But US voters still want drug pricing reforms, a new Data for Progress survey finds.
The pharmaceutical industry is enjoying new popularity with the American public after delivering effective Covid-19 vaccines at record speed, according to new polling from Data for Progress.
But that doesn’t mean voters have lost their interest in bringing down prescription drug costs, the same survey finds.
More than half of voters, 56 percent, say they have a favorable view of pharmaceutical companies in the Data for Progress poll of 1,225 likely voters conducted in late March. Just 24 percent said they have an unfavorable view.
That is a substantial improvement in public feelings toward pharma from a November 2019 Data for Progress poll that found 48 percent of voters had a favorable view of “pharma research companies” and 38 percent had an unfavorable view. In September 2019, a Gallup survey showed the industry’s reputation in even deeper trouble before the pandemic, with 58 percent of Americans holding a negative view of drugmakers and just 27 percent saying they had a positive opinion.
It is not hard to understand why the public is feeling so magnanimous toward an industry that is usually a political villain. Pfizer, Moderna, and Johnson & Johnson have all developed effective Covid-19 vaccines in less than a year (the previous record for vaccine development was four years). Those specific companies are even more popular than the drug industry as a whole: Pfizer has a 65 percent favorability rating, Moderna is at 60 percent, and Johnson & Johnson registers 68 percent favorability.
More than 100 million Americans have received at least one dose of a vaccine. A return to relative normalcy in the US by this summer is actually plausible. The industry can rightfully argue it delivered critical innovation at a moment when it was desperately needed (though those efforts were supported by a lot of public investment).
Pharma’s popularity is a stark reversal from the past decade, when headlines about price-gouging induced bipartisan outrage and lawmaker interest in policy changes that would reduce drug costs. But though the public seems grateful for the industry’s work on Covid-19, they are still supportive of drug pricing reforms, according to Data for Progress.
Three-fourth of Americans say they disapprove of how drug companies are handling the rising cost of prescription drugs. And 77 percent said that while pharmaceutical firms did a good job developing the vaccines, they still need to be regulated to reduce drug costs; just 16 percent said drug companies shouldn’t be burdened with any more regulation because it would prevent the development of new treatments.
Proposals to allow Medicare to directly negotiate with drugmakers on prescription drugs, to allow the federal government to manufacture generic alternatives to brand-name drugs, and to link US drug prices to the prices paid by other countries are all supported by strong majorities of the American voting public.
But public support for reforms has not always translated to government action. Pharma enjoys massive clout with Congress and the rest of the federal government. As I reported in December, the drug industry’s reputation is just one reason lobbyists and policy experts are skeptical about major movement to rein in drug costs over the next few years.
“Now that it’s looking like we’ll have successful vaccines, drug companies could come out of this pandemic as heroes that saved us from the evil virus,” Larry Levitt, executive vice president at the Kaiser Family Foundation, told me. “That will make it harder to demonize the pharmaceutical industry in a fight over drug pricing.”
For now, the Biden administration and Democrats in Congress are still promising big actions. The Wall Street Journal reported this week that a provision to give Medicare more authority to negotiate drug prices directly with manufacturers is expected to be a priority for Biden’s next legislative push. There could also be smaller, more targeted reforms that attract bipartisan support, particularly those that encourage the development of generics. And Biden has plenty of administrative authority to set up pilot programs or pursue other policy changes in Medicare and Medicaid that could reduce the cost of medications, as I reviewed a few months ago.
The drug pricing issue is a complicated one, in part because it’s actually two distinct problems. One is the actual list prices set by pharma companies, which most insured patients and health systems don’t actually pay but that still set the top line from which various discounts and rebates are applied. (And for the uninsured, that is their price unless they get some kind of assistance.) The other issue is out-of-pocket costs, or what patients must pay under their insurance plan.
But regardless, depending on the specific policy, Congress and the White House risk alienating drug companies, hospitals, doctors, or all of the above when they discuss how to bring down health care costs. That’s why it’s proven so hard to get anything done.
Activists argue that the urgency of reducing drug costs for Americans has become only more apparent during the Covid-19 pandemic, even if pharmaceutical companies try to use their success with vaccines to their political advantage.
“If there is anything that this pandemic should have taught us, it’s that something should be done. We shouldn’t allow ourselves to think it’s not possible,” Dana Brown, who promotes drug pricing reform for the Democracy Collaborative, told me in December. “Can we literally afford the status quo? For me, the answer is no.”
The American public has been demanding action on drug prices for a while, with limited success. Millions still struggle to afford necessary medications. This Data for Progress polling suggests Biden would have voters behind him if he decided to tackle drug costs, even with the industry’s vaccines set to bring the pandemic to an end.
Early education in the US is endlessly convoluted, and a massive expense for lower- and middle-class families. What if the solution were as straightforward as making child care a “good” job?
When I graduated from college in the mid-2000s, I moved to Seattle to find a job waitressing. After weeks of handing over résumés, I was still unemployed. Then I saw an advertisement in the local alt-weekly for a teacher’s assistant position at a preschool, just across the street from the University of Washington. I’d babysat, usually for around $2 an hour, since fifth grade. Infants, toddlers, 4-year-olds: I’d spent endless hours with them all, sometimes all at once, sometimes even overnight. I had great references. I got the job, which paid $8 an hour — just over the state’s then-minimum wage of $7.16 — almost instantly.
In the toddler room, where kids were between 1 and 2 years old, another teacher and I handled the care of a dozen squawking, endlessly curious kids. The job, as anyone who’s worked in a child care center or preschool can tell you, is incredibly physical; I was sore every night in some new way.
This was before the Affordable Care Act, and I had no health insurance. I caught colds and flus from the kids, got the familiar tingle of strep throat, but instead of getting antibiotics, I let it ride out, lucky it didn’t get worse. I was living with three friends in a small house nearby and watched as the $500-a-month rent, plus $80 a month for a subsidized bus pass, ate up the majority of my paycheck. I tried to cut costs by grazing on the leftovers of the food provided for the kids for breakfast and lunch. My small savings, accumulated over the summer while working at a dude ranch, began to dwindle.
When a friend told me about a nanny agency that could get me at least $13 an hour, paid time off, and a stipend for health insurance, how could I say no? I could’ve taken some night classes to get my early childhood accreditation, but that would bump my pay by a dollar, maybe slightly more. I loved those kids, and I honestly loved the group care environment, which would stand in stark contrast to my long, lonely days as a nanny. But I couldn’t survive on the pay long term. So I became a statistic: one of hundreds of thousands of workers who leave early childhood care and education — an umbrella term for home child care, child care centers, and private and public preschools for children under 5 — every year for higher-paying work, whether at the Starbucks down the road or in the K-8 public school system.
The vast majority of early childhood jobs, at least as they’re currently conceived, are not good jobs. The pay is breathtakingly low: In 2019, the median was $11.65 an hour, or $24,230 a year. As a result, turnover is incredibly high. A recent study in Louisiana found that every year more than one-third of early childhood educators leave their jobs. Not for competitors, not for slightly higher-paying jobs. They leave the sector altogether.
Between 43 and 54 percent of early childhood workers are enrolled in some form of government assistance; in most states, the share of the workforce living below the poverty line is somewhere between 15 and 25 percent. An ongoing study of 49 early childhood education (ECE) centers in Seattle and Austin found that 42 percent of the workforce was food-insecure. Like other fields with low pay and the subsequent stress and anxiety that accompany poverty, workers have higher rates of chronic disease and are two to five times more likely to report clinically depressive symptoms.
Child care workers are paid so little, yet the cost of care continues to rise. “Child care is my second mortgage,” one friend, who’s solidly middle-class enough to have a first mortgage, told me. “I’m lucky that I don’t have student loans, because there’d be no way for me to pay those plus what I’m paying for two kids,” said another. Parents love their children’s teachers and caregivers, but when confronted with the reality of their low pay, they also wonder: Where is all the money going?
These are the hallmarks of a broken system. The cost of care places an unsustainable burden on parents, working to hollow out the middle class and close it off to lower- or working-class parents, but the wages keep many practitioners teetering on the edge of poverty, prompting many of those most adept at the work to seek employment elsewhere. Early childhood care is, as one policy expert put it to me, a total market failure, and has been, whether we realized it or not, for decades.
How do you fix a fundamentally broken system? It’s not as simple as blowing it up and starting over. The failure is so textured, so tied up in ideas of gender and race, of women and work, of “choice” and “kids are best cared for at home,” solutions thus far have largely been piecemeal: Add an incentive here, cut a cost there, even take the big step of establishing universal pre-K. Some of these reforms have meaningfully changed kids’ (and parents’) lives, but the entire process feels, as Lea Austin, executive director of UC Berkeley’s Center for the Study of Child Care Employment, put it to me, “like pouring water into a bucket with a hole in the bottom.”
The first step toward lasting reform has to be a conceptual one, the sort that will have cascading effects on the entire sector and our society as a whole. We can start thinking of early child care and education the same way we think about public parks or sanitation or libraries or public schools: as a public good, foundational to a functioning society regardless of whether you directly benefit from its existence. Like other public goods, access shouldn’t be limited by employment, income, or location, and those who make it run should, at the very least, be paid a living wage.
This scenario is only possible, of course, when and if early childhood care is robustly funded with tax dollars, just as public schools are. To be clear, tax dollars are already being used to inadequately prop up the system, whether in the form of vouchers for parents, pay supplements for teachers, incentives for practitioners to pursue ECE degrees, or government assistance programs such as Medicare and SNAP for child care workers who cannot pay their bills or provide for their families with their current wages. What if we stopped using tax dollars and massive additional portions of our income to keep pouring water in the bucket, and just plugged the hole?
That sounds like a straightforward solution, and in some ways it is. In other ways, it’s endlessly complicated. The conversations most people have about child care usually start with the astronomical cost, touch on the difficulty of waiting lists, glance toward the difficulty of finding a “good fit” (often code for perceived quality), and then stop. Families somehow figure out a way to make it work, even if that means someone dropping out of the workforce, relying on informal “kith and kin” care, or emptying out savings, and then everyone breathes a deep sigh of relief when the youngest kid hits kindergarten. The struggle to pay for care is acute, but ultimately too short-lived to accumulate political might.
That can change. Regardless of whether you have children, whether you have three in care or yours have already left the home, we can identify the burden — and the way it exacerbates racial inequities, sustains the gender pay gap, discourages parenthood, and generally makes life really, really hard for millions of people — and agree it doesn’t have to be this way.
In the United States, child care (like paying for higher education) is conceived of as an individual problem, with individual solutions. There is an alternate reality for the United States, a clear fork in the road we didn’t take. Back in 1971, the Comprehensive Child Development Act made its way through Congress with overwhelming bipartisan support. Building on the success of Head Start, which had launched in 1965, the Child Development Act would’ve made high-quality child care available for all on an affordable, sliding scale basis. Nixon vetoed the bill — a move that, as Anna K. Danziger Halperin, a historian of the child care movement, explains, “surprised even officials within his own administration.”
The reasoning, according to Halperin, was fear from the right wing of the Republican Party that the bill would encourage women to join the workforce, thereby destroying the “integrity” of the middle-class family unit, while also providing solutions that felt dangerously close to communistic, “un-American” care. There was also conservative concern that the bill was an “overreach” into the lives of low-income people, and that its primary beneficiaries were families of color. As Elizabeth Palley, a professor who studies the history of child care, told Vox’s Anna North, “White people don’t want to pay for Black people’s children to be cared for.”
/cdn.vox-cdn.com/uploads/chorus_asset/file/22414716/Spot1_v2.png)
Decades later, patriarchal fear is still alive and well, as evidenced by the state of Idaho’s rejection of $6 million in early education funding in March. “I don’t think anybody does a better job than mothers in the home, and any bill that makes it easier or more convenient for mothers to come out of the home and let others raise their child, I don’t think that’s a good direction for us to be going,” state Rep. Charlie Shepherd said during the discussion of the bill. “We are really hurting the family unit in the process.”
It’s too simple to just blame a bunch of right-wing conservative men for where we’ve found ourselves; the idea of child care as an individual responsibility was, however inadvertently, supported by feminists as well. After Nixon vetoed the Child Development Act, the broad coalition that had worked to get it through Congress dispersed, including various feminist groups whose focus shifted to getting more women into jobs and combating the gender discrimination that faced them once there.
“They stopped fighting for child care, and other sorts of collective issues, and really focused on individual professional success,” Halperin tells me. “When you think of child care as a personal choice, it creates all of these new inequalities. Women of color, Black and immigrant women — they end up caring for the children of professional women. Those professional women, in turn, don’t want their whole paycheck going to child care, so it gets undervalued and underpaid.”
This attitude has long been part of the critique of second-wave feminism. In its focus on getting women into the workforce, the movement lost sight of the inequities that were reproduced and exacerbated in the process. Indeed, many white, educated women were satisfied with the child care situation as it was, even with low pay levels for workers, because it still fundamentally worked for them. As more and more of those women entered the workforce, regulations that govern the ratio between children and caregivers expanded, and insurance, real estate, and staff turnover costs continued to rise.
Finding affordable, reliable care has never not been a problem for lower-income women, particularly for women of color. But as early as 1979, Columbia professor Jane Price, author of How to Have a Child and Keep Your Job, was referring to the difficulty of finding care, particularly in the suburbs, as “a crisis.” Price predicted that the problem, if ignored, would only get worse, and she was right. Between 1970 and 2000, the cost of care per child rose 200 percent; today, the average cost of care for families with children under 5 hovers around 10 percent of a family’s monthly income, with many families paying considerably more.
The pandemic has clarified just how dire the situation has become, and there are hopeful steps forward in raising pay and creating universal or sliding scale programs in pockets all over the United States. President Joe Biden’s stimulus plan includes more than $25 billion to support child care centers and $15 million in child care assistance to families, as well as a $3,600 annual tax credit for every child under 6 (and $3,000 a year for children between 6 and 17). Richard Nixon he is not; his forthcoming infrastructure bill will have a child care component, too.
But any lasting solution to our current crisis demands a shift in our thinking when it comes to accessing high-quality early childhood care: from a personal responsibility to a public good. If you have children, this shift will directly benefit them — but it will also benefit you, as their parent, and whoever else’s mental and financial load is lessened as a consequence. It will benefit employers, who, as the pandemic has shown, rely on their employees having access to reliable care. It will benefit their coworkers without children. And, for countless reasons, it will benefit the caregivers themselves, providing a pathway into the middle class, but only if we transform ECE work into a “good job.”
There’s a pretty straightforward way to do this: Pay early childhood teachers like public school teachers. Providing quality care is expensive. It just is. In fact, it is too much for individual families to bear — just like hiring teachers to provide care for K-12 students would also be too much to bear, and is the reason we have a publicly funded school system. Even if you don’t have children, you can see the benefits of a public school system. The same should hold true for a publicly funded care system, in whatever form that might take.
Right now, depending on the state, a pre-K teacher with a bachelor’s degree can make up to 50 percent less than a kindergarten teacher. In Vermont, the difference is about 17.2 percent — the sixth-smallest such gap in the country. Lawmakers know it’s still not enough. H 171, currently moving through the legislature in Vermont, with two-thirds of the House of Representatives signed on as co-sponsors, aims to close the pay gap entirely, while also paying off existing student loans for educators in the system in order to increase retention.
The state bill, if passed, would add an estimated $13 million to the yearly budget. As with its previous bailout of the industry during the height of the pandemic, the legislature seems to understand that a healthy economy is only possible with a healthy child care system. H 171 promises to fundamentally remake the child care system in the state: No family would be asked to pay more than 10 percent of their income for care, hundreds would be able to stay in their profession, and it would significantly decrease the 10.9 percent of Vermont care workers who, as of 2020, lived in poverty. Just imagine the effect that a similar bill would have in Tennessee (where 22.9 percent of the ECE workforce is in poverty), or Nebraska (29.2 percent), or New Mexico (27.4 percent).
“The people who do the work are the linchpin of good child care and good early learning,” Lea Austin, with UC Berkeley’s Center for the Study of Child Care Employment, explains. “The stability of the workers in a particular program, the continuity of their relationships with children, all that is disrupted when we have turnover. It’s disruptive to the children and their families, and it’s disruptive to the centers, who have to do the hiring, recruiting, training, and all those costs, and it’s disruptive to the employees who remain in the program, who have to take on extra work. There’s a ripple effect, all around.”
There’s a ripple effect when the job is unstable, and there’s a different ripple effect when you stabilize the job. Decrease the stressors in workers’ lives — their need to worry about groceries or their own children’s care or health care — and they become better workers. This is particularly important for child care and child education, which calls workers to be fully engaged and attentive. “It seems obvious,” Austin says, “that we would want anyone working with children to be healthy and supported and as present with children as they possibly can be. We have to provide the conditions for them to do so.”
Most advocates, policymakers, and caregivers that I spoke to agreed that a publicly funded system should not simply require existing elementary schools to extend care. This is where choice can really be preserved: If you’d rather your child go to the home of a certified caregiver in your neighborhood, or someone from your same cultural or linguistic background, those caregivers can also receive funding. They’re entrepreneurs and small-business owners, who, as any politician will tell you, form the backbone of the American middle class. And, in this case, they’re almost all women, and an estimated 40 percent are women of color.
“When we talk about universal child care, that doesn’t mean that all kids, from 0 to 5, need to be in school,” Juliet Bromer, a research scientist at the Erikson Institute in Chicago, tells me. “It means honoring these places and spaces that families have long relied on. For some people, that might be a center, but for many, it is not.” Bromer points out that when we talk about “quality,” we often talk about low ratios of teachers to children and accreditation, which is important but misses less quantifiable components. “One dimension of quality, especially for Black and brown children, is being in a setting where you’re really able to see yourself,” Bromer said. “That really happens with home care, particularly for Black boys, who, in a school setting, have to have this sort of vigilance.”
That’s exactly the sort of care that small providers like Miren Algorri, who has run a child care center in Chula Vista, Texas, since 1997, wants to provide. It’s most possible when she and her employees are making a living wage, which is what she, along with her union, Childcare Providers United, has been agitating for in the state of California.
“If we could have quality care, and keep this small ratio, it would be a dream come true,” Algorri says. “To have that peace of mind, knowing that at the end of the month, we’d have some money left to buy a book! I’d have an extra $20, as opposed to wondering, ‘How do I pay my electric bill?’ I live very close to the border, so a lot of my colleagues are postponing their medical checkups, because they usually go over the border to Mexico. Why should we have to do that? Why do I have to put my health on the back burner so I can continue to perform as a public worker?”
Like many forms of feminized labor, child care has long been thought of as part of the domestic, private sphere — something that comes “naturally” to women and, as such, something that any woman can do well, instead of a discrete skill. I’m personally good with children not because I’m a woman, but because I spent years figuring out how to do the work, and I’m not nearly as good with kids as the people who’ve made this their life’s work. Not even the scarcity of child care over the past year and the rippling effects on the economy and millions of parents’ mental health has effectively driven home just how essential, how valuable, this work really is.
“The job of caring for and educating young children is so hard, and so complex,” Lea Austin explains. “People understand that it’s low-paid work, but they have no idea how low. I’ve found myself in meetings, even with people who work in the sector, in various policy roles, and you put out that number, that the median wage for a child care worker is $11.65 across the country, and that more than half of ECE workers use aid programs, and sometimes there’s an audible gasp. When people make that connection and understand the consequences, they find it shocking and egregious.”
Yet most people don’t make that connection. As Austin explains, “work performed by women and performed by women of color is historically undervalued. We have a convergence of those two categories in the ECE workforce.”
“Don’t get me started on the racism and sexism,” Algorri told me. “Our work is infantilized and minimized, and the vast majority of it is done by women like myself, a woman of color.”
It’s incredibly difficult to elevate any occupation that’s undervalued. When a type of labor is not considered a skill or is conceived of as something that people “naturally” want to do for free, it keeps wages down. When wages are low, employers have to lower their necessary qualifications, which in turn reinforces the idea that the work is unskilled. In most child care centers in the United States, teaching assistant positions require only a high school diploma or GED, plus a background check. Teacher positions require an associate or bachelor’s degree in ECE, but the pay bump is so small that many who obtain their certification, which extends to children in third grade, move to the K-8 system. Various government programs have attempted to “upskill” the profession, encouraging existing care workers to pursue certification, but the low pay remains a consistent barrier.
“I’ve seen providers have to close their doors because they cannot find or pay an assistant,” Algorri says. “I’ve been lucky, but I’ve sacrificed a lot to keep the quality of assistants over the years. It’s disheartening, because providers will have to downsize, going from a license for 14 kids down to eight or six, because they just can’t afford to keep paying, which then causes issues in the community because people need care for infants or toddlers but they can’t find it anywhere.”
There’s demand, in other words, but at current pay levels, inadequate supply, which can lead to “child care deserts” — places where infant to 3-year-old care is incredibly difficult, if not impossible, to find, no matter the cost — in urban, suburban, and rural areas. In Crawling Behind: America’s Childcare Crisis and How to Fix It, Elliot Haspel points out that as many as 95 percent of Americans live in child care deserts, where three or more children are in need of care for every available spot; people with above-average income are as likely to live in these areas as people with less income. The number of centers and homes providing care simply cannot keep pace with the demand. Before the pandemic, centers, some of them the only infant-to-3-year-old providers in the area, were closing at alarming rates. As of March 2021, an estimated 20,000 care centers have closed permanently.
In its current figuration, child care is not a lucrative business. Unlike so many other industries, demand is simply not enough to spark the creation of new businesses. That’s how broken the market is, and without a significant refiguration of funding sources, it’s not going to change. In Texas, like many states, the state workforce commission has allocated funding to subsidize students pursuing degrees in “high-growth, high demand, and emerging occupations that are critical to the state and local economies.” Depending on the location in Texas, targeted occupations include registered nurses, electricians, dental hygienists, respiratory therapists, and many more.
As Cathy McHorse, who heads up the United Way’s Success by 6 program in Travis County (home to Austin), told me, early childhood educators are nowhere to be found on the list. “Child care would qualify,” McHorse says. “But we can’t be a ‘targeted’ occupation because the job doesn’t make a living wage. You’d get the degree, and your wages wouldn’t change.”
Betsy, who currently lives in South Carolina, has a bachelor’s of science in child development. She’s worked in the field for 14 years, and most recently worked as a teacher’s aide for a Montessori public charter school, pulling in $19 an hour because of previous experience. She lives in a 600-square-foot apartment with her dog, and had to take on a second job waiting tables to cover costs. “I was so miserable and exhausted,” she says. She lost her Montessori job with the pandemic, but has been making solid money — around $25 an hour — tutoring kids doing remote school. Now those kids are back in full-time school, and she’s applying to preschool teacher and kindergarten assistant positions. The highest she’s been offered is $15 an hour, which, she says, you can make at Target for a lot less effort. She’s decided to drive for Uber Eats instead.
/cdn.vox-cdn.com/uploads/chorus_asset/file/22415070/spot1_v3.png)
In Missouri, Danielle has worked as a senior development teacher at a center that doubled as a university learning laboratory for four years, and has a degree in ECE with a focus on teaching young children. Her salary is currently just over $28,000, and even though she splits rent for a small home with her partner who works at a nonprofit, they still struggle to cover costs from month to month and live paycheck to paycheck. Her student loans have been in forbearance since she graduated from college in 2019. She recently watched a coworker leave her position to work at a bank, where she now makes double her old salary. Other coworkers regularly leave for fast food jobs.
At a previous center, the director would often tell workers to be mindful of just how lucky they were, despite their low pay, to have health insurance and paid leave. “But these are basic needs of employees,” Danielle tells me. “Health insurance is a need, not a want. Paid leave is necessary for teachers to still maintain their own lives outside of work.”
“It makes me feel so underappreciated that teachers working in K-8 are taken more seriously and paid way more than ECE educators,” she continues. “But there is a vast difference in how our society views K-8 teachers compared to ECE.”
All over the country, there are people who feel called to the work, who want to continue doing the work, but simply cannot afford to keep doing the work. Because in the end, none of the piecemeal solutions actually address the real problem: that instead of figuring out ways to make care into a public good and caregiving into a good job, many people still think that women, preferably children’s own mothers, should be doing this work for free.
“Here in Charleston, there are many [ECE] jobs that start at $9 and $10 an hour,” Danielle explains. “The profession seems to be looked at as a babysitter, something that a housewife can do for some extra cash,” she says. “But that’s not how we provide quality education and care, and that’s not a living wage.”
Over the past 50 years, the decline of the American middle class has been inseparable from the decline in unionized manufacturing jobs, which paid well enough for many families to be supported by a single salary. As those jobs disappeared, more and more middle-class women entered the workforce, spiking the demand for child care outside the home. The two shifts cannot be untangled: As one sector declined, another rose, at least in part, in response. Both were performed by a mix of workers with and without college degrees, but for many reasons, including a burst of anti-union sentiment and a resistance to viewing child care as a skilled profession, the child care workforce did not unionize en masse. Even as the workforce became more and more essential, the jobs never even came close to providing the sort of pay and benefits that made a manufacturing job a potential pathway to the middle class.
Those manufacturing jobs aren’t coming back, at least not in any approximation of what they once were.
Instead of waxing about their decline, we could shift our attention to transforming a whole sector of existing jobs, jobs with incredibly high demand, jobs that serve as the backbone of our personal and public lives, into good, middle-class jobs. This transformation could have cascading effects on the lives of the existing, majority-white middle class, many of whose middle-class salaries depend on the ability to access care. The greatest economic effect, however, would be to open up the middle class to over 2 million caregivers — and remember that 40 percent are women of color.
UC Berkeley’s Center for the Study of Child Care Employment has calculated what it would cost to transform each state’s current system into one that was “values” based, with a “well-qualified and fairly compensated early care workforce” providing high standards of care. In Missouri, where Danielle lives, the proposed increase in funding would raise salaries for early educators with bachelor’s degrees to $49,626 (on par with elementary and middle school educators) and teacher’s assistants to $29,776. Both positions would come with benefits including paid time off and health insurance.
With this proposal, Danielle’s current income would be doubled. “It would change my life significantly,” she says. “It could lead to me living a comfortable, less stressful life. I could pay off my debts, my student loans, and even be able to save for my future.” Doubling pay might seem extreme, but these salary increases aren’t exorbitant. What they are is stabilizing: for the millions of kids in care, for the millions of parents who depend on it, but also for the millions of women who do this work.
“The stimulus plan is an interesting opportunity to say, we’re capable of making significant investments in people when everyone can see the need,” Molly Sullivan, the director of national initiatives at First Children’s Finance, says. “We don’t often publicly talk about not being able to afford child care. It’s often a private struggle that we keep out of the spotlight, and I think there’s an opportunity to see this as a wake-up call. It’s okay to acknowledge that what we were doing in the past wasn’t working, so let’s build a system that didn’t exist.”
That system will be complicated. You can read about what happens when you extend universal pre-K, as New York, Boston, Nashville, San Antonio, Charlotte, and a handful of other cities have, and don’t consider what sucking the older students out of the system does to drive up the price of toddler and infant care. You can deliberate whether the funding should come directly from the federal government or remain the provenance of the states, and how that will reinforce existing discrepancies in educational outcomes in places like Idaho and Mississippi that refuse federal dollars. Some people told me there’s too much demand in some areas with universal pre-K, with the same long waiting lists as private preschool, and others directed me to complicated rules about when a pre-K student enters the system, which then make it difficult to give a kid an extra year, if they need it, before moving on to kindergarten.
It’s a tangled set of problems, set against a backdrop of historical and cultural prejudices — and an undeniable part of the current quagmire, as Anna North recently argued, is the sheer number of hours that Americans have to work to arrive at a living wage. But as Sullivan put it to me, “as a country, we have proved that we can tackle big, complicated, incredibly complex things, from the WPA to the Covid vaccine rollout. This is just an area where policy has not really ventured yet.” At least not in a substantive way that doesn’t just fiddle with the margins — and at least not since 1971, when Nixon chose that other fork in the road, and mired us in our current, broken approach.
We’ve shown that we can care about inequities even when they don’t primarily affect us. We’ve shown that we can support public projects even when we are not the primary beneficiaries. If you’re drowning in child care costs right now, probably none of this will get done in time to help you. That’s the thing about conceiving of child care as a public good: It will serve you, someday, in ways you might not yet appreciate. A public good is good, in some way, for everyone. Plug the hole in the bucket, and the benefits overflow.
If you’d like to share your experience as part of the hollow middle class with The Goods, email annehelenpetersen@vox.com or fill out this form.
The legal arguments in Kelley v. Becerra aren’t exactly good arguments, but five justices have signaled that they agree with them.
Tell me if you’ve heard this one before.
A team of conservative activists filed a lawsuit last year which asks the courts to strike down several key provisions of the Affordable Care Act. The plaintiffs’ legal arguments are at odds with longstanding precedents, but the case is assigned to a very conservative Republican-appointed judge. And that judge has already signaled that he’s likely to rule in those plaintiffs’ favor.
Kelley v. Becerra is the fourth round of litigation attacking major provisions of the Affordable Care Act. It seeks to take out several provisions of Obamacare governing which forms of preventive care — things like birth control or vaccinations or cancer screenings — must be covered by health insurers. And it primarily relies on the kind of legal arguments that fell out of vogue in the federal courts more than 80 years ago.
But there’s a twist. Though the primary legal argument in Kelley is tough to square with existing legal precedents, five members of the Supreme Court recently signaled that they intend to abandon longstanding legal principles in favor of the same interpretation of the Constitution proposed by the Kelley plaintiffs.
The case, which was filed in a federal court in Texas, is being heard by Judge Reed O’Connor, a former Republican Capitol Hill staffer who once ruled that the Affordable Care Act must be repealed in its entirety. (That case is now before the Supreme Court, and a majority of the Court appeared likely to reject key parts of O’Connor’s arguments when the case was argued last November.)
So the Affordable Care Act’s preventive care provisions could be in for a rough ride. Their immediate fate rests in the hands of one of the most partisan judges in the country. And a majority of the justices recently signaled that even fair-minded judges should look upon these provisions of Obamacare with extreme skepticism.
The Affordable Care Act’s preventive care provisions, briefly explained
Several provisions of the Affordable Care Act require group and individual health plans to cover various preventive treatments and to not “impose any cost sharing requirements,” such as copays, for them. When Congress wrote Obamacare, however, it did not itemize which treatments must be covered. Instead, it delegated that power to three different government bodies.
An expert panel known as the United States Preventive Services Task Force (PSTF), for example, has the power to place many health services on the list of services that insurers must cover without imposing out-of-pocket costs on patients. Another panel, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention, may add vaccines to the list. And the Health Resources and Services Administration (HRSA), a federal agency within the Department of Health and Human Services, may require insurers to cover “preventive care and screenings” for women and children.
Congress had a very good reason for writing the statute in this way. If Obamacare had itemized which health services insurers must cover when the law was written in 2010, then Congress would have needed to pass an entirely new law in order to add new items to this list. Covid-19 did not even exist in 2010, for example. So, if Congress had decided to itemize which vaccines insurers must cover in 2010, it couldn’t have known to include the Covid-19 vaccine on that list. (The federal government is purchasing Covid-19 vaccines for public use, but once the initial vaccination campaign is over, it may make sense for private insurers to take over the burden of paying to vaccinate children or teenagers when they reach a certain age.)
The three federal panels and agencies have placed about 80 items on the preventive services list. That list includes things like blood screening for newborns, vision screening for children, contraceptive care, pap smears, and screening for conditions like depression, hepatitis, HIV, and some forms of cancer.
And yet, the plaintiffs’ theory in Kelley could potentially endanger patients’ access to all of these health services — although the full implications of this lawsuit are a bit nuanced. If the plaintiffs’ theory prevails, insurers could be free to refuse to cover preventive care services or, at the very least, to impose new costs on patients who seek those services.
So what are the Kelley plaintiffs’ arguments?
The plaintiffs in Kelley are an array of religious conservatives, and what Judge O’Connor labels as “Free-Market Plaintiffs,” who wish to purchase health plans that do not cover some of the preventive services that insurers are currently required to cover.
Some of these plaintiffs, for example, object to a requirement that insurers pay for pre-exposure prophylaxis (“PrEP”), drugs that are very effective in preventing the transmission of HIV, because those plaintiffs believe that PrEP “encourage[s] and facilitate[s] homosexual behavior.”
The plaintiffs raise a number of legal claims against Obamacare’s preventive care provisions, including a pair of constitutional arguments.
The first of these arguments claims that the PSTF and the ACIP, the two expert panels empowered to add items to the list of preventive services, are not composed of “officers of the United States” and therefore cannot wield regulatory power.
The Constitution provides that “officers of the United States” may only be appointed by the president, the “courts of law,” or the “heads of departments.” ACIP members — members of the panel that deals with vaccinations — are appointed by the Secretary of Health and Human Services, who unquestionably qualifies as a “head of department.” But members of the PSTF are appointed by the director of the federal Agency for Healthcare Research and Quality, and the director of this agency may not qualify as a “head of department.”
This argument about whether the members of these two panels were properly appointed, however, could prove to be a bit of a sideshow in the Kelley litigation because the plaintiffs raise a different constitutional argument that is very likely to prevail in the Supreme Court.
Under current law, Congress has broad authority to delegate regulatory power to federal agencies. As the Court held in Mistretta v. United States (1989), Congress may permit agencies to regulate private entities so long as it “lay[s] down by legislative act an intelligible principle to which the person or body authorized to [exercise the delegated authority] is directed to conform.”
Dissenting in Gundy v. United States (2019), however, Justice Neil Gorsuch proposed replacing this longstanding rule with a vague new standard that would effectively empower the Supreme Court to veto any regulation promulgated by a federal agency. And, while Gorsuch wrote that opinion in dissent, five justices have since signed onto the general framework that Gorsuch laid out in Gundy.
The framework laid out in Gorsuch’s Gundy opinion is complicated, and important parts of that opinion are so vague that it’s not possible to predict its full implications. But the heart of Gorsuch’s approach is that there should be strict constitutional limits on Congress’s power to delegate regulatory authority to agencies.
A federal law permitting agencies to regulate, Gorsuch wrote in Gundy, must be “‘sufficiently definite and precise to enable Congress, the courts, and the public to ascertain whether Congress’s guidance has been followed.”
And that brings us to the Supreme Court’s decision in Little Sisters v. Pennsylvania (2020). Little Sisters involved a Trump administration regulation that permitted employers with religious or moral objections to birth control to refuse to cover contraceptive care in their employee’s health plans. But, in his majority opinion upholding this Trump-era regulation, Justice Clarence Thomas also strongly suggested that the provision of Obamacare governing women’s preventive care is unconstitutional.
That provision, which permits HRSA to lay out “comprehensive guidelines” regarding which “preventive care and screenings” for women should be covered by insurers, gives HRSA “virtually unbridled discretion,” according to Thomas — a clear sign that Thomas and the four other justices who joined Thomas’s opinion believe that this provision is unconstitutional under the framework Gorsuch laid out in Gundy. (Thomas elected not to strike down the provision because “no party has pressed a constitutional challenge to the breadth of the delegation involved here.”)
The other preventive care provisions of the Affordable Care Act — the ones dealing with vaccinations, pediatric care, and other preventive care services — are similar to the provision dealing with women’s health care. And thus they are also potentially vulnerable under the approach that Gorsuch laid out in Gundy and that Thomas laid out in Little Sisters.
So what happens if the Kelley plaintiffs win?
In the short term, it is exceedingly likely that O’Connor will strike down the challenged provisions of the Affordable Care Act. O’Connor hears an unusually large diet of Obamacare-related cases, including the case where he ruled that the entire law must be repealed, because conservative litigants often intentionally file challenges to Obamacare in O’Connor’s court in the hope that the case will be assigned to him.
Yet, because O’Connor so frequently hands down orders benefiting anti-Obamacare litigants, his opinions sometimes reveal the limits of the judiciary’s power to diminish access to health care.
In 2018, for example, O’Connor issued an injunction forbidding the federal government from enforcing the requirement that health insurers cover birth control, at least with respect to individuals who “object to the Contraceptive Mandate for sincere religious reasons.” But, as O’Connor lamented in a more recent opinion, this injunction had little effect “because few, if any, insurance companies are currently offering contraceptive-free policies.”
So, even though O’Connor issued an order that permits insurers to offer contraceptive-free policies to people who object to birth control on religious grounds, the insurers themselves have elected not to do so.
A likely reason for this decision by health insurers is fairly straightforward. The cost of birth control is much less than the cost of a pregnancy. Indeed, one of the Obama administration’s arguments for requiring insurers to cover contraceptive care is that insurers would break even or even save money if they provide free contraceptive coverage to their customers.
For similar reasons, many insurers may still choose to cover many preventive treatments even if they are no longer required to do so. It may be cheaper, for example, for an insurer to pay for vaccines rather than to pay to treat the disease prevented by that vaccine.
But not all preventive treatments are likely to be cost-effective from the perspective of an insurance company driven solely by a profit motive. According to the National Cancer Institute, for example, the median age when a cancer patient is diagnosed with that disease is 66 years old — which means that the majority of cancer patients are over the age of 65 and therefore are eligible for Medicare.
For this reason, health insurers may not be willing to offer free cancer screenings to their patients, on the theory that the cost of paying for cancer treatments is likely to be picked up by the federal government.
The biggest victims of the Kelley litigation, in other words, could be patients who put off being screened for deadly diseases until after those patients are eligible for free care under Medicare — thereby risking that, by the time the disease is discovered, it may be too advanced to treat it successfully.
And yet, given the Supreme Court’s opinion in Little Sisters, there is a very good chance that this fate will await cancer patients and other people whose lives could be saved by preventive care.