Hawaii and the nation have made progress in caring for children, seniors and others in need, but there is much more that can be done, starting with paid family medical leave.
Editor’s note: The Civil Beat Editorial Board and reporters spoke on Thursday with Deborah Zysman, Executive Director for Hawaii Children’s Action Network and Hawaii Childrenʻs Action Network Speaks!, and Ai-jen Poo, executive director of the New York City-based Caring Across Generations and president of the National Domestic Workers Alliance. Poo was in Honolulu last week. This interview has been edited for length and clarity. The care advocates began by explaining the work of their respective organizations.
Zysman: Hawaii Children’s Action Network is a local-based nonprofit. We have friends in other states, but everything about us is local across the state. We work on child and family issues fairly broadly, but it runs the gamut. Our work goes back about 25 years. We started in early education. We now work across the board on education, health, a lot on economic and social justice. We drive all of our work really through a lens of equity.
I would say we’re doing a lot more organizing than perhaps we used to. We have done more policy-wonky work for a while and we are now doing a lot more parent voice, parent organizing and also kind of coalition building. The Hawaii Children’s Action Network Speaks!, which is our 501(c)4 arm, does more of our political work as we’re gearing up for 2024. Since I’m here with Ai-jen, I would say we’re doing a lot more organizing than perhaps we used to.
Poo: The National Domestic Workers Alliance represents the 2.2 million nannies, house cleaners and home care workers around the country who work inside the private home context. We call it the work that “makes all other work possible” because the workforce makes it possible for every family that they support to do what they do in the world. But it’s also some of the most undervalued and insecure work in our entire economy. And so our organization advocates to make sure that the jobs can actually become secure — good jobs where you earn family sustaining wages and have dignity and respect at work.
Caring Across Generations was started by the National Domestic Workers Alliance and a group called Jobs With Justice back in 2011, looking at the reality that with a growing aging population in this country, there’s going to be a growing need for care on the part of families on all sides of the generational spectrum, and that it was an opportunity to both improve the quality of jobs in the care economy, like domestic-work jobs, home-care jobs, child-care jobs, and to expand access to affordable quality care, child care, paid family and medical leave for people who are caring for loved ones, and also aging and disability care. (It involves) actually enacting a set of policies and programs that would support us to take care of our families across the lifespan.
It is said that our care system is broken, and that’s a major reason that you’re here today. I wonder if both of you might just start talking about what you mean when you say the care system is broken.
Poo: Every year, 4 million people turn 65 in our country and 4 million babies are born, as millennials are having families now. And we’re the most age-diverse country in the world. And we have not created systems like universal child care, paid family and medical leave or long-term care. So most of our systems that support caregiving in this country are a means-tested patchwork. And then the workforce that we have is severely underpaid and undervalued. We have high rates of turnover. So instead of a kind of safety net and infrastructure for care in this country, what we have is a patchwork system and 53 million overstretched family caregivers and 9 million or so underpaid care workers who are majority women of color.
And so I would say that it’s not sustainable for anyone. It’s very costly for families and the workforce is living in poverty. We really struggle to get good access to good care, whether it’s child care, aging and disability care. And to be eligible for some of the publicly funded programs, we have to be extremely impoverished. So working poor, working-class people are not eligible for many of the programs because they earn too much money.
Deborah, what is the local view?
Zysman: From where we sit it’s a big issue of why we’re seeing outmigration of the workers. Right? We’re seeing folks in what’s called the panini generation. They have elder care or they have child care or they are getting squeezed horribly in the middle. When we work and reach out with families, the major things that we hear are difficulty in staying here, wanting to stay and live and work here, but difficulty largely due to high cost of living, which is often housing coupled with high costs of care. Child care is incredibly expensive. (Parents) want time with their families, but they’re working two, three jobs, the gig on the side, or they’re contemplating moving elsewhere where that equation balances out better, right? Pay is higher. There’s more systems in place that we’ve built in other states for more affordable child care somewhere else. There is paid family leave in other states.
So it’s pretty broken here, and I think you folks know, as you talk across every sector of the workforce that I talk to right now is desperate for employees. And we don’t have this infrastructure to help support the employees, regardless of the sector that they’re in.
In 2021 it’s estimated that about 35,000 residents from Hawaii moved to states where they had paid leave laws. Why don’t we have a paid leave law here in Hawaii?
Do you understand how paid leave laws work?
Tell us a little bit.
We have 13 states now (with paid leave). California put their policy in place about 20 years ago. We’ve seen a rapid increase in the number of states with paid family leave in the last five. And I know a number of states are contemplating it in their upcoming legislative sessions. We are not alone. We’ve been having conversations about it for, I would say, at least 15 years.
The way it works in the states that have them — there’s a few variations, but they’re kind of all the same-ish how they’re run — which is that everyone pays in to a type of insurance fund. You sort of socialize the risk on it. Payroll deduction where employees pay in, employers paying similar to what we do in, say, Social Security, or we currently in Hawaii do with (Temporary Disability Insurance).
Who pays what percentage varies state by state. Generally in states it is their version of Department of Labor that is administering this program. That’s what we are hoping for in (Hawaii), because they also manage unemployment. Theoretically, they do enforcement for TDI.
And then the way it works is when you do need major medical leave for birth or adoption of a new baby -— this is not “I’m sick. I need a day off” — and then it is like an insurance claim, right? It comes with Medicaid, you have to submit a bunch of paperwork in those other states with medical sign-off on the claim, and then it’s a percentage payout of what you made in the last year. We would be advocating (in Hawaii) for it to be progressive so that higher-wage workers are paid a lower amount with a cap — like a lower percentage — and the lowest wage workers might get, you know, 90% so they can actually afford to take that. The idea is that it’s a safety net.
We work a lot on the ALICE population (Asset Limited, Income Constrained, Employed). The majority of our families are now living paycheck to paycheck. You have no savings or very limited savings, right? So where we see folks needing a safety net that does not exist, it’s often when it’s a medical event — the husband gets the cancer diagnosis and there’s a baby in the family and then all of a sudden they have to scramble to take off from work. At best, they might have unpaid leave. There’s not a guarantee for most of our workers that they would have unpaid leave. They may have to go begging with an empty hand — unless you’re under the Family and Medical Leave Act, but those are for larger employers. A lot of our companies are small, so they’re not covered under the FMLA and most of our families can’t take unpaid leave.
So what we see happens is that folks quit. Maybe they have an employer that is kind and will give them unpaid time off, and then they max out their credit cards. They drain their 401(k), if they had anything, they could drain their savings. So the idea of that safety net is you take the time off you need for your new baby. You go to L.A. for your cancer care. You come back after your set amount of weeks and you return to your job and you haven’t gone bankrupt in the process.
Do you want to chime in with anything, Ai-jen?
Poo: I would say that more broadly than just paid family medical leave, one of the things that happened I think before the pandemic, most people thought about caregiving as kind of more of a personal responsibility to be managed in our families, mostly by the women in our families. And if we struggled to afford it or manage it for whatever reason, we considered it a personal failure, like “We don’t have the right job or we didn’t buy the right long-term care insurance” or any number of things that we tell ourselves as opposed to kind of a system failure. But I think what happened in the pandemic is that people realized that we can be doing the very best we can, and it’s not sufficient because this is actually a societal need, right?
It’s almost like infrastructure, bridges and tunnels and broadband. It’s part of what makes our economy function, our society function — having access to care. Especially when we’re living in a time when 70% of young children are growing up in households where all the adults in the household have to work outside the home to make ends meet. It just doesn’t work without a care infrastructure.
It’s as if care work makes all other work possible. Is that kind of overstating it?
No, that’s exactly, exactly right.
And conversely, if you don’t have care work …
So in Covid, in between April and May of 2020, when the shutdown happened, 4 million women left the workforce in a span of two months, largely due to caregiving challenges. And so we realized that this is actually a collective need that we have as a country and a societal responsibility that we have to create these systems. We’ve been doing this advocacy for many, many years. But in the context of the pandemic, the movement really exploded and we saw so many champions step forward. And Congress and President Biden made the care economy and the care agenda core to his economic agenda for the first time. In the past it’s always been “the women’s agenda, the children’s agenda,” right? The family economic agenda.
This time with this administration in the context of the pandemic, it became one of the four pillars of the economic agenda. And it included big generational investments in child care and included the establishment of a national paid family and medical leave program. And it included a massive investment in access to home care, in particular for older adults and people with disabilities, and the ability to raise wages for the home care workforce, which is a big problem because we have about a 30% turnover rate. The average wage is $23,000 a year. So it’s hard to imagine sustaining for very long.
I think the figure that was given to me — and these are Hawaii stats only — child care providers are making between 13 and 17 bucks an hour.
Zysman: And that was from last year. The University of Hawaii worked with RAND (Corporation) to do a worker’s study, and, depending on where they are in the state, it’s $13 to $17.
I just want to ask for clarification because I’m doing a quick Google search. And there’s an article which says as of January 2023, a bunch of states including Hawaii have laws that mandate paid leave for an employee’s own serious health condition or disability.
So we currently have Temporary Disability Insurance. It’s fairly limited what we have. In theory, with the Department of Labor, it is an employer mandate. I run a nonprofit, so I have to buy TDI insurance for my employees. It’s a percentage of payroll. There is very little enforcement over it, which is supposed to happen. The Department of Labor is supposed to enforce. So we hear frequently from people in the workforce that they didn’t have it, they didn’t know they had it because it’s privately run and it says employers should purchase it.
So for example when I gave birth to both of my kids, I qualified for five weeks of TDI. That’s it. And so you put in the claim — partial pay for five weeks — and nothing for my spouse because it’s considered my own disability. There’s nothing if you’re an adoptive parent, there’s nothing if you used a surrogate, there’s nothing for parental and there’s nothing then for kupuna caregiving, or for a spouse. It’s literally your own disability. And pregnancy is considered a disability in the state, or childbirth. I have to tell this to my employees.
Okay. So how do you get around that?
What we’re proposing is that a new policy or new law would encompass TDI. We would have the Department of Labor run all of it combined. It would continue to be for your own disability, which is how it’s run in the other states.
You have a governor who’s a medical doctor and probably is sympathetic to medical needs, who’s also a parent of two kids as well. This is going to come in the form of legislation in the 2024 session, correct?
Yeah. We’re working with the labor (committee) chairs and leadership, kind of shopping some of the details around what it would look like. We will likely put in for as comprehensive a benefit as possible — you know, as much pay — because, again, we come at it from the perspective of families and what families need, and likely as many weeks as we think we can get away with. We are looking at the range of, I don’t know, 12 to 20 weeks. I don’t know at this point, but we’re having these conversations.
What other countries do better than we do on paid family leave?
Poo: There are only three countries in the world who don’t have it. It’s us, Papua New Guinea and one other place that doesn’t have a national paid family medical leave mandate. Most states have no program. Some states have put programs in place, which is what we’re hoping Hawaii will do. But on average in the country, because we don’t have this program, one out of every four mothers returns to work within two weeks of giving birth.
Wow. That’s just amazing to me.
Deborah, because we were talking about outmigration and about the pressure on people for child and dependent care, I wonder if you could talk a little bit about how House Bill 954 (now law) in terms of the earned income tax credit and whether you think that’s going to have any effect on the pressure on low-income families.
Zysman: It sounds like you already know what the legislation is, but we have doubled the earned income tax credit. It will start this coming tax year for the next five years. In the year prior, it was made permanent, but the bump up will sunset, if that makes sense. So it will go back down. It’s still decent. We’re very proud of working to pass that because these are all pieces of the same issue, which is the economic sustainability and justice of families, what they need. So the earned income tax credit, especially for the ones who benefit the most, are single parents, mothers most of the time, because it’s refundable. So even if you have zero tax liability in Hawaii, you will get cash back. It is so great to just put cash in people’s wallets to put back into our local economy and all of those things.
Will it impact the outmigration? I don’t know. We will see. Part of it I think it is just the sustainability of it. It can’t hurt. But it’s not every family getting an earned income tax credit back. Everybody is struggling with the lack of child care and the lack of time off for caregiving. So, we need all of it, if that makes sense.
It was trimmed down substantially from the initial vision, right?
So are you trying to get some sort of permanence to those kinds of things or expand them?
Oh, 100%. 100%. I think this coming year, because we just helped lead the work to lift the minimum wage. We just two years in a row sweetened the earned income tax credit. We also lifted the food tax credit, and this year we’re going back in to do some housekeeping. There’s a child and dependent care tax credit, but it got messed up in the cattle call at the end (of the 2023 legislative session). So we’re going to fix that.
We’re probably not going to have more tax credits this coming year because we’ve worked heavily on that for the last three. You have got to pace yourself at the Legislature. We got these wins, but let them go into effect, see how they’re going. I know one of the conversations we’re having with some of our coalition partners is continuing to bump the earned income tax credit to try to see if we can work with Department of Taxation to give that credit out more frequently, because that was one of the things we were trying to negotiate but we’re not able to win, because right now you’re just going to get a big check back in April.
But families need to pay rent every single month and pay for any type of child care every single month. And that’s how when we had the federal child tax credit, which functionally is pretty much the same as an earned income tax credit for Department of Taxation purposes, the nice thing about that structure was the IRS was sending money every month.
But I do think that is something we’d like to look at. Can we bring it up even higher, because it’s still hitting pretty low-income families and not really reaching the needs of even ALICE families or higher Alice families who owe a lot? It’s hugely needed. I mean, we fought hard for it, right? It is enormously needed, but it is definitely targeted at lower-income families. The child and dependent care tax credit would hit those higher income families that are paying for it.
But again, it would have to then be families that have enough income that they can pay the child care, pay the primary care, and wait a full year plus to get back some of it later. Not a bad thing, but we actually would prefer to see the investment upfront in free or affordable child care and kupuna care. Otherwise, you’re having to loan the government money for it.
Ai-jen, you are in town to give a talk at UH, “From the Crisis Economy to the Care Economy.” Can you give us a summary?
Poo: Yeah. The message is that we’re in a generational moment for a change in the care economy. This is the opportunity we have to establish the kinds of policies and programs that will help us sustain an economy for the next era where we have a much older workforce, where we have more need for care than ever before. This is our moment and we have momentum coming out of Covid. People are really aware now that this is a societal issue that we have and states around the country are taking initiative.
Washington State launched a long-term care benefit. That’s a social insurance program called WA Cares. New Mexico passed a ballot initiative to permanently fund child care in its state budget. We’re hoping paid family medical leave happens (in Hawaii). And this momentum from the states is really part of a national groundswell where we are in this moment of really resetting our economic framework and the care economy to support families for this next era.
You mentioned four blue states. Was this awareness learned and understood by red states as well? Did they start getting the message, too, that this is a moment here?
I think so. One thing that happened was, if you remember the American Rescue Plan, really sweeping legislation to stabilize as much as possible coming out of Covid. And there was a big investment in Medicaid that was specifically to stabilize home care, access to home and community based services for older adults and people with disabilities. There was $12.7 billion that was earmarked for that. And that fund, because it’s Medicaid, it’s matched by the federal government.
And so there was a fear because it is Medicaid and because of how partisan the Affordable Care Act Medicaid expansion was around the country, that Republican states wouldn’t take the funds. All 50 states applied to receive funds and all 50 states have received funds through Medicaid, home and communities through that American Rescue Plan. So it is clear that every state knows that they have to invest in care.
Now, their approaches are going to be different. To what extent they think it should be publicly supported is obviously all over the map, but especially when it comes to home care for older adults and people with disabilities, there is broad bipartisan support because so many of these red states have really quickly growing aging population and they don’t have any home care infrastructure. It’s all nursing home care.
There will always be a need for nursing homes. But the vast majority of older adults right now would prefer to age at home and in the community. But there’s no workforce, there’s no infrastructure, and especially in a lot of the red states. And so this is going to be a real challenge. And home care costs a third of what nursing home care costs in the Medicaid program. So from a fiscally conservative point of view, investing in your home care infrastructure is actually a way smarter way to go.
How much does it cost on average nationally for nursing home care?
If you pay out of pocket for, for example, a nursing home, a room in a nursing home, it’s on average $90,000 a year.
That’s thousands of dollars a month, at least.
And higher in Hawaii, I’m guessing, because of the general cost of living.
Right. And the average income of an American worker in 2023 is just under $60,000 a year. So the numbers just don’t add up.
You’re talking about these benefits, which need to be stronger to attract workers. How do you attract workers?
You do have to raise the wages. They have to be better jobs. There’s no way around it. Right now, they are poverty-wage jobs. Their profession is to take care of our families, but they can’t take care of their own on the incomes that they earn. So that has to change.
And actually, I think it’s such an interesting opportunity because these are jobs that can’t be outsourced or automated. We know we’re going to need them for the foreseeable future. If we invested in them becoming good jobs, some economists are predicting that if you take child care and direct care jobs combined, it will represent the largest occupational category in the entire U.S. workforce because of displacement of other jobs by technology and AI and the like.
Now, manufacturing jobs used to be poverty-wage jobs. They used to be dangerous sweatshop jobs that immigrants did. And then they became the largest on-ramp to the middle class in the history of the world. That’s what could happen for care jobs if we invested in them. The way that we pay for care now is so costly and inefficient. If we leaned into building policies and frameworks that were modernized, updated, and focused on making the jobs good jobs, it would mean it could be revolutionary in the best of ways.
And this is not easy work.
No, no. And you have states that are passing wage boards that mandate a minimum of $15 an hour for fast food.
Zysman: And on both ends of the spectrum, we frequently want folks with at least a college degree. And now you have a college degree and you’re making $12 an hour and you have debt from that. That’s the piece we’re working on continuing at the Legislature. And you cannot just charge families more. That’s where the market is flawed in this, right? We can’t lift child care wages by charging families more because, in this state, it’s already costing $1,100 to $1,800 a month for child care.
We just talked about ALICE, right? They’re not making enough to live anyway. How do we charge a family more than $1,800 a month? But when you’re talking infant care, one worker’s supposed to have two to three infants. It is in some ways more costly than, say, a daily classroom, where my fifth grader has a classroom with 23, 24 kids in it and one teacher. You cannot do that with infants and toddlers, nor can you do it with seniors that are needing intensive care. So this is where the market is flawed. So you cannot charge families more. And that’s why the wages are so compressed.
Poo: Whenever we increase the reimbursement rates, for example, through Medicaid, because there’s no requirement that a set percentage of those rates have to go to the worker’s wages, then oftentimes they don’t. So even when rates go up, wages might not. And that’s part of what needs to get reorganized. And actually the Department of Health and Human Services at the federal level is trying to do some of that right now. But it is having the wages and not having to pass the cost on to families, because families are really at their limit.
Zysman: So that’s where in the child care and pre-K space, the way we have structured it — and we’ve worked with the Department of Human Services — are two proposals that we’re bringing. One is new and one we’re bringing back this year. The first one is that the Department Human Services would directly supplement salary, because we have child care workers registered there. There’s a registry. We know who they are. We know where they live. We know what their educational attainment is because it’s a regulated industry. The Department of Human Services would directly pay additional supplemental wages to those workers as a pilot (program). So the families are still paying.
And the other proposal we’re working on currently with the lieutenant governor is to have the Department of Human Services begin full classroom contracting for child care. You have Kamaaina Kids or a KCAA Preschools of Hawaii, and DHS would say, great, we have a (request for proposals) out, we’re looking for providers.
I don’t know yet if it’s going to be infants and toddlers or older kids — we’d like both — but we’re going to try to get a pilot to get it off the ground, and you’re going to run a full classroom for however many children it will end up being. And then you can also lift wages, because in that contract you can say, “We want to have the lead teacher have at least a bachelor’s-level degree.” Pay needs to be at this level to lift it up, right? It’s more money that you’re putting into the system.
I wanted to follow up and just talk a little bit about the racial equity dimension to the domestic workforce, given the representation of primarily women of color. This is also, I assume, an important dimension to efforts to kind of raise raise wages in that sector. It’s also related to both poverty but also racial equity.
Poo: That’s right. That’s right. It is. Domestic workers are majority women of color. Black women, Latinas are disproportionately represented in both child care and in direct care in the publicly funded programs as well. I think 33%, for example, of the home-care workforce is Black women. And so definitely women of color are overrepresented.
And so if we were to make these jobs good jobs — for example, there was a bill that passed through the House of Representatives that eventually became the Inflation Reduction Act, the budget reconciliation bill. The version of that that passed the House included $150 billion for Medicaid home- and community-based services that would have gone to raise the wages for the workforce and expand access to services to people who are eligible. That would have been the single largest investment in the creation of good jobs that would benefit women of color in the history of the United States. So it’s massively a women’s jobs program, basically the way that the infrastructure bill created lots of jobs, but mostly for fields that are dominated by men. This is the exact opposite.
I’m sorry, did it pass?
It passed in the House.
But not in the Senate.
But not in the Senate. And yet the idea is (to push for jobs) in 2025. And we’re next because (the Inflation Reduction Act promoted clean energy), prescription drugs (were lowered), Obamacare got extended.
It’s your turn.
It’s our turn now. It’s our turn.
I think it’s the American Rescue Plan Act fund that’s been supporting child care right now. And there’s a lot of talk about the child care funding cliff. I was wondering, is this a big concern from Hawaii? How is this going to (impact) providers and families going forward?
Poo: Great question.
Zysman: I do want to say it’s a massive concern nationally and locally, because the last few years we have been floating a lot across child care with those extra federal dollars that are now gone and going away. The Department of Human Services still has some requests. We’re spending them down. We just worked with them this fall to reallocate some of those monies to Maui, which is a good thing. We really need to push some money there. But they run out shortly. And in a Band-Aid sort of sense, we’ve been propping up some of the wages — wage supplementing.
So that’s kind of why we’re telling Department Human Services we can keep it going. You can, but it’s still not high enough. It was like trying to put putty in the leaky bucket. And it was running out during Covid, at least to keep people in the sector.
I do think we’ve been doing an okay job in our state at not having a huge loss of child care and an early learning workforce. It worries us that that money is going away and it didn’t convert those jobs to good jobs, like Ai-jen is saying. It didn’t help us grow the workforce, which is where, you know, thinking about the radical vision or universal child care vision, we need to grow the workforce a lot. So this was like stabilization. We treated those monies as (they) stabilized the workforce, stabilized those employers. If we want to grow, I think it’s a very different mindset we need to take on.
Poo: And the president has proposed a $16 billion supplemental budget item to address this, the child care cliff. I mean, obviously there’s going to be a lot of negotiation.
This is in the current budget that runs out in less than two weeks.
Yeah, I think they have like three priorities — and this was one of them — of what they’re going to be negotiating for.
Zysman: And I think just for us in Hawaii, I think it’s important from where we sit that we can’t wait for Congress. I mean, I think we will keep pushing. We push our delegation. Our delegation tends to be supportive. But who knows? And therefore, I think we may need to just take care of this at home. And it is what other states are doing, moving these things ahead (to) drive the federal conversation forward.
Ai-jen, since you have this national perspective, I wonder if you can talk a little bit about how you see Hawaii in this context. Maybe you could give us a broader view of how we compare to the rest of the country.
Poo: I remember the first time I came to the state Legislature — it must have been around 2010. Hawaii was the second state in the country to pass the Domestic Workers Bill of Rights. Now, there’s 10 states and four cities. But Hawaii was number two right after New York, and Hawaii was the first state in the country to pass a family caregiver benefit to help family caregivers who are trying to keep their aging loved ones at home — the kupuna caregiving. It was in 2017. And then it didn’t get funded until 2018, so it’s kind of been an ongoing process, but it’s never been done before, a family caregiver benefit like that one.
And I remember talking to legislators, talking to advocates in the community. The conversation was completely different because the starting point of the conversation is fundamentally that we have a shared responsibility to take care of our elders, to take care of our children. We are intergenerational families and communities, and so the embrace of the social, the collective or shared responsibility of caregiving is very different here. It’s core to the value system here.
And so it’s more just a question of making sure that the systems are reflective of the diverse needs of the people here in the state. In every state it’s slow. We’ve been in an incremental period. And I think we had this opening to now make much bigger strides. And we’re all looking to Hawaii to kind of help lead the way nationally as a state, to kind of keep the momentum going.