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OCR for page 64
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
OCR for page 66
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
OCR for page 67
67
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OCR for page 68
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
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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
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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.
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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
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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
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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
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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
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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~.
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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.
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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
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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
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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.
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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~.
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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~.
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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~.
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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
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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
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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.
Representative terms from entire chapter:
nursing home
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