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4 How Adults Cope: Dependent Care For the next generation, two long-term trends in U.S. society will add to the demands on working-age adults in caring for dependents. One trend is the increase in the proportion of elderly people in the U.S. population; the elderly depend to varying degrees on their grown children, especially daught- ers. The second trend is the steady influx of women into the work force, which reduces the amount of time they have available for the traditional roles of caring for the elderly and for children and creates conflicts for employed women who are responsible for dependents. As a result, the work-family conflicts experienced by adults of working age in the United States seem likely to grow in the future unless policies are instituted that will help to alleviate them. The costs of care for elderly parents and the cost, quality, and availability of child care are important factors in decisions about work. The mix of costs and benefits available to a given person at a given time-from insurance coverage to public and private subsidies such as employer-subsidized day care can relieve con- flict and stress, or aggravate it. The cost, quality, and availability of care for children and elderly people are therefore among the crucial issues that deserve attention. This chapter reviews who needs care, who provides it, and how it is paid for, to show the range of offerings and apparent short- comings in the care of dependents that confront working-age Americans. CARE FOR THE ELDERLY The increasing numbers of older Americans absolutely and as a per- centage of the total population-have been well documented (U.S. Congress, House, 1987; Rivlin and Wiener, 1988; Gilford, 1988~. Between 1950 and 64
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HOW AD ULTS COPE: DEPENDENT CARE 65 1980, the percentage of people over 65 increased 108 percent, compared with a 62 percent increase for the rest of the population (Taeuber, 19831. The "oldest old," age 85 and over, increased by 281 percent, from 0.6 million in 1950 to 2.2 million in 1980. The Census Bureau projects that the proportion of the elderly (65 and older) in the population will more than double again over the next 50 years, from 11 percent in 1980 (25.5 million) to 22 percent in 2050 (67.1 million). In 1980 almost half of all the elderly lived in just eight states: Califor- nia, Florida, New York, Pennsylvania, Texas, Illinois, Ohio, and Michigan. While the elderly population is expected to grow in every region by 2000, growth rates in the South and the West will be dramatically higher than in the Northeast. Projections call for a 60 percent increase in the South and the West compared with 12 percent in the Northeast (Taeuber, 1983~. To the extent that the elderly live far from their adult children, they will need more institutional care, and arranging for care will be more complex and expensive for their children. Hence, health care and nursing home facilities are likely to be strained in regions experiencing a heavy influx of older people. On average, women live considerably longer than men. In 1988 there were approximately 17 million women and 12 million men age 65 and older (Bureau of the Census, 1989d). Because of their greater longevity and because they tend to be younger than their husbands, women are more likely to be left alone: 82 percent of elderly men live in a family setting, 74 percent with their wives; only 55 percent of elderly women live in a family setting, 36 percent with their husbands (Gilford, 1988~. A higher proportion of elderly people are able to live independently longer than ever before (Palmer et al., 1988; Preston, 1984~. Social Secu- rity benefits are the largest single source (40 percent) of their income. Noncash benefits, such as Medicare, Medicaid, food stamps, and subsidized housing, account for an additional 10 percent of income (Gilford, 1988~. However, elderly people who are disabled and need long-term care continue to be of concern. Among them is a significant number of the oldest old (age 85 and older), most of them women who live longer and have more multiple chronic health problems than older men (Palmer et al., 1988; Rix, 1984~. While fewer elderly people live in poverty, 12 percent in 1988 compared with 25 percent in 1969, a larger proportion of elderly women (15 percent) are in poverty than men (8 percent). These differences are expected to narrow in the future, because more retired women will be eligible for pen- sions and Social Security benefits in their own right (Gilford, 1988~. In the near term, the number of very old women living alone and in poverty will remain significant. There are also differences in the elderly by race and ethnicity: 6.3 percent of white men, 23.7 percent of black men, and 18
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66 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE percent of men of Hispanic origin live in poverty. Comparable figures for elderly women are 12.6 percent of white women, 38 percent of black women, and 25.9 percent of Hispanic women (Bureau of the Census, 1989b). Car- ing for these elderly people is often a key responsibility of relatives, espe- cially their grown children. Types of Care The majority of elderly people can take care of themselves and live independently. For others, care is a mix of institutional care, community- based care, and unpaid care by family and friends. Table 4-1 provides an overview of the projected numbers of the elderly using long-term care in nursing homes and paid home care; the number using both types of care is expected to increase markedly. For example, the number of those over 85 in nursing homes will double by 2020. The problems of caring for disabled elderly people are particularly seri- ous for employed adults. Of the 28.6 million Americans age 65 and over in 1985, 22 percent (6.3 million) were disabled. And 9 percent of the elderly, or 2.6 million, were severely disabled and required assistance with one or more activities of daily living, such as bathing, eating, or shopping. A disproportionate share of the severely disabled are the oldest old; they are most often widows. The majority of disabled elderly are cared for by their family and friends. In 1985, between 4.6 million and 5.1 million disabled elderly (depending on the definition used) lived in the community and were cared for by family and friends with some community support (Liu et al., 1986; Macken, 19861. Of the 1.2 million "frail elderly" (as defined in the 1982 National Long-Term Care Survey, LTCS), 10.7 percent lived alone, 40 percent lived with only a spouse, and 35.7 percent lived with their children, with or without a spouse. One-third of the disabled elderly reported family incomes in the poor or near-poor category (Stone et al., 1987~. These statistics may undercount elderly mentally disabled people who live with their families. Only 21 percent of the disabled elderly and about 50 percent of the severely disabled are in nursing homes (Stone et al., 1987; Rivlin and Wiener, 19881. Furthermore, nursing home care does not completely relieve family members of care responsibilities. They continue to visit nursing home pa- tients, frequently providing such assistance as doing the laundry, arranging doctor's appointments, shopping, managing financial matters, and monitor- ing the quality of the purchased care. Theoretically, the supply of nursing home beds could be expanded to accommodate all those whose physical disabilities are so severe that they can no longer manage independent living. However, nursing home care is very expensive. So pressures exist to expand paid home care given by
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Representative terms from entire chapter:
67 o o C~ 1 o Ct o ~o s~ Ct V o o Cq Ct o ._ C~ - o - $ - - ao E~ o o - o o - oo cr oo o oo U~ ~_ C~ . . . _ C~ _ ~ ~3 . . C~ - C~ C~ _ ~ ~V~ - ~ oo .. . oo ~ o ~ _ ~ 7 ~-} c~) ~ _ ~o ~ o ~ ~o o ~ o ~ o o _~ o o o _ ~_ ~CA - 5 ~C) ~ O _ _ _ ~ _ ~ t_ C~ ,~_ ~CN oo O ~ oo U~ - _ ~ .< _ .~ O (~ ·- ~ 3 C~ _ _ C~ Ct ._ ~ o .= V) ._ ~ C~ ~ . . . o ~ o o - ~r~ - ~ ~t ~U~ oo . . . ~ ~ o oo - - ~ - ~- ~o oo o - ~o - o ~ o ~ o ~ ~ o o o - - - - ~ cn u, o ~C) ~L) - ~ - ~ c ~50 (~ cL, ~ - o~o o~o O.o c :5 D co D O D ~ ~ D C ~ce ~
68 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE relatives and nonrelatives. A major conflict in work-family relations is the number of working-age relatives who work part time or do not seek em- ployment because of the need to care for elderly relatives. This problem is likely to grow as the number of employed people with care obligations for elderly relatives increases. Nursing Home Care Nursing homes provide the primary form of institutional care for elderly people. Of all expenditures for long-term care, 80 percent is for institu- tional services (General Accounting Office, 19889. Although long-term care spending is dominated by nursing home costs, there are shortages of nursing home beds, costs are high, and the quality of care is mixed. These are major national issues, now and for the future. The first national nursing home survey in 1954 identified 9,000 nursing homes: 86 percent were proprietary, 10 percent were nonprofit, and 4 per- cent were public. Recent estimates place the number of certified nursing homes at approximately 19,000 with 1.6 million beds: 70 percent of the facilities are run for profit, 22 percent are run by nonprofit organizations, and 8 percent are owned and run by governments (Committee on Nursing Home Regulation, 1986; Rivlin and Wiener, 1988~. Most experts agree that nursing homes are operating at capacity and that states limit the number of nursing home beds to keep down state Medicaid costs (Rivlin and Wiener, 1988; Committee on Nursing Home Regulation, 1986~. This creates a short- age of beds, which is likely to increase with the growing elderly population. The cost of nursing home care is so high that it rapidly exhausts the resources of all but wealthy families. The average annual cost per person for nursing home care in 1988 was estimated at between $22,000 and $25,000 (Price and O'Shaughnessy, 1988~. Slightly over half of nursing home costs are paid for by the elderly and their families; Medicaid pays for most of the remainder. Of the $33 billion annual estimated cost for nursing home care (1986-1990), 43 percent ($14 billion) is paid for by Medicaid, 55 percent ($18 billion) by families, and 2 percent ($0.6 billion) by Medi- care (Rivlin and Wiener, 1988~. Medicaid was intended to provide coverage only for poor and near-poor individuals. When nonpoor elderly people deplete their savings and spend most of their income on nursing home or other health care expenses, how- ever, they may eventually qualify for Medicaid; this is called the Medicaid "spend-down." Recent analysis of data from the 1985 National Nursing Home Survey and the 1982-1984 National Long-Term Care Survey shows that a large proportion of the elderly spend down until they reach eligibility for poverty programs such as Medicaid before going to a nursing home (Liu et al., 1990~. In other words, many elderly may put off going to a
HOW AD ULTS COPE: DEPENDENT CARE 69 nursing home until they have reached the poverty level and the cost can be covered by Medicaid, even if nursing home care was needed much earlier. The quality of nursing home care remains a concern, although efforts have been made to improve quality through regulation. Certification is done at the state level, with federal guidelines established in 1974 to control the use of federal monies. Medicaid is jointly financed by federal and state funds and administered by the states. A review of nursing homes by a panel of experts at the Institute of Medicine (Committee on Nursing Home Regu- lation, 1986) concluded that 10 years of government regulations had im- proved nursing homes but that quality of care and quality of life in many facilities remained unsatisfactory. The review concluded that poor-quality homes outnumbered very good homes. The report called for more effective government regulation and enforcement and a stronger federal leadership role. It concluded: "Skilled and properly motivated management, well- trained, well-supervised, and highly motivated staff, community involve- ment and support, and effective consumer involvement all are required" (Committee on Nursing Home Regulation, 1986:241. Improving the quality of nursing home care is a thorny problem. In- creased regulation and enforcement will improve quality but will also increase costs. Regulatory changes commonly lead to the closing of facili- ties when meeting new standards is prohibitively expensive. Given the shortage of beds, policy makers are reluctant to act except in circum stances in which conditions are so bad as to represent an immediate threat. There are many parallels between nursing home care and child care. In both instances, competent, trained, and motivated staff are essential to pro- viding high-quality care. Attracting such staff is difficult and expensive. In 1988, "nursing and personal care facilities" employed over 1.3 million people a number expected to grow by 3.1 percent annually over the next decade (Personick, 1989~. Many nursing homes lack the professional staff of doctors, nurses, and therapists to provide high-quality care. They often hold down costs by employing nurse's aides who are poorly trained, inad- equately supervised, and underpaid. The staff is typically required to care for too many patients. Not surprisingly, staff turnover ranges from 70 to 100 percent per year, further impairing the quality of care (Committee on Nursing Home Regulation, 1986~. Paid Home and Community Care For many elderly people, home care might be a lower-cost alternative, one that many of them prefer. An impressive range of noninstitutional services has developed over the last two decades and are now available in many communities. Services include home health aides, homemaker help, personal care, "meals on wheels," respite care, adult day care, telephone
70 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE monitoring, and special transportation. There are also community-based programs serving both healthy and impaired elderly people, such as senior centers offering congregate meals and other services. The availability and use of such services are increasing. In 1987 approximately one-third of the elderly with functional disabilities used these services (Table 4-2), an increase from 10 to 25 percent reported in earlier surveys (General Accounting Office, 1988~. Federal support of community services has ex- panded over the last decade; funds are available from Medicare, Medic- aid, Title XX, the Department of Veterans Affairs, and under the Older Americans Act. Of the 5.6 million disabled elderly living at home in 1987, 3.6 million received no formal (i.e., paid) services. The fact that almost 60 percent of those who might benefit from home health services did not receive them could reflect limits of service availability but it also results from inability to pay. The majority of all noninstitutional care is paid for directly by recipients or by their relatives. Federal and state support for noninstitution TABLE 4-2 The Elderly Population with Functional Disabilities Using Paid Home and Community Services, 1987 Percentage with Service Population Population AtIn Characteristic (thousands)a HomeCommunity Both Total 5,619 22.4 9.9 4.0 Age in years 65-74 1,993 18.4 8.2 5.4 75-84 2,315 22.8 9.3 3.9 85+ 1,310 27.7 13.3 2 Oh Male 1,788 14.3 8.6 2.5b Female 3,830 26.2 10.5 4.6 Functional status IADL only 2,261 17.3 9.6 3 3h 1-2 ADLs 2,108 21.3 12.2 4.5 3 or more ADLs 1,061 38.5 4.1b 4 5b Lives alone 2,364 29.5 13.0 6.9 Lives with others 3,255 16.9 7.4 1.7b aEstimates include the population with walking difficulties except where the level of Activities of Daily Living/Instrumental Activities of Daily Living (ADL/IADL) difficulties is specified. hRelative standard error equal to or greater than 30 percent. SOURCE: Agency for Health Care and Policy Research. National Medi- cal Expenditure Survey Household Survey, Round 1.
HOW AD ULTS COPE: DEPENDENT CARE 71 al services is limited but growing. Medicare spent $2.3 billion on home care in 1985 (General Accounting Office, 1988), but Medicare services are limited to treatment of acute conditions that have previously been treated in a hospital or skilled nursing facility. Medicaid coverage of a broader range of in-home services is slowly expanding. The Omnibus Budget Rec- onciliation Act of 1981 offered states the opportunity to apply for waivers from federal regulations governing Medicaid programs in order to provide a wide range of services to impaired beneficiaries. Medicaid expenditures for home and community-based services were about $0.5 billion in 1985 (General Accounting Office, 1988~. Congress has been considering legislation that would expand services: the 1987 Omnibus Budget Reconciliation Act (U.S. Congress' House, 1988) provided additional Medicaid waiver authority specifically for the elderly, and a 1987 amendment to the Older Americans Act (Title III-D) created a separate authorization for in-home services for the frail elderly. Finally, the Veterans' Benefits and Services Act of 1987 directs the Department of Veterans Affairs to emphasize community services instead of nursing homes. Although these trends are hopeful, the fact that only 2 million disabled elderly out of 5.6 million received paid services indicates that the programs have a significant distance to go to meet all genuine needs. Supporters argue that paid home care will substitute for nursing home or hospital care and, because they are less expensive, reduce the overall costs of long-term care to individuals and society. However, home-based pro- grams appear to have had little effect on nursing home or hospital use. Data from 15 home care demonstration projects, such as the Chicago Five Hospital Home-Bound Elderly Program, show paid home care has been a complement to, not a substitute for, institutional care, and it actually in- creases total expenditures (Rivlin and Wiener, 1988~. Opponents of paid home care also argue that it will substitute for the current unpaid care by relatives. While the substitution effect has not been extensively studied, there is some evidence from the demonstration pro- grams that paid home care appears to enable unpaid caregivers to provide additional specialized services rather than reducing the amount of unpaid care (Rivlin and Wiener, 1988~. Hence, expanded paid home care offers an opportunity to improve the morale, well-being, and life satisfaction of the elderly themselves while giving limited relief to unpaid caregivers. It also offers some financial relief for out-of-pocket expenses for the elderly and their families (Rivlin and Wiener, 1988~. One variation on paid home care services is to pay family members who provide care. At present, Medicaid rules and regulations in several states prohibit paying family members for providing personal care prescribed by a physician. Yet a survey of 46 states, the District of Columbia, and 3 ter- ritories found that 35 of the responding jurisdictions provided for some
72 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE form of family caregiver payment. Although these are small, limited pro- grams, they represent an alternative that deserves further exploration (Linsk et al., 1988~. Tax incentives are another means of subsidizing paid home care. Tax credits and deductions are easy to administer, involve cost sharing with caregivers, and increase consumer choice. Unless refundable, however, tax credits and deductions will not benefit the many elderly people who are members of low-income families. Some relief is now provided through the federal dependent care tax credit, but less than 10 percent of this tax benefit is estimated to help the elderly (most of it is used for child care). Five states also encourage family care through the tax code, but utilization is low. In both cases, restrictions on eligibility and newness may limit use (Rivlin and Wiener, 1988~. Unpaid Home Care The extent and market value of unpaid home care are hard to quantify. Partly this is because it is an extension of normal family and community relationships; in addition, important unpaid care by relatives such as emo- tional support eludes attempts to value it. Despite its being hard to quan- tify, support provided by family, friends, and neighbors is the critical un- derpinning of independent living for frail or disabled elderly. However, the long-term demographic changes in the United States will certainly strain and could erode substantially relatives' ability to provide this essen- tial care. These changes include the increase in numbers of dependent elderly people, higher percentages of working-age women entering the work force, and geographic mobility separating elderly parents from their adult children. The decline in availability of family-provided care can be offset to some extent by new types of living arrangements, such as senior apartments or other types of congregate housing offering meals, emer- gency medical care, transportation, and other services. Even so, many eld- erly will not have money to substitute these forms of purchased care for unpaid care. Most of the elderly are tenaciously independent, preferring to live at home rather than have any kind of institutional care (McAuley and Bliesz- ner, 19851. When they can no longer live unassisted and independently, most older people prefer living at home with some assistance from relatives and friends. Elderly persons with relatives who can provide home care are least likely to enter institutions. In a study that controlled for severity of disability, Smyer (1980) found that the best predictor of institutionalization was the family's self-reported ability to provide home-based care. In other words, most elderly people will avoid nursing home care as long as pos- sible, regardless of physical condition or family finances. Supporting this
HOW AD ULTS COPE: DEPENDENT CARE 73 observation are two studies showing that elderly people who have family support enter institutions with much higher levels of impairment than those without family support (Barney, 1977; Dunlop, 1980~. These findings suggest that helping relatives maintain support for frail and disabled elderly people should be an important public policy goal. Absent such support, far larger numbers of elderly people will require insti- tutional care. There are not sufficient nursing home beds to meet current needs, and significant expansion of such facilities is unlikely. Who cares for the elderly? At present, according to the National Long- Term Care Survey, approximately 2.3 percent of the U.S. population (4.2 million persons) actively provide unpaid assistance to disabled elderly in the community. The amount and duration of care given depends on the older person's level of disability. Women (2.6 million) are more often caregivers than men (1.6 million), and children (2.7 million) more often than spouses (1.5 million). Wives and husbands are most often the sole caregivers for their spouses, 60 percent and 55 percent, respectively. Care- givers are of working age; their average age is 57 years. And 30 percent of caregivers reported their incomes in the poor or near-poor category; one- third rate their own general health as no better than fair or poor (Stone and Kemper, 1989b). Care can include: emotional support with v Sits and telephone calls; assistance with daily living such as transportation, shopping, meal prepara- tion, and financial management; and more personal forms of care for the most severely impaired (e.g., bathing, feeding, dressing, toileting, and medi- cal assistance) (Stone et al., 1987; Soldo and Manton, 1985~. In the Na tional Informal Survey of Caregivers (part of the National Long-Term Care Survey), 60 percent of the caregivers reported related expenses: 31 percent for travel, 25 percent for phone bills, and 24 percent for special diets or paid medicine for elderly dependents. On average, a frail or dis- abled elderly person living at home requires 1 to 4 years of care; 80 per- cent of caregivers provide care 7 days a week. Because the majority of working-age unpaid caregivers are women, their increasing entry into the labor force raises questions about who will care for the growing elderly population in the future. Table 4-3 shows that almost 11 percent of full-time workers now or will soon face elder care decisions and that almost 2 percent of full-time employed workers are active care- givers: over 500,000 (or one-third) full-time workers have primary respon- sibility for elderly dependents. Approximately 12 percent of women who work full time are active or potential caregivers (i.e., have a very old parent who might suddenly need care) (Stone and Kemper, 1989a). McLanahan and Monson (1989) found that 3.5 percent of women and 2 percent of men have obligations for both an elderly parent and a child. Almost 200,000 daughters are "women in the middle," caring for young children as well as
74 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE TABLE 4-3 Potential and Active Caregivers to the Elderly Age 16 and Over Who Are Employed Full Time (thousands) Active Caregiversa Potential Caregivers Primary Secondary Total Men Number 4,418 168 523 691 Percent, employed menb 9.2 .3 1.2 1.5 Women Number 2,952 409 425 834 Percent, employed womenb 9.2 1.3 1.3 2.6 Total Number 7,370 577 948 1,525 Percent, employedh 9.2 .7 1.2 1.9 aDoes not include Caregivers of disabled elders in institutions. hPotential and active Caregivers as a percentage of U.S. population employed 30 or more hours for each gender and total. SOURCE: Stone and Kemper (1989a:Table 6). Data from 1984 National Long- Terrn Care Survey; March 1984 Current Population Survey. Reprinted by permission. parents. Almost 1 million women employed full time are potential care- givers for both a child and an elderly parent (Stone and Kemper, 1989b). Surveys of employers and other small, nonrandom samples using broad- er definitions of care than the national surveys provide additional infor- mation on the prevalence of care by employees (Creedon, 1989; Friedman, 1988; Brody, 19851. For example, the Travelers' Companies and IBM report that 30 percent and 20 percent, respectively, of their employees over age 30 provide care for an elderly person. Caregivers are reported to spend from 12 to 35 hours on elder care each week, the amount of time determined mainly by the level of dependence of the person cared for (Creedon, 1989~. At Travelers, women reported 16 hours of elder care per week; of those, 31 percent were also caring for young children (The Travelers' Companies, 1985~. CARE FOR CHILDREN As Chapter 3 explained, American workers' choices of employment- their choice of shift jobs, part-time work, or not working at all are influ- enced by family duties: by the need to care for both elderly relatives and children. Satisfactory, affordable child care arrangements can relieve stress, reduce absenteeism and tardiness, and increase worker satisfaction. Con- versely, the absence of affordable child care that conforms to parents' val- ues and the failure of child care arrangements can increase stress, absentee
76 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE played mothers at home has declined to about 40 percent, far smaller than 20 years ago, and is expected to decline further. In 1988, of the approxi- mately 65 million children under age 18, about 69 percent were under age 13 and 29 percent were under age 6. At any given time, the majority of American children live in two-parent families, but at some point in their lives almost half of all children will live in a single-family home (Garfinkel and McLanahan, 1986~. Single parents face particular problems in securing appropriate child care arrangements. In effect, it is a vicious cycle: single-parent families tend to have low incomes and a higher proportion of children living in poverty. They also have greater difficulty finding or paying for quality child care that would enable them to go to work or to work more productively. The proportion of children under 18 living in poverty increased from 15 percent in 1970 to 20 percent in 1987. The fact that one American child in five will spend part of his or her childhood in poverty is startling, and the proportion is far higher among some minority groups. In single-parent, female-headed families, poverty rates are 46 percent for white children, 68 percent for black children, and 70 percent for Hispanic children (Bureau of the Census, 1989b). Overall, children today have the highest poverty rate of any age group; black and Hispanic children are two to three times more likely to live in poverty than white children. Estimates of the number of homeless children range from 100,000 to 500,000 (U.S. Congress, House, 1989~. Many parents of poor children experience extreme work-family stress. Not all poor families are out of the labor force or receiving income support from government programs. In 1988, about 59 percent of poor families included at least one person who worked in that year; 18 percent included two or more workers. In 42 percent of poor female-headed families, the mother worked. Almost 10 percent of poor female householders worked year round, full time. And 65 percent of the poor female householders not in the labor force cited family responsibilities as the reason (Bureau of the Census, 1989b). Although the focus of this section is on the care of young children be- fore they enter school, as well as their care before and after school, it is important to note that the business community has expressed concern about the quality of public school education, its effect on future workers, and the appropriate role for employers in that system. The severe problems in public education have been extensively documented. Well over one- quarter of the nation's young people do not finish high school. Nearly 13 percent of all 17 year olds enrolled in school are reported to be functionally illiterate and 44 percent to be only marginally literate. Test scores confirm deficiencies in U.S. precollege education, particularly in math, science, and literacy (Kutscher, 1989~.
HOW AD ULTS COPE: DEPENDENT CARE 77 Employers are already starting to experience the effects of a poorly edu- cated labor force. Business leaders have called for a stronger role for busi- ness in education, through such activities as private-public partnerships (Committee for Economic Development, 1985), and programs have been initiated in several cities. In Chicago, for example, corporations have joined together and established a corporate community school for low-income children (Corporate/Community Schools of America, 1989; see also Weiner, 1989, and Will, 1989~. Yet even more notable than employers' concerns about education has been their increased interest in providing child care directly or through indirect subsidies. Recognizing the link between child care and employ- ment, many companies have become concerned about the larger forces af- fecting the present and future work force, such as poverty, and deficiencies in the education system and health care of workers and their families. A1- though employer involvement has increased in some areas, there is no gen- eral agreement on the appropriate ongoing role employers should play in organizing and financing family services. Types of Child Care Much of the care for children of working parents is arranged informally: some of it is unpaid care by family members, and some of the paid care is unlicensed. Employed parents pay for most child care. However, there is a growing mix of publicly and privately subsidized centers, including nurs- ery schools, prekindergartens, and kindergartens. Schools and religious organizations sponsor child care. Some school systems operate centers. School-based child care programs are growing, including before- and after- school programs and special programs such as Head Start for poor chil- dren. Table 4-4 shows care arrangements for children whose mothers are employed. The type of care used varies with the age of the child. Parental care and care by relatives and in-house babysitters or nannies are declining; care in centers and in family day care is increasing, and these trends are likely to continue in the 1990s (Hofferth and Phillips, 1987~. Care by Parents Even when they are both employed, parents may choose work schedules that allow them to provide a substantial amount of in-home care. More than 9 percent of children with employed mothers are cared for by their fathers. One study found that in about one-third of young families (parents ages 19 to 27), the spouses worked different shifts (Presser, 1988~. Such parents are able to care for their children themselves, but there is a toll on their ability to interact with each other and to be together as a family.
78 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE TABLE 4-4 Primary Child Care Arrangements Used by Employed Mothers of Children Under 15, 1984-1985 (percentage) Type of Child Care Under 1 1 and 2 3 and 4 5 to 14 Arrangement Total year years years years Care in child's home 17.8 37.3 32.7 27.0 11.8 By father 9.4 18.2 16.2 14.3 6.6 By grandparent 2.7 7.4 6.4 4.5 1.3 By other relative 3.0 3.2 4.5 3.3 2.7 By nonrelative 2.6 8.5 5.7 5.0 1.1 Care in another home 14.4 40.6 41.9 31.0 4.3 By grandparent 4.3 12.6 11.0 8.5 1.7 By other relative 1.8 5.1 4.0 4.7 0.5 By nonrelative 8.3 23.0 26.8 17.7 2.1 Organized child care facilites 9.1 14.1 17.2 32.2 2.8 Day/group care center 5.4 8.4 12.3 17.8 1.6 Nursery school/preschool 3.7 5.7 5.0 14.4 1.2 Kindergarten/grade school 52.2 1.7 75.2 Child cares for self 1.8 - 2.7 Parent cares for child 4.7 8.1 8.2 8.1 3.2 Total 100.0 100.0 100.0 100.0 100.0 Total number of children (26,455) (1,385) (3,267) (3,516) (18,287) (thousands) NOTE: Includes mothers working at home or away from home. SOURCE: Bureau of the Census (1987:Tables B and D). Another 4.7 percent of children of working parents are cared for by parents, mainly working mothers. Some work at home; others provide tele- phone access, most often to school-age children. The Bureau of the Census (1987) reports that 2.7 million children, most of them of elementary and junior high school age, care for themselves or are "latchkey" children be- fore and after school. The U.S. Department of Labor (1988) concludes that care for this group may well be the largest shortage. Relative and Nanny Care Another 11.8 percent of children are cared for by relatives, most often grandmothers: 5.7 percent in the child's home and 6.1 percent in the home of the relative. Relative care is most often used by low-income families. Some research suggests that relatives are preferred caregivers because of the low costs as well as common cultural values (Waite et al., 19881. Other research finds that low-income mothers using relatives are dissatisfied or would prefer another arrangement (Kisker et al., 1989; Sonenstein and
HOW AD ULTS COPE: DEPENDENT CARE 79 Wolf, 1988~. But they have difficulty using alternative services because of the hours they work, the cost, or the unavailability of such services in their neighborhoods. In fact, relative care has declined from 68 percent of all care in 1970 to 40 percent in 1985. Care by relatives is expected to de- crease further as more working-age women who are grandmothers stay in the paid labor force. The use of nannies or in-home babysitters is also declining; they now pro- vide care for about 2.6 percent of children. Nannies are often immigrants or young women from other countries participating in living-abroad programs. They may live with the family and have other housekeeping responsibilities as well. This is the most expensive type of child care (lIofferth, 19881; the majority of such care is unregulated, and little is known about its quality. Family Day Care Family day care is the second-fastest-growing form of child care after child care centers. Generally, one woman cares in her home for between two and six children, some possibly her own. Estimates of the number of such homes range from 420,000 to more than 1 million. Whereas only 15 percent of employed mothers used family day care in 1958, 30 percent used it in 1985 (Hayes et al., 1990~. It is the least expensive form of care other than that by relatives. An estimated 60 to 90 percent of family day care is unregulated, and little is known about it (Hayes et al., 19901. In 1988, only 27 states re- quired some form of licensing, 13 offered voluntary registration, and 6 had some form of certification for those seeking federal support (Blank and Wilkins, 1985; Morgan, 1987~. Research suggests that women who provide this type of care generally earn little, are often isolated, lack training, and frequently do not do this type of work for very long (Fosberg, 1981; White- book et al., 1989~. This is a matter of concern when considering the large proportion of American children who will spend their formative years in family day care arrangements. Center Care The fastest-growing type of child care is group care or centers. Overall, 9 percent of children are in center care: 3.7 percent in nurseries or pre- schools (often part day). For children under the age of 5, centers account for 23 percent of the care (Figure 4-2~. In 1984-1985, approximately 14 percent of infants (under age 1) and 17 percent of toddlers (ages 1 to 2) with employed mothers were in organized child care facilities. The largest group in center care are 3 and 4 year olds, for whom preschool pro- grams have become a widely accepted educational and socialization
80 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE In home, nonrelative 6% Care by mother Kindergarten or school L 1% -. a' . ~ · - o; ;~ Out of home, relative ;, FIGURE 4-2 Primary child care arrangements of employed parents with children under age 5, winter 1984-1985. SOURCE: Data from Current Population Reports Series P-70, No. 9, 1987. Reprinted in Hayes et al. (19901. process; over 1 million 3 and 4 year olds are in such programs. Almost all 5 year olds are in some type of public school kindergarten, although many are in part-day programs. Children age 6 and older are in school; many up to age 8 are also in after-school center programs. A 1986 survey estimated that there were 62,989 child care centers, with a capacity for approximately 2.1 million children (Haskins, 1988~. This represented an increase of over 200 percent since the mid-1970s. Centers have a growing diversity of programs and sponsorship. There are not-for- profit centers run by government agencies, community groups, employers, and parent cooperatives, as well as for-profit centers, from small "Mom and Pop" operations to large corporate chains. Like nursing homes, centers are regulated by the states, although religious and part-day programs are usually exempt. There is a lively debate about the adequacy, effectiveness, and consequences of regulation, discussed below (Reisman et al., 1988; Blank et al., 1987; Hayes et al., 19901.
HOW ED ULTS COPE: DEPENDENT CARE Child Care Availability and Need 81 Women's labor force participation is obviously a major factor driving demand for child care. The availability of acceptable child care also affects women's labor force participation (e.g., Leibowitz and Waite, 1988; O'Con- nell and Bloom, 1987~. Frequent discussions of demand for child care are generally couched in terms of need and disregard the effect of price on demand. Although there appears to be a large unmet demand for free or heavily subsidized child care, there is hardly a shortage in the usual eco- nomic sense. Furthermore, the issue often is not that child care is unavail- able at affordable prices but that the quality of affordable care is unac- ceptable. A recent report of the National Research Council (Hayes et al., 1990) examined the issues of child care availability, affordability, and quality in detail. We note here some of the findings most relevant to this study. · There appears to be a shortage of quality infant care. Infant care is more expensive than other forms of child care (except care of disabled children); the unavailability of affordable quality infant care causes severe hardship for low-income families, particularly single mothers who must return to work shortly after childbirth. · Overall, the growth in child care spaces for children ages 3 to 5 has kept pace with the number of such children who have employed mothers, but there remains a serious deficiency in affordable quality care for children from low-income families, children with disabilities, and children whose parents work nonstandard hours. · The number of latchkey children is increasing, and they could be at greater risk for drug use, violence, and various problem behaviors. Costs of Child Care The costs of a parent's staying home to care for children are long term as well as immediate. When a mother leaves her job, she not only gives up current earnings, but she will also, to some extent, reduce her future earn- ings, especially if she is in an occupation in which experience is highly valued. In addition, she may also lose retirement benefits. In general, the labor market rewards continuity of employment and penalizes interruptions. This long- and short-term earnings reduction contributes significantly to female poverty. Of an estimated $16 billion spent on out-of-home child care, employed parents spent about half, after tax credits; federal subsidies amounted to almost $7 billion, up from about $2.5 billion in 1980 (Besharov and Tramon- tozzi, 1988), and state subsidies were about $1 billion (Hayes et al., 1990~.
82 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE The fastest-growing type of support has been through the tax system, ben- efiting middle- and upper-income families. In 1985, among families with employed mothers, 77 percent paid for care for children under age 5, and 57 percent paid for care for those over 5 (Hofferth, 1988~. Among families whose youngest child was under 5 and who purchased child care for at least 30 hours per week, the average amount spent has been approximately $1,820 per child per year. According to the Survey of Income and Program Participation, however, 27 percent of fami- lies paid more than $50 per week per child (Brush, 1987~; similarly, Kisker et al. (1989) report the median total expenditure for those paying for care was $50 per week. Both Hofferth (1987) and Brush (1987) found that families who live in metropolitan areas, have more education, are white, and have higher incomes tend to pay more for care. The average costs in 1987 ranged from $20 a week for a preschool family day care program in Miami to $90 a week for infant center care in New York City (unpublished data, Work/Family Directions, Watertown, Mass., 1987~. In general, costs are higher for infants and for children with handicaps (Grubb, 1988; Brush, 1989~. Another way to look at costs is as a percentage of income. Using the 1985 National Longitudinal Survey of Youth, Hofferth (1988) found, on average, that families pay 10 percent of their income for child care. This is comparable to average family food expenditures (Bureau of the Census, 1989f). In both cases, however, they constitute a far larger share of the budgets of low- and moderate-income families. Poor families average 23 percent of their income for child care while other families pay 9 percent. Single parents also pay a higher proportion of their income for child care than do two-earner families. This reflects the lower earnings of single parents and also the fact that single parents have fewer opportunities for shared care arrangements. The dependent care tax credit repays a portion of these costs to families that earn enough to owe taxes. Child care is often viewed as a cost of women's labor force participa- tion. Waite et al. (1988) calculated that, in middle-income families, child care costs average approximately 25 percent of wives' incomes. Confronted with the same costs, one family might choose eagerly to make the expendi- ture to allow both parents' careers to progress; another family might bear the expense reluctantly out of financial necessity; while a third might with- draw one parent from the labor force. Low-income families have fewer choices, and spending over one-fifth of family income for child care presents a serious hardship for them. The proportion is even higher for young families with infants or children with disabilities (Hayes et al., 1990~.
HOW AD ULTS COPE: DEPENDENT CARE 83 Quality of Child Care As previously noted, the quality of child care is also a matter of serious concern. After a careful review of available research, the Panel on Child Care Policy concluded that, although there are some methodological con- straints on the research, quality of care is very important for children's development. For example, children's scores on school readiness and vo- cabulary tests were related to center group size, teacher qualifications, and center orientation (Ruopp et al., 19791. Howes and Olenick (1986) found that children from low-quality centers were less likely to restrain their be- havior in situations in which that would be appropriate. The panel also concluded that much of the care now available is of inadequate quality and that quality varies considerably within and across different types of care and different types of sponsorship. The report identifies key components of quality. One important measure is the stability of caregivers, yet the wages and benefits of child care work- ers are very low (Grubb, 1988; Fuchs, 1988; Hartmann and Pearce, 1989), and they have one of the highest turnover rates of any occupation (Eck, 1984~. Other measures of quality are staff/child ratios, group size, features of physical facilities, and caregiver training. Although states regulate child care, many states' regulations are inadequate. Children from low-income families are more likely to have poor care unless they are enrolled in pro- grams, such as Head Start, which are of high quality (Howes, in press; Hayes et al., 19901. Not surprisingly, higher-quality child care usually costs more. Estimates by Clifford and Russell (1989) range from a low of $2,937 per child for what they consider to be the typical existing program (with low salaries and low staff/child ratios) to a high of $5,267 per child for a high-quality program that includes relatively high salaries for staff ($20,000 per year for teachers) and high staff/child ratios (1:4 for infants, 1:6 for toddlers, 1:8 for 3 year olds, and 1:12 for school-age children). Their estimates of the costs of high-quality care coincide with Head Start projections for the costs of quality care for economically disadvantaged children. Because pay for staff amounts to 60 to 90 percent of child care costs, any improvement in wages or staff/child ratios will raise the costs of care. As with elder care, higher standards and more stringent regulations for child care, while improving quality, are also likely to increase costs and thus decrease affordability. Without subsidies, low-income families are unlikely to be able to afford that care. There is also a question about who should make decisions regarding quality and cost trade-offs for child care. For example, parents might not value quality, as defined by the experts, as much as location, costs, and hours (Waite et al., 19881. Or they simply may not have sufficient information about what experts believe constitutes quality (Grubb, 1988~.
84 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE A number of government programs provide direct and indirect assistance for child care. Working parents receive subsidies through the tax system and poor families through programs such as Head Start, Aid to Families with Dependent Children, Title XX, and the earned income tax credit. In addition, a small but growing number of employers and unions are address- ing problems of child care: some sponsor on-site and consortium child care centers or provide subsidies to employees to reduce the costs of purchasing care elsewhere, through vouchers or tax-based dependent care assistance programs; others sponsor resource and referral programs that offer informa- tion and attempt to improve quality. CARE FOR THE WORKING-AGE DISABLED In addition to elderly people and children, disabled adults also need care. The 1980 census defined disability as a limitation in the ability to work because of a physical, mental, or other health condition that had lasted 6 or more months. Approximately 13 percent of nursing home residents are under 65 years of age (Committee on Nursing Home Regulation, 19861. The loss of income and the cost of care for people with disabilities are burdens on families. Because these burdens may cause stress for employees, they are also of concern to employers. Numerous cross-sectional and longitudinal surveys provide an over- view of the prevalence and severity of existing disabilities and of the pro- grams and policies to help people and their families. Wide variations in findings are attributed to differences in the wording of questions and inter- viewer training (Haber, 1989~. Among the 19 surveys conducted between 1960 and 1980, estimated rates of disability ranged from approximately 8 to 17 percent of the population. Estimates of severe disability ranged from 2 to 6 percent of the population. The most recent data from the Current Population Survey (CPS) (Bureau of the Census, 1989d) indicate that 8.6 percent of the population have a work disability and 4.8 percent have a severe disability, with similar rates for men and women. In the 1987 CPS, 3.6 percent of working-age men and 2.9 percent of working-age women reported that they had not worked the previous year because of illness or disability (Bureau of the Census, 1989e). Severity is very generally de- fined, and very little is known about the duration of disabilities. These figures also may somewhat overestimate those in need of care because people who are occupationally disabled that is, not able to work may not require the care of family members. These surveys provide demographic and economic patterns for persons with disabilities. In general, the findings on the relationship of disability to age, education, race, and income have been consistent over time and across surveys. Disability is more common with increasing age, among blacks
HOW AD ULTS COPE: DEPENDENT CARE 85 than whites, among unskilled and semiskilled workers than among skilled and professional workers, among those with less than a high school educa- tion than among high school and college graduates, among rural than among urban populations, and among people in the South than in other regions. Because disabled workers tend to have lower earnings than other workers, poverty is not only a predisposing factor, but also a consequence of disabil- ity (lIaber, 1989; Bureau of the Census, 1989d). Other sources of information are records on participation in programs established to assist the disabled. As in most industrialized countries, pub- lic policies for the disabled in the United States are a mix of income trans- fer programs and employment programs, but with a much greater empha- sis on the former. In 1985 there were approximately 2.7 million people covered by disability insurance programs, 1.9 by the Supplemental Security Income program. Only 200,000 were in narrowly defined job programs, such as sheltered workshops, and 900,000 were in vocational rehabili- tation programs. Rehabilitation programs have a success rate of about 30 percent in getting a person back to work (Burkhauser and Hirvonen, 19881. There is little information on how people with disabilities are cared for and to what extent their caretakers are in the work force (Zitter, 1989; Paula Franklin, Division of Disability Studies, Social Security Administra tion, personal communication, 1990~. According to the 1987 National Survey of Families and Households, during that year approximately 8 percent of wo- men under the age of 65 lived with someone who was chronically ill or disabled. And 3 percent of white women, 2 percent of white men, and 1.3 percent of nonwhite women and men of working age were providing care to spouses in their home (McLanahan and Monson, 1989~. Employed women are somewhat less likely to care for a spouse than nonemployed women, even though one early study found that wives of disabled husbands were likely to go to work because of loss of income (Franklin, 19771. Disability insurance, funded through employer and employee contributions, totaling over $18 bil- lion in 1986, and workers compensation, amounting to $32 billion in employer contributions, are major sources of funding for disabled people. CONCLUSIONS How dependents are cared for is in large part determined by the re- sources of individual families and the mix of funding mechanisms avail- able. As we have seen, responsibility for dependents continues to rest primarily on working-age adults in the family. More care is purchased, paid for mainly by families, but partly by governments and employers. Nonetheless, much care continues to be provided by relatives, chiefly women, even though most of them are now in the labor force. Families directly pay for the majority of dependent care. The role of employers in supporting
86 WORK AND FAMILY: POLICIES FOR A CHANGING WORK FORCE dependent care is influenced by tax policies, government mandates, the demands of employees and their unions, and the needs of business. Em- ployers rarely pay for services directly, but make substantial contributions through taxes and mandated and voluntary insurance systems. The responsibilities of working-age adults in the United States to care for the elderly, for children, and for disabled friends and family members is bound to increase with time, given demographic trends. Responsibilities tend to change with stages in the life cycle: younger women care for their children; and middle-aged and older women care for husbands after their children have grown; and middle-aged women more than men have primary responsibility for caring for elderly parents. Adults can now expect to spend 28 years with children under 18 and/or parents over 65. The years with parents now exceed those with children (Watkins and Menken, 1987~. The economic status and health of the elderly have improved in recent decades, due in large part to programs such as Social Security and Medi- care. The increasing number of elderly, however, means that there is a growing proportion of people in need of care by others. Nursing home care is very expensive, and there are substantial concerns about the quality of care provided. Paid home care services are developing but apparently will not significantly reduce the need for nursing home care. For children, the use of paid care, particularly center and family day care, has increased rapidly over the last 20 years as the proportion of chil- dren in two-earner and in one-adult families has increased. There is evi- dence that adequate care for infants, for children with disabilities, for eco- nomically disadvantaged children, and for children whose parents work nonstandard shifts are in short supply. Very little is known about the care that working-age adults with disabilities now receive. Inadequate wages, poor training, and high turnover among staff nega- tively affect the quality of paid care that is available for both children and the elderly. Improved standards and increased regulation of care will in- crease costs, however, and questions have been raised about the effective- ness of regulations. The work-family conflicts now experienced by adults in the work force, and the frustrations of those who are not but would like to be, are likely to increase with time. While government policies and programs can play some role in their solution, employers are likely to be called on to play a major role as well.
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Representative terms from entire chapter: