be social grounded in social insurance, anchored in social insurance. So whenever people are working, they would pay into the program. If you're not working, you wouldn't, but when you're working, you would pay in over the life's course. And then when you needed care supports, you would receive benefits. Reflexible and portable, just like social security or Medicare. It would have a single access point for a variety of supports, as we just discussed. And it would also invest in the care workforce, which I won't talk about further because I know that Elise and Robert are gonna talk about that. Just to give you a broad sense of how this could be designed, the study panel came up with two broad approach, structural approaches, the way a program like universal family care could be designed. It could be a classic contributory social insurance approach based on investing, like social security, where you have to contribute for a certain number of quarters to qualify for benefits. Or it could be a more comprehensive approach where you try to cover everyone the way other long-term care programs in Germany or Japan or South Korea or Taiwan or Scandinavia do, in which case, you would need more than just payroll taxes, you would need supplemental funding from another revenue source as well. We also delineated to, you know, you could obviously either have a core set of benefits that are modest, like in Washington State, for example, they only provide up to a lifetime maximum of $36,500 of long-term care benefits. So a limited lifetime amount of benefits that they derive that from $100 a day times 365 days a year equals $36,500. So most people wouldn't use that all in one year, it's about enough for two years of a typical person's care. You could have modest benefits like that or if you are a more generous state or a state with a political culture of more elaborate social policy, maybe you would have a more expanded benefits. We did a preliminary, we asked the actual research corporation to do a preliminary ballpark estimate of what this would cost using various tax bases. This is the middle of the road, universal family care benefits package. It's a very generous childcare package, which is based on the National Academy of Sciences proposal which would provide universal childcare where families pay in 7% of their household income as a maximum amount of contribution but the rest is covered by the program. The Family Act paid family leave benefit level which is a generous, middle of the road, maybe generous and then a modest program in long-term care like Washington state. Using that benefit package and using the Medicare part A tax base, the Medicare hospital insurance tax base, the payroll tax rate that ARC estimated would be 1.55% of earnings up to the threshold of $200,000 for an individual or 250 for a household or an additional rate of 0.66 on earnings above that. This is to give you a ballpark estimate. We are planning on doing more modeling this winter with Urban Institute to get more detail modeling. The financial integration of the trust fund has a couple of different options, but I won't cover that here because I don't want to go too far over my time. I'd just like to finish by saying that there are a lot of benefits that a program like universal family care could bring and it's important just to, obviously it would cost money but it would also bring a lot of benefits and it's important to keep them in mind. First of all, it would make care supports universally affordable to all families. So every child could get a decent start in life in terms of its early childcare and education and access to long-term services and supports would be available as well, which is extremely important, especially for Gen Xers and who, many of us, the rate of marriage is declined over time and there are a lot of LGBTQ marriages and it's not clear that we're all gonna have children, the rate of child birth is declined, it's not clear that we're all gonna have spouses or children to take care of us in all the age, so this is an increasingly important issue. Secondly, it would empower families to manage their own care. So it wouldn't replace the family role in caregiving but it would give family caregivers a set of tools so they could choose to what extent, what is the optimal algorithm for our family in terms of the combination of family care and professional supports. Each family could choose that and have this program as a tool for that. For workers, it would reduce lost wages and reduce the lost lifetime savings that afflicts family caregivers when they have to reduce their work hours. For people with disabilities, it would increase their access to self-directed care because professional supports would be readily available so it would be a significant improvement in the quality of life for people with disabilities who need long-term services and supports. For the care workforce, it would provide sufficient revenue as social insurance programs do to allow not just meeting the consumer benefit need but also to invest in care jobs. For states, it would reduce the burden on Medicaid spending that the aging population is going to present in the coming decades. And for the economy, it would free up like the tremendously, tremendous untapped resource which we have in terms of productivity growth which is prime age working women whose peak productivity is sapped by the lack of professional care supports in our society. With that, I'll pass it to Elise and Robert to talk about workforce implications. Thank you. It's certainly an ambitious undertaking to think about solving all those problems at once. I commend you for the report and the details and all the different financing mechanisms to have it so complete in one place, I think is pretty impressive. So thank you. So I'm going to talk about early care and education. So I'm going to leave aside some of the other issues that have already been talked about. The EPI has a long history of doing research on social insurance, primarily health and retirement security. In the last several years, we have been doing increasing amount of work on early care and education. And to be clear, it's early care, a lot of what we're talking about is care, but it is education for these youngest of children. So the work began at the Economic Policy Institute when we had been doing our family budget calculator, which we've done for a couple dozen years now. And what we noticed one year when we were doing it is that rent was no longer the highest cost that many families faced. Many families were finding that infant care costs were far exceeding how much they had to pay for housing. So maybe they needed a two or three bedroom apartment and yet their cost for childcare exceeded that even if they only had two kids in the family. So then that made us do more research because that's what we are interested in doing here. And we looked at how high quality childcare is out of reach for many families so looking at their incomes. And then we looked at the flip side of that and how childcare workers aren't paid enough to make ends meet themselves and how that compromises the quality of care that children receive. We have done a lot of state level work. I don't know if you're familiar with it, but we have in addition to our very local level family budget calculator, we do have our childcare fact sheets that provide data on a state by state basis. You'll see an example of some of that data when I'm looking at California in the report I'll be talking about in a minute. After that, we tried to look at the holistic idea of what it would mean to have an ambitious national investment. It's gonna cost a lot of money. We're already hearing that today. To do this right, it's gonna cost money, but the return is well worth it. In the last couple of years, EPI has developed a partnership with Berkeley's Center for the Study of Child Care Employment, particularly Leah Austin and Marcie Whitebook, the co-directors of that program. And we have engaged with them on a couple of projects. The first thing we did was to look at what good childcare reform should look like. And it has some of the components we've talked about today. We do wanna make sure that parents have the ability to stay home so the paid family and medical leave would have a paid parental leave component to it. And we wanna make sure it's affordable for families and you have high quality care and you need to pay for that and you need to pay the workers to get that high quality care. And so those are some of the components. The latest research that we released in July is breaking the silence on early childcare and education and looking at really breaking the silence on how much it's gonna cost to have the kind of system that our children, our families and the workers deserve. And so I'm gonna be talking about that research today. And the few things I'm gonna talk about, I'm gonna highlight the problem, the problem with the system we have now and that there is a lot of money that we have in the system now. And the second is the values consistent with the kind of system that we would like to have. So what are those values that should underlie that? We've heard a little bit about that already but I'm gonna talk about them more clearly in terms of early care and education. I'm gonna talk about how we estimated how much that will cost for the state of California, little details on our methodology and then the bottom line of how much that values-based budget will cost and I'll conclude with the next steps of what we are doing here at EPI on this research. So the root problem is underfunding. What parents can afford to pay is not enough to provide teachers with a fair wage and ensure high quality care and education for their kids and early educators are expected to underwrite the cost of the broken system with their low wages. So essentially it's too expensive and it's not expensive enough, right? So that means that we need to make sure we have other sources of funding to be able to pay for what it is that children and parents and caregivers deserve. So we know that early care and education is unaffordable and I'm gonna talk about California here. That's the example you used in the paper. We are actually producing reports for every state in the country. I'll talk about that at the end. Child care in California is expensive. The average cost of infant care is almost $17,000. Four year old care is lower because the ratios are lower but it's still about 11.5, almost $1,000 each month. In California, yes, is one of the more expensive states but it's expensive across the country. So California comes out third in 50 states and we heard a little bit about there are some programs for lower income families but the combined state and federal investments fall short of serving many children that would be eligible and those that qualify for the subsidies are not the only ones in need. Many low and moderate income families are also heavily burdened by the cost. It goes far up into the income distribution, the families that need assistance. And you can see that when you compare the costs of infant care or four year old care to other costs that middle income families might face, their housing costs are higher than four year old care but are about the same as what it costs for infant care and college. So if you look at in-state tuition at a public university that is cheaper in California than it is even for four year old care, full-time four year old care.   That's really not feasible for many families. They simply cannot afford it. And even if you look at the median family, so this is looking at the median family in California makes about $68,000 a year. To pay for infant care would take about 25%, a full quarter of their budget. So with their budget they have to pay for housing and putting food on the table and healthcare, transportation going to and from work, all the other costs that they have, you're gonna immediately take out a quarter to pay for that infant care. If they only have one kid, they have more, it's gonna be even more. So then there's the flip side. Right now early care and education is funded through low pay. It's essentially the low pay of those workers that allow even the feasibility of those families that can afford those costs. And what we also know, and we've heard this already from Alexander, she's talked about this, that teacher skills, knowledge and well-being are crucial to children's early learning and development. So you need to have those good teachers to have the kind of care that you want for your kids. And yet they're pay in California. The median early educator wage is about $13 an hour. So they're at about the 28th, 30th percentile of all workers in the state. So 70% of California workers are paid more than the typical early educator. And if you compare them to K through 12 teachers, even early educators with at least a bachelor's degree, they're being paid half as much as other educators in the elementary and middle school teachers are being half as much. And we all know that that's kind of a low bar, right? From the teachers striking across the country, we know that pay is already low for teachers with bachelor's degrees or more. So their pay is low. It's not surprising them that they are economically insecure. A study in Alameda County found that 75% of early educators worry about paying their bills, paying for their housing, about halfway about having enough food for their families. These are the teachers that are teaching the youngest children in our country. And they have a lot of economic security. They are far more likely to live in poverty. And early educators that are black are actually a quarter of them are likely to live in poverty. And so those teachers, again, we are giving them a life of economic insecurity. And that low pay is not only bad for those teachers, it's actually bad for the education and care that the children are receiving. So we know that stable care is critical for young children, but low pay fuels turn over among those early educators. Inadequate resources and professional support undermine teacher practice and well-being. So we know the best standards cannot be enacted in a situation like this. So that poor compensation undermines efforts to attract and new teachers can keep skilled ones. It's no different than any other labor market, I'm a labor market economist, it's no different than any other labor market situation you need to pay to attract and retain the highest quality workers. And we are failing at that and we are that drives the turnover, the high turnover rates. That means that kids aren't getting the consistent care that is what the psychologists are gonna say is best for those kids. So what do we need to do? We need to think about what our values are, really. I know it's not something that we often talk about, but I think we need to think about what our values are in terms of providing care for kids. And we need to align the cost with those values that makes those investments that are necessary. So here are six values that we have. Young children, we know, regardless of age or setting, they need well-prepared teachers. To attract and retain those teachers, here we're talking about California, it happens in any state, then we must offer good wages, benefits and working conditions. To provide high quality care and education, you need to make sure you have limited reasonable limits, so reasonable ratios of teachers to children. And also you should have enough staffing so you can have adequate coverage at all times. And you need all times, you need those aren't just eight hours a day, right? Parents need care for their kids for much longer than that. And teachers also need to have time, we call it non-contact time, to make sure that they can prepare lessons, that they can talk to parents when they need to, take care of other professional responsibilities as well as invest in further professional development. You also need to have program administrators and other key personnel. They have to have fair pay and healthy working conditions as well. And you need to think about meeting the increased demand for services anticipated. Do you create a better system for all of these things? You can use the universal care model, you can think about having an ECE system, you can think about what we've done in DC here. So having four year olds, three year olds, what's gonna happen? You're gonna have increased demand. If you've increased demand, you have to increase the pipeline of highly qualified and committed teachers. So all you need to think about that holistically. So then what do we do? We have to answer a bunch of questions to think about how to, this is our methodology, how we are going to actually estimate the costs. And so these are the four basic questions we're looking at. One, how many children are expected to participate in the early care and education system? So you could build a great system and you could think that they will come and there'll be a lot more kids enrolled than there are today and that's likely what will happen because we know that the cost today of not having a very high quality and affordable system has meant that many parents stay home with other kids and that's fine if they wanna choose to stay home. But we also wanna make sure they have the options to stay in the labor force and to have that they need to have an affordable high quality option. So there is a large range in the number of kids that might participate. There's also a large range in estimates based on whether or not kids are gonna choose center-based care or some home-based setting. And so based on those, in all of our estimates, we have a range of costs because of those differences. How many staff are gonna be needed to serve the early care and education system? Again, that depends on which setting we think people are gonna go into and some of the youngest children wind up in home-based settings and those that are closer to school age wind up in center-based care. And so using the research that's already out there, we allocate kids throughout the state into different settings and using the highest standards for ratios for each age. How much should early educators and other staff be paid? There again, we're using state-level data and we're going to equate the salaries of those BA teachers with BA teachers in the elementary and middle school system. I think that that is a... We know that the education of the youngest of kids is very important for kids' mental and academic and emotional development and we should be putting those investments in those teachers as well and we'll have in each of those classrooms, we're gonna have a BA teacher and you'll have an assistant teacher which doesn't have the same education needs. And so we allocate those in the model according to the different size centers that we're gonna be estimating. And then there's obviously non-personal costs. All the costs are not labor, a lot of them are, but rent is the other leading costs and so we look at rental costs within the state of California for either residential for the home-based care or commercial for the center-based care and then other costs, we take information from other models about food and instructional materials, other things that have to be put into that model. So we are trying to be as comprehensive as possible. And so again, there's gonna be a range but our top line numbers for a fully-phased and high-quality comprehensive ECE system in California, it's about $50 billion, it ranges from 30 to 37,000 per child. And the range of costs, as I mentioned, reflects the fact that we have different assumptions about the age and number of kids participating and where they're gonna be participating in the system. And so that may have some shock value, that kind of number, but it is more expensive than a K through 12 system because of those lower ratios and the longer days, the more hours that they have to be open to be present for what parents actually need from those systems. Also, it's more expensive, but you might argue that we don't have enough investment in the K through 12 systems that may be a low bar in terms of comparison. I also wanna point out that our estimates don't take into account how much money is already in the system. So there already are federal, state and local contributions to the system, not nearly enough, I would argue, and we need to look there for additional sources of funding. And then parents are already putting a lot of money into the system, and we need to make it more affordable, but there is money, we are paying for it, one way or the other, we're also paying for it by oftentimes, parents are staying home because they can't afford it, and that has a cost on the economy as well. So there will be substantial returns on this kind of investment. You've heard about some of those already in terms of what the system can do. You're gonna create a skilled and stable ECE workforce that can deliver high quality services and meet growing demand. We're gonna improve children's wellbeing and success with a solid early childhood foundation, remove barriers to work, increase employment and earnings among parents, particularly mothers are the ones who are impacted by that. We can provide benefits to employers from reduced absenteeism and turnover when more stable childcare is in place. So when they have more child, better childcare than parents that are working, we're gonna be even more productive employees. And then you provide that support for education and professional development for early educators that can help address wage disparities within the occupation and relative to teachers of older children. So we can have a little bit more equality there in across the children that are being served. And then you can create opportunities. You're paying more to attract and retain those workers. You can, that can be a better path to a career for many young people who want to be teaching our youngest of children. Just to conclude, let you know what we are, what's coming. So I've talked about our research on California. We are actually actively right now pursuing all the states in the country. We are doing many reports on all of the states. So we'll have estimates just like this across the country in any states that you're interested in. And we are also diving deeper on the money that is already in the early care and education system. We'll be producing these reports and releasing them in early January. Thank you. Good afternoon. There we go. By way of introduction, my name is Robert Espinoza, and I'm the Vice President of Policy at PHI, formerly the Paraprofessional Health Care Institute. For those of you who aren't familiar with PHI, we are a national organization focused on research and consulting to strengthen the direct care workforce, specifically their role in the health care and long-term care system. The philosophy of our work is that when we strengthen the quality of direct care jobs through a variety of measures, we ultimately strengthen the quality of care that all of us receive. This summer, a PHI in collaboration with Caring Across Generations issued a report that looked at how do we strengthen the direct care workforce in state-based social insurance programs focused on LTSS. And I'm going to focus most of my 10 minutes on that report. Direct care workers, by definition, are home care workers and nursing assistants that support older people and people with disabilities with a variety of activities of daily living. There are about 4.5 million workers in the US as of the latest data. In January of this year, PHI released data that showed that by 2026, we'll need to fill about 7.8 million jobs in direct care. And that's caused by a few trends. One is growing demand, caused by growing numbers of older people and increased longevity, but also people who exit the labor force for a variety of reasons, and workers who exit direct care for other sectors, primarily jobs that are paying more than might be offering better workforce supports. Home care in particular is the largest growing job occupation in the country. The vast majority, when you look closely at home care workers, the vast majority of home care workers are women, about 87%. About 62% are people of color. 31% are immigrants, totaling about 1 million immigrants in the sector. And the median age is about 46, although it should be known that one in four direct care workers is aged 55 and older. So it's an increasingly older workforce. One of the reasons that we need to think about strengthening the direct care workforce is that turnover hovers at around 60%. We don't have any reliable workforce data on turnover for a variety of reasons, but our experience shows that that tends to be around 60%. In many states, direct care workers leave the direct care field for retail and fast food as two top industries. These are jobs that pay more, offer more stable schedules, and might be psychologically easier jobs for a variety of reasons. And then there's a widening care gap as well. The growing number of older people is far outpacing the number of working women, which is the primary demographic for these jobs. When we look at what we need to do to strengthen direct care jobs through state-based social insurance programs, our report looked at nine areas in particular for time purposes. I'm gonna zero in really briefly on four of these areas. The first area is increasing compensation. The median wage for direct care workers is around $11, $12 an hour, and too often low wages lead to high poverty and lead to high turnover in the sector. So we argue that when we're developing state-based social insurance programs in LTSS that we should establish wage floors that increase wages for direct care workers and account for that in the revenue that's being generated. We also believe in accounting for benefit cliffs and benefit plateaus. This is a phenomenon among low-wage workers who are eligible for public benefits that if they work past a certain number of hours, the money they receive in public benefits decreases and it disincentivizes workers from working more than a certain number of hours. And we think these measures should really account for those benefit cliffs and benefit plateaus. And also financial literacy and counseling programs that low-wage workers can primarily benefit from. Training requirements across the country are not very strong for this workforce, especially for personal care aides. And we think this is an opportunity to strengthen those requirements, also strengthen the quality of training programs. Too often when we work with states and local providers, local agencies to implement training programs, we find that the quality of those programs is low. They're not adult learner-centered, they're not tested for their ability to actually increase knowledge and skills and confidence in this role. I mean, that's primarily because they're underfunded, so we can think about how to strengthen those programs. Increasingly, can we think about boosting e-learning programs to reach a wider swath of workers across any given state, but also for people who might benefit from these skills in these programs and also create, implement and test role advanced roles in home care where workers can play a more expansive role in the delivery of care through peer mentoring, through supporting people with specialty conditions like dementia or HIV or a variety of increasing challenges. And how can we think about also finally implementing and supporting recruitment and retention efforts? The best way to promote recruitment and retention in this sector is of course by promoting high quality jobs that pay enough. But short of that, there are also a variety of innovations that we think can be supported. Can we commission a statewide study, for example, that would best understand from workers themselves the main reasons they leave this sector and the main reasons that they don't enter it? Can we also form a statewide fund where we would be supporting innovation at the state level among innovators who might have unique ways of boosting both recruitment and retention? And can we establish a state level direct care advocate? In New York City, there is a division of paid care and we argue for these kinds of divisions at the state level as well. Finally, I mentioned that there is a real dearth in data on this workforce. So can we think about how to establish the infrastructure, the data collection infrastructure, to really systematically collect data on the direct care workforce, collecting data on variables like turnover, vacancy rates, compensation and whatnot and telling us in what parts of the state our workforce shortage is the greatest, for example. Can we also use these systems to centralize training and certification systems in these programs? And can we fund original studies on the direct care workforce specifically in areas that are chronically underfunded like the gray market, for example, where consumers are paying for workers out of pocket and off the books but it's a big part of this sector that unfortunately we have very little data on. In closing, I would say that the premise of this approach is really that direct care workers are central to the long-term care system, to the lives of millions and to our economy that quality jobs might actually also create cost effectiveness, not just improved care, that when we think about programs we should think about not just making them more accessible and affordable through social and programs but also be able to access workers on many levels. And how do we finance a long-term care system that is at its core workforce centered? All of this information is available on our website at PHINational.org and shameless plug, follow us on show some media at PHINational. Thank you so much. Great, thank you. Thank you so much for all of those fabulous presentations. Now we have an opportunity to hear from you. Questions that you have, issues that we haven't dealt into, something you've read that we didn't reference yet. We have a couple of mics coming around and we can start there. Hi, thank you. I wanted to say thank you to all of you. This was an incredible presentation and I feel like I learned a lot. I work in the Maryland State Legislature. I'm a staffer for a delegate there and had the privilege to work on attempting to pass paid family leave in Maryland last session and though we have not done it yet, it's coming back this year. But I would love to just kind of hear generally from any of you thoughts that you have or research that you have seen on how to best kind of communicate the benefits versus the costs, right? Because at the state level, budgetary constraints are a very real concern and so in Maryland's case, for instance, we had a difficult time getting past kind of the sticker shock, right, of how much a paid family and medical leave insurance program in Maryland might cost, even though I, and I'm sure everyone in this room, knows the tremendous benefits and the cost saving in the long term. But just sort of if there's any modeling or research or any of you can speak to the kind of how we translate that best at a policy and legislative implementation level. So in terms of modeling, I would say talk to Jeff Hayes. No, Jess, no, don't talk to him. Talk to Jeff after the call, Jeff, after the panel. IWPR has done great work in this area. In general, I mean the key, well there's also research I should mention on paid family and medical leave from Jane Watt-Fogel and others that shows that in states that have had paid family and medical leave for a while in California, that employers do not report any negative consequences from that for their businesses. So that's important. She looked at several states, so that's important. In general, the argument from social insurance perspective is simply that we're already paying for these things, right, just because it's not evident in fiscal budgets doesn't mean we're not paying for it already. And finally, states that we've talked to have said often that there's interest, when you talk about bringing in new revenue through social insurance, a new program with social insurance revenue source would not impact the existing state budget. So right now they're having to cope with a lot of these costs by having Medicaid costs go up or childcare costs become hard to manage for the state. In Washington state today, 6% of the budget goes towards long-term care. The population of people who might need long-term care is doubling in the coming decades. So there's no way they can imagine that going to 12% of their budget, right? So a new program that brings in new revenue in any ways could solve a lot of those problems that they would otherwise have to face through their existing pie of state funds. Yeah, and just to add to that a little bit, because we look at the way, I think there's like the, there are several different ways that these can be funded. So you might have a lot of states, especially for the combined programs that go with either a shared employer and no employee or an employee only cost. But these are often, yes, the sticker shock of the whole thing sounds really big, but when you boil it down to, I think one state it was really harping on the fact that it was the cost of a cup of coffee per week, roughly like it was $2 for employee, right? And when you break it down to that level and say like, what are you gaining from the cost of a cup of coffee a week about the protection that if I had a child, I get eight weeks off to provide care or if my mom gets sick, I get six weeks off to provide care. Putting it in those terms makes it a lot more palatable I think for like folks on the ground because there's like talking to high level wonks, but a lot of legislators are dealing with their constituents and sort of really translated into the terms of like, okay, yes, like it's, you know, X per cent or whatever, but what does that really actually look like? What are you, what are you spending your money on? Where are those, those are things that I think when we actually look at the true kind of real individual person level cost, people are not so stick or shocked anymore. And we've seen that be really successful. And then also from an employer perspective, even when employers are sharing the cost, this is a burden relief on employers because instead of people taking fully covered time off from work that is usually paid for by the employer, it's a state funded, like tax funded system that is completely removing that burden from their pot of money. They don't have to pay that person to take the time off, the state fund pays for it. And so instead of paying for that six weeks of PTO that the person might have, the state is paying for that six weeks of PTO. So it's actually removing a burden on the employer as well. So from both constituent perspectives, there's like really good arguments to be made. Great. Can you just start by introducing yourself, please? Yeah, I'm Gregory DeClay. Here in Washington, of course. Now, key question for today. Since Elizabeth Warren has a plan for everything, how or does she or what is her plan for universal childcare, university family care? And if she does have a plan, will her master plan work? Do you guys want to? All right. I don't, I haven't read all of her plans, but that was supposed to be a joke. There's so many, I don't know how many got that. But I think one of the things that I've, in the early care and education space that I think that she has acknowledged that not everyone has, is that you have to look at all sides of the issue. So it's not just about affordability for families. We have to deal with affordability for families, but she's also talking about the workforce side. And the workforce side is really important. You're hearing that for the care workforce across the spectrum. And I think that you can't, you can't just look at one half of the problem. And I think that, that her plan is trying to achieve that on both sides. Do other comments on that? Yeah. Hello. I'm Rachel Chambers. I'm working with NLC currently kind of trying to look at how technology and innovation is changing workforce and looking at that sort of challenge. Additionally, I'm a master's student at Carnegie Mellon. So as they are rapidly transforming the world with robots, I kind of was curious to see if your research has sort of accounted for in what ways automation can both benefit the workforce that's existing for care, but also how that's potentially challenging models for developing revenue at the state level as the workforce that is contributing to various social services are sort of going to be at least in projected in many models constrained by the lack of workers paying into it as a result of a decrease in jobs over the next 20 to 50 years. And I was wondering if you were looking into that or could speak to that at all. Did you want to? Yeah. I don't think robots are taking over, but I'll get more in a second. Yeah. Yeah, I think it's a big question. A few reactions that come to mind. One is that there's research that's been done, I think, looking at the ways in which automation is distinctly affecting women workers. And in the direct care sector, where women make up 80% to 90% of that sector, it's clearly a fear. And we've been seeing at least anecdotally through the work that we've been doing with providers, it's changing the way in which care is being delivered. It's changing the nature of job. It's displacing a certain percentage of workers and then it's completely changing the jobs for people who remain, right? And unfortunately, what we're not seeing enough of are workers informing the design of automation and getting a sense of what really can work for both as a worker but also for the clients they're supporting. We're also not seeing enough testing of technology. I think there's a kind of a wild, wild west of innovators implementing technologies both for altruistic purposes but also for profit. And it's not being tested or screened or regulated. And it's quite frightening, especially in the mobile app world. The pieces that I would say though is taking away from automation and more technology, there are a number of ways in which technology can support at least direct care workers and the quality of care. And the ones we highlight, one are in advanced roles where workers are playing a more expansive role in the delivery of care at home. The use of mobile devices and technologies can really be used to better communicate changes in clients' conditions, observe a recording report at a heightened level, and also better integrate the worker in the full care team so that they're communicating with the physicians, the social workers, the family, and more. We're also seeing e-learning as a promising strategy, as technology. And we're also seeing the development of what are called matching service registries or caregiver registries where states fund and develop these online job platforms where consumers can better find workers and workers can better find consumers based on their preferences, their needs, and their availability. So I do think it holds promise. I think it's great when you think about how technology can enhance the quality of services. I guess my quick off-the-cuff response was based on two things. One is that if we were thinking that technology was, those investments were being made, we would be seeing much higher productivity growth right now and we're not seeing that. So I'd say when I think about the labor market in general, we're not seeing that. Another piece of data I'd point to is that when we look at jobs of the future, when we look at what jobs are gonna be, the Bureau of Labor Statistics projects the fastest growing jobs in the next 10 years, there are these type of jobs, right? So they're care jobs, they're restaurant workers also, they're a lot of lower paid industries, so home health aids and such. So I think that those jobs directly, you weren't suggesting it, but those jobs directly are not at risk in that sense. I think about when you say there may be fewer jobs and we can think about how we wanna construct our economic system, that's a whole nother question, which I'm happy to have a discussion about now. If I can add to that, I would echo everything that's been said but also add that it's important that we think not just about innovation in terms of technology, but also innovation in terms of public policy and we're very good at innovating in terms of technology. We don't innovate in public policy very often in adopting, considering an idea like universal family care that would be a paradigm shift in the way we approach care from a private responsibility to something that we address collectively is also innovation, not technological innovation but public policy innovation and I think we need to focus on that as well. It's Paul Bergeron, I work for the National Apartment Association. At the beginning of your presentation today, you mentioned some of the programs that are existing now, I think Head Start was mentioned and some of the participation rates of people who were eligible were kinda low and I'm just kinda curious what could and should be done to encourage participating in existing programs if a program as comprehensive as this doesn't get far forward. Yeah, that's a great question. The answer's pretty simple, there's no money. That's, it's not a question of getting people to want to participate, it's a question of the line, the waiting list, the amount of money that's been invested in those programs and especially with federal funding, it can be unpredictable as we've seen in recent years. And investments go up and down and we just, it's been learned that you often can't rely on those things, things that are not universal, don't get as robustly consistent funding as things that are universal so I think one of the things to consider when you're looking at the policy options is the investment that the public is going to perceive in that thing and when everybody doesn't feel like they are part of a program or they benefit, those tend to be very voluntarily funded programs. When a program is a buy-in from everyone, there is some perceived benefit for society and those can be much more consistently and robustly funded, especially when you're talking about something that has a consistent payroll tax rate, for example, like social security or Medicare that have long had this universal, everyone is involved kind of perspective. So I think that that's really my answer to your question. Hi, this has been fascinating, thank you very much. My name is Mindy Reiser, I'm a sociologist. I've been long involved with the DC chapter of the Labor and Employment Relations Association, DC Lyra, I hope some of you will come to our monthly meetings and programs. Okay, the end of commercial. Robert, really fascinating what you've been talking about, I'd like to know more about what kind of training options there are for home health care workers, how they find out about them, their duration, their quality, where you see this going. I can say now I have two friends who are working with home health care aids, I really don't know what the background of these people are. And again, they're subject to all kinds of medical challenges, lifting up people, how do they learn how to even do these things properly so they don't really damage their own health? Yeah, it's another big question. A few reactions, one is that the level of training for direct care workers varies by state and it varies by occupation for the most part and a number of other factors, right?  If you're a personal care aid and you're not handling the clinical task, there is no federal requirement. And no state for personal care aids goes past 40 hours and many states it's a handful of hours. So depending on that occupation and what state you live in, that's kind of the legal framework, the standards, so to speak. They also vary by employer. And so within a state, where do you go to find a worker and find out how they're trained?  What does the workforce look like? What does the program look like? We found that even in states where there is better regulation and higher requirements and stronger funding for programs, oftentimes we'll go to at the employer level and we'll see training programs that are just so poor in quality in terms of how the content is being delivered. They're not being tested. It's really trying to just meet a basic need. And when you speak to the employer about why that is, some of it's no-how. The other is kind of financial pressure. They feel there's a concern around that. And the third reason is the sense that if turnover is so high already, 60% or higher, why would you invest in training so much at the front end if there's a good chance that within three months our workers will leave, right? And so that's kind of a perverse incentive, a cycle that challenges providers and ultimately workers and clients from receiving the kind of quality training. There's a whole lot of other dimensions, but I'm happy to talk more offline. I think hopefully it's for the better. I mean, I think there's a variety of reasons why we should be training workers at a higher level. You know, the training a consumer should feel that the worker is equipped with the right skills and knowledge and confidence. People are living longer, increased longevity, so there's a pressure for getting training. You're seeing higher rates of certain conditions like dementia, cardiovascular disease, special populations like LGBT, people of color, et cetera, and all of them are really demanding higher levels of training and advocating for that. So I'm hoping that that creates the groundswell to convince policymakers to change that and employers. The challenge will always come down to cost, and that's why I think a state-based social insurance program is so important and why those programs should account for training is that providers will say, look, I can afford to train my workforce for 10 hours from the beginning, 75 hours in a way, 120 hours, which is the National Academy of Medicine's recommendation, absolutely not, right? And so how do we create both cost-effective and effective training programs, but also how do we boost the state to fund that? I think that's gonna be the main dilemma for states to grapple with, yeah. My name is Eleanor Lacane. I'm the policy director for a presidential candidate. I'm very interested in this integrated universal family care plan. It's like a bold and big and important approach. It's fascinating. And it seems like it could really work for people in the sense that it simplifies, here's your one point of entry, and then we work out all the details to help that family. It also could work from the delivery side because this whole workforce problem we have, we've got to be able to recruit, retain, and train care workers for the children, for home care. We've already got shortages in Maine and Iowa and other places, so this is a big issue, and it could be a big, bold answer for how to solve that problem. I have two questions. One is, is this integrated family care actually operational anywhere right now, like which countries have it? What are the best models that are out there now? And secondly, do we have an operational plan now if the next president said, I want universal family care, you have a plan that we could put into motion? I could take that. So first of all, is it operational? No, it's not operational anywhere in the world yet, but we've certainly, we have a 320 page report that outlines how it could be done. It's well thought through. I did an interview last week with a German newspaper on this topic, and they were flabbergasted that the United States could leapfrog them and become the avant-garde of social policy worldwide, so they didn't expect that. I would say that Washington State has passed a paid family medical leave program last year, social insurance program for paid family medical leave. This year they passed a long-term care social insurance program, so it's two of the three legs, and they also have one of the best child care systems in the country and have a goal for themselves to have universal child care by 2025. So Washington State could be the state that gets there first, and interestingly, I was just doing a site visit out there a couple of weeks ago, the paid leave program is a year ahead of the long-term care program there, so they already have a website that they're developing, and the long-term care program now is trying to leverage that website infrastructure for their program. So they're already trying to figure out how they can work together, and they both have the Department of Employment Security in Washington State administering parts of their programs, both programs. So they're already starting to think about this, but yes, we absolutely have thought that through and it could be operational. The best models, again, Washington State would be the best place to look. Several other states are considering this right now. I'm meeting regularly with different states who are considering this, so this could be something that runs, that becomes a piece of legislation next year, the year after in several states. Could the next president implement this? Absolutely, I mean, it's, we already know how to do paid family medical leave. We've known how to do that for a long time. It's been existing, since the 1940s, we've had temporary disability insurance, which is paid medical leave, and we've had paid family leave since around 2000. We know how to do social insurance for LTSS. Six other countries do it already. Washington State's doing it now. And affordable childcare is the missing piece, but it's not hard how to imagine adding that to the other two. So absolutely this could be operational for the next president. Is, yeah, so I'm Fran Hoffman, and sociologist, and I work with Capitol Hill Village, the advocacy committee very interested in workforce. So I've been quite interested in your presentations. This is a question probably for Robert, just about the state of Maine. There was a ballot initiative in 2018, I believe, for universal home care that did not pass. But could you talk about that initiative in the context of what you've been discussing today? That was actually my organization that worked on the ballot initiative, so I can take that, working with Maine People's Alliance. Sure, that was a very ambitious initiative for universal home care that have covered everyone right off the bat with no duration, temporal duration on the duration of care, and it wouldn't require investing. So it would have been very expensive because of that. It would have been about five times as expensive as the Washington State program because it was very generous. So, and the funding mechanism was two tax earnings above the social security tax cap threshold, the payroll tax rate applied just to that population. So it was a unique proposal, different from the ones we've talked about today, but it didn't pass. But like I said, it did pass in Washington State a couple of years later with a funding mechanism that was more universal in scope and a more modest benefit, yeah. I'm Debbie Weinstein. I'm with the Coalition on Human Needs and thank everyone for talking about, excuse me, this extremely important topic. I wanna take a very brief page from Caring Crest Generations and the way you lift up personal experiences since so many of us have those. In my own experience, caring for my father before his death, two extremely wonderful caregivers were afterwards basically driven out of the field because they couldn't afford to stay in it. And then being sandwich generation, like seeing my daughter and grandchildren struggle with childcare costs, early childhood education costs. I'm certainly a person who would be very eager to see ballot initiatives or action to pass the kinds of things you're talking about. So I'm hoping you can tell a little bit about, and you did start to just now, about the kinds of experiences where states were either able to or not able to enact these moves forward, what was learned about the arguments that bring forth a movement to actually get the enactment what we can learn so we can do it in more places, thanks. So, I mean, a social insurance framing is a very powerful framing. In Maine, we didn't have that framing and I think it made it harder to have the conversation. I think the most compelling case, really what we're talking about here is just a paradigm shift. It's like flipping a switch. It's a very simple switch, which is that rather this is not the old paradigm that state home caregivers handle this or that we can all afford to pay for it out of pocket. We all know it's not true and it has been true for a long time. This is no longer a private responsibility or that we can handle on our own or we shouldn't even be handling it on our own. All families need professional care support so that we can optimally balance our work and care in a way that makes sense for our families and for our loved ones. That's the paradigm shift. I think with a universal social insurance approach, when you talk to people, you can say, look, we're all struggling with this now. Let's solve this problem together. Let's all pay into a fund. It's a modest contribution. The one I mentioned, our preliminary cost estimate would have been $79 a month for the typical family for universal family care would fund the benefit. Let's solve this together. And so I think that's a narrative frame that works well. If I can just, from a state perspective, looking at a lot of the paid family leave battles and I think that the UFC battle is kind of just a grander version of some of those battles, the things that I've seen be successful in that space are the unity of the movement. So the many voices coming together and fighting for something. So rather than pitting employers against workers or families against their labor force participation, it's about getting all stakeholders at the table and kind of reminding folks that this is an investment that benefits all of us. And I think universal family care is an even more, is an even better example of that than paid family leave in and of itself because there you're talking about a workforce-only issue rather than the entirety of a state, really, when you think about adding in childcare and elder care and care for folks with disabilities. We're talking about an investment in the kind of the betterment of society and when all of those stakeholders come to the table and can agree that this is an important issue, that's when I think we've started to see movement really work. It's what made it work in DC. I know when we were talking with folks here and working on that movement, it's what I've seen work in other places and where we get held up and where things are unsuccessful is where we don't see it as a unified vision or a collective thing that we're working towards together but or we're gonna tax this group over here or we're only gonna talk about this issue, we're gonna leave out these people. The more exceptions and pulling out that we start to do the less robust, the less successful that program is gonna be because people don't see it as a shared benefit or a shared vision. It's, oh, it's only for those folks over there. So that's my insight. That's great. Oh, I'm sorry. So I was gonna say, why don't we take one or two more questions? Maybe we can take them in a row and then we can just do one last, go around down the line. Les Robert, you want to throw in one more? Okay, great, thanks. Hello, my name is Soraya Tose. I'm with Ascend at the Aspen Institute and I'll make my, I really love this presentation, great information. The question I had, one of the things we talk about is what we call the childcare conundrum.  So in your studies or implementing it, how have you seen, because you pointed out that you would factor in higher pay for childcare workers but how do you ensure they get a higher pay? Would there be, you know, a floor or how would that work in a program? Yeah, so we've thought about this a lot and both for the childcare and the direct care side. I mean, there's a couple of ways. One is, you know, with the social insurance program you have a trust fund, with a trust fund you have a trust fund board. You can have, you know, participate, stakeholder participation on that trust fund board. Workers, employers, beneficiaries or contributors could all be represented on there to have a stake, to have a voice in shaping the program. You can have a minimum wage for the workforce. You could have, you know, as Robert was talking about, different levels ladder, different steps on the ladder, the career ladder for those workforces with different certification requirements and different wage levels. Most importantly, you can have a requirement in order to be reimbursed by the state program for direct, as a direct care worker or a childcare worker. In order for his agency or employer to reimbursed for providing services, they have to meet these job quality standards. So no provider could participate in the public program unless they met the job quality standards. That's a strong lever in a new program. Washington State is using that lever in their new law-term care program to make sure that they're good quality jobs. Yeah, I think one of the things that we've seen is sometimes states have requirements but don't have money behind it. So it's really important that the money is behind it so that they can meet those qualifications and those requirements and have that be fully funded. I think we have one last question. Thank you. This has been really wonderful. My name is Nils Franco. I'm with the Altarum Institute. We've been focusing at the program to improve elder care on long-term care insurance and looking at a tripling of the oldest old 85-plus population between now and 2050 with only 10% if we're being generous of Americans who are insured for these incredible costs which are averaging for those who need it, $266,000. And so I'm curious about how the federal government can step in and sort of structure their own activities better so that the savings that you're discussing from these programs can be shared with the states, can be allocated appropriately or optimally with Medicaid or what have you. I guess what you're saying is if there were... If you introduced a new social insurance program how could that relieve the pressure on the states and so forth? I mean, you'd be bringing in new revenue to fund the new program presumably, right? And that would fund the new program and that would then relieve the burden on the state Medicaid budgets as well as the federal Medicaid budget which would then relieve the burden to tax to fund those programs. So what you'd be doing is creating a contributory social insurance pool to fund this new program which would then relieve a lot of the burden on the existing programs. That said, some Medicaid LTSS would still be necessary as people with severe disabilities need more generous care than a program like this would provide. So some of Medicaid LTSS would need to remain in place. And I think though the other thing in terms of what can the federal government do, I mean, there's a couple of really messy things about the way our system currently exists and the way that it currently exists is that you must get to a point of crisis before you get help. Like, let's be honest about that. And so instead of waiting until things are beyond catastrophic cost, if we were investing in earlier interventions or if we were making sure every state had home care, not just some of them, it wasn't just a waiver, every state had access to home care. Those are huge cost saving mechanisms. It could be half as much as an institutional care. We're placing many folks in institutions that don't need to be because they have literally no other options in their states. So we wanna think about ways that the federal structure is holding back, long-term care in particular, but really things in general where we're putting these kind of roadblocks to like, okay, you can't get care until you're like actually in crisis. Well, that's your problem. Now that is a way more expensive care than it would have been if we had put a handlebar in that person's house in their shower before they fell or whatever those things are, right? So those social determinants, those preventative costs that are hard to see the benefit of because public health is the invisible thing that we don't notice until it happens, until it becomes a problem, that's where you wanna see your money in my... Thank you so much.  Thank you so much. And for all of you who are sticking with us and don't forget to get your copy of their important study.