Care Matters: A 2024 Report Card for Policies in the States

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What You Should Know

Care policies impact everyone. Transformative investments in robust child care and early learning, as well as in home and community-based services and comprehensive paid family and medical leave are critical for families and communities. Together with paid sick and safe days and support for both the family caregivers and paid care workforce, these priorities help ensure gender, racial, and economic equity and a thriving economy.
This report, in partnership with Caring Across Generations, grades states on their care policies across multiple issues—child care and early learning, home and community-based services, paid family and medical leave, paid sick and safe days, fair working conditions for care workers, and family-supporting tax policies.
Despite tireless work from advocates throughout the country, the combination of limited financial resources, entrenched well-funded opposition, and a lack of political will have long stymied state progress on care policies.
The COVID-19 pandemic and pandemic-relief investments, including the American Rescue Plan Act, not only lifted the invisibility cloak that had hidden the nationwide need to invest in care, but also supported states to innovate and take action. The historic underinvestment in care, however, means that even those measures were not enough for any state to receive an A.
The top five highest-scoring states, in order, are Oregon (B+), Massachusetts (B), California (B), Colorado (B), and Minnesota (B). The five lowest-scoring states are Alabama (F), West Virginia (F), Florida (F), Wyoming (D−), and Idaho (D−).
The Century Foundation (TCF) launched its first care report card in 2021. The methodology has been updated for this current report card, so direct comparisons cannot be made, but the combination of both report cards makes it clear that the United States has a long way to go to enact comprehensive care policies.

Introduction

The Century Foundation published its first care policy report card, “Care Matters,” in 2021.¹ That report card graded each state on a number of supportive family policies and worker rights and protections, such as paid sick and paid family leave, pregnant worker fairness, and the domestic worker bill of rights. The 2021 report card revealed the tremendous gaps in state care policies and a fragmented and insufficient system of care workers and families in most states.² This update to the care report card, co-authored with Caring Across Generations, and with an updated methodology, takes another look at how states are doing.

In the years since the 2021 report card, the federal government invested unprecedented resources in care infrastructure through the American Rescue Plan Act (ARPA), which supported states to innovate and improve their policies, serve more families, and pay higher wages.³ Although they were short-term, the ARPA funds were a lifeline across the care economy and made clear what is possible when the federal government comes together with families, states, workers, employers, communities, and others to build the care infrastructure America needs. The historic lack of investment in care infrastructure means that even temporary investments make a big difference. At the same time, the historic lack of investment means even with progress, states still have a long way to go. Some of the progress made as a result of ARPA and related funding is not yet reflected in the grades due to lagging data. (See Appendix 3: Methodology and Data Caveats, for detailed information of data sources and analysis.)

The goal of this care report card is to show the status of essential care policies in the states. Grades don’t reflect the efforts of advocates and policymakers who have long fought for stronger care policies in their states, rather the political realities faced and the overarching need for federal and state investments. Substantial federal investment—on top of state and local prioritization—is needed to fuel economies, improve the well-being of children and families, create millions of good jobs, promote equity, and support disabled people and older adults to live independently with safety and dignity.

The Historic Undervaluing of Care

Care is, and has always been, woven into the fabric of daily life—from women doing a majority of unpaid care work at home, to the Black, Brown, and immigrant women supporting families in their homes through domestic work, and those providing care and support to children, older adults, and disabled people in their homes and communities. Despite the essential nature of the services that care workers provide, care work continues to be undervalued and underpaid. The devaluing of care work can be traced back to the use of chattel slavery in the United States, when Black women were enslaved and forced to care for the families of their white enslavers. The persistence of historical and present-day oppressions are embedded in the lack of commonsense public policies on care and the working conditions for care workers today. That’s why progress on building a care infrastructure does not just materially help those impacted, but also helps dismantle the legacies of racism, slavery, xenophobia, sexism, ageism, and ableism that have devalued care.

Despite the essential nature of the services that care workers provide, care work continues to be undervalued and underpaid.

Recent Changes in Federal Policy

The 2021 report card was published in the midst of the fight for the Build Back Better (BBB) care infrastructure policies, which ultimately did not pass, and so the current report card reflects the steps the United States has taken forward and backward since the first report card came out. Three legislative wins—the American Rescue Plan Act (ARPA), the Pregnant Workers Fairness Act, and the PUMP Act—have moved the United States forward in policies that prioritize care and caregivers, although the progress via ARPA was only temporary. At the same time, the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization was a major step backward that took away the rights of millions of women and has endangered the health and well-being of people trying to access health care.

American Rescue Plan Act and Build Back Better

The American Rescue Plan Act was a historic investment in states amid the broader context of an acute public health and economic crisis and decades of disinvestment in care infrastructure. The federal resources provided by ARPA included flexible funding for states, direct aid to families, and investments in critical areas of the economy.

ARPA helped stabilize and strengthen the child care sector, giving states close to $40 billion in federal emergency relief funds for child care, on top of $13.5 billion from earlier pandemic-relief packages, which proved a much-needed lifeline for many child care providers. While the pandemic sent the child care sector deeper into crisis, ARPA stabilization funds prevented it from collapsing altogether. The U.S. Department of Health and Human Services found that the $24 billion in relief funds distributed to states served 220,000 child care providers, saved the jobs of more than 1 million early educators, and enabled continued care for as many as 9.6 million children.⁴ ARPA also provided funding to reimburse child care providers for food costs, and provided states with funding to help make child care more affordable for families.⁵

Section 9817 of ARPA funding helped strengthen home and community-based services (HCBS) for older adults and disabled people by increasing funding for Medicaid-funded HCBS programs for two years.⁶ States received a temporary 10 percentage point increase in their federal medical assistance percentage (FMAP) for HCBS and were required to use the additional federal funding to supplement and not supplant state services by strengthening, enhancing and expanding their HCBS programs.⁷ This funding for HCBS—approximately $12.7 billion in federal dollars that leveraged $37 billion in state dollars—helped states to increase coverage, expand benefits, improve conditions for the workforce, support family caregivers, and improve how funding operates in the state to pay for state Medicaid programs.⁸

ARPA also included a temporary one-year expansion of the Child Tax Credit. In addition to raising the amount of the tax credit to a maximum of $3,600 per child age 5 or younger and $3,000 for children ages 6–17, from the previous amount of $2,000 per child, the expanded CTC was fully refundable and—for the first time—half of the credit amount was available as monthly payments, which helped families meet their budgetary needs as they incurred them. The expanded CTC significantly cut rates of child poverty, especially for Black and Latinx children. In 2020, the Black child poverty rate was 17.2 percent. With the CTC expansion, the Black child poverty rate dropped by more than half to 8.3 percent. Similarly, the Latino child poverty rate was 14.7 percent in 2020 and dropped to 8.4 percent with the expanded CTC.⁹

ARPA also included expansions to the Earned Income Tax Credit (EITC) and the Child and Dependent Care Tax Credit (CDCTC,) increasing the number of people who were able to benefit from these tax credits. The EITC was expanded to cover more low-wage workers without children. This was calculated to have benefitted 17 million adults in low-wage occupations, including child care workers, retail sales workers, and home health aides—occupations that are disproportionately composed of women.¹⁰ The CDCTC was also temporarily expanded by ARPA to be more generous, progressive, and fully refundable.¹¹

States were also given flexible time-limited funds through State and Local Fiscal Recovery Funds (SLFRF). These funds have allowed states to identify the most relevant investments, and many states have used these funds to advance care economy investments. For example, Colorado used funds from SLFRF to support the funding and implementation of its paid family and medical leave program,¹² Arizona used funds to provide child care to airport workers,¹³ and Nebraska increased rates for HCBS providers that provide assistance with day-to-day activities to people with disabilities.¹⁴

ARPA investments helped bring the United States closer to having a cohesive social and care infrastructure, but these one-time funds were time-limited.¹⁵ Since most funds have expired without renewal, there have been increases in child poverty rates,¹⁶ and child care programs have seen price increases and closures.¹⁷ The direct care sector continues to experience workforce shortages in every state due to stagnant wages. This is true even as the demand for aging and disability care in the home and community continues to increase and three-fourths of states have waiting lists for Medicaid-funded HCBS programs.¹⁸

Part of the reason why these negative consequences are surfacing now is because ARPA was only a temporary answer to the ongoing need to build a U.S. care infrastructure.

Part of the reason why these negative consequences are surfacing now is because ARPA was only a temporary answer to the ongoing need to build a U.S. care infrastructure. The care provisions in Build Back Better would have been core to the long-term solution. BBB included $400 billion to build a comprehensive child care and early learning system, including universal preschool for 3- and 4-year olds.¹⁹ It would have also included funding for HCBS, extended the ARPA child tax credit expansions, and offered universal preschool for 3- and 4-year olds.²⁰ While Congress successfully moved forward the climate and physical infrastructure provisions of Build Back Better, the care investments remain unfinished business.

Pregnant Workers Fairness Act

After more than a decade of advocacy, inspired by a 2012 op-ed by Dina Bakst, president of A Better Balance,²¹ Congress passed the Pregnant Workers Fairness Act (PWFA) with bipartisan support, and President Biden signed it into law in December 2022.²² The PWFA ensures that workers with limitations stemming from pregnancy, childbirth, and related medical conditions receive reasonable accommodations from their employer, as long as that accommodation doesn’t pose an “undue hardship” to the employer. Modeled in many ways after the American with Disabilities Act (ADA) and other civil rights statutes, this law ensures that pregnant workers are able to remain employed when pregnancy results in a limitation for the workers’ job duties.²³ The law covers a range of accommodations, many of which are low-cost and easy for employers to provide, including more frequent bathroom breaks, providing seating for pregnant workers, and temporarily changing work duties to avoid tasks that may be harmful, such as lifting heavy boxes.²⁴ Other transformative accommodations include time off to recover from childbirth, access to light duty and flexible scheduling for prenatal and postnatal medical appointments, the ability to avoid toxic chemicals, and lactation accommodations.²⁵ Although the federal law applies to every state, the extra credit granted in the 2021 report card is retained in this one for states who had their own PWFA’s in place, to provide these states the credit they deserve for being pioneers.

While state laws can exceed the protections afforded by the federal PWFA, to date, few states in practice have expanded on the current law post federal passage.²⁶ The Equal Employment Opportunity Commission recently issued a proposed regulation to ensure that the PWFA will be implemented effectively, including guidance around reasonable accommodations.²⁷ The PWFA is a strong and overdue protection for the health and safety of pregnant workers and this new policy will support workers in every state.

PUMP Act

The PUMP for Nursing Mothers Act was passed by Congress, with the Pregnant Workers Fairness Act, and signed into law by President Biden in December 2022.²⁸ The PUMP Act builds on a 2010 law that provided some nursing mothers with workplace protections to take breaks and have an adequate space to pump.²⁹ The PUMP Act extends the coverage of the 2010 law to millions more nursing mothers and includes additional protections such as enforcement provisions to hold employers that violate the PUMP Act accountable.³⁰ While the 2021 report card did not grade states on protections for breastfeeding, this law is an important advancement for mothers to have a safe and healthy work environment with respect for caregiving responsibilities.

Dobbs Decision

One of the most significant shifts in terms of the protections afforded to the people that live and work in the United States was the decision to overturn Roe v. Wade through the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization.³¹ The Dobbs decision fundamentally altered the care landscape in the United States by removing a constitutional right that Americans have had since the 1970s. Access to abortion is foundational for women’s freedom and economic security, and families’ ability to choose how they are composed. This is a care policy issue because it impacts people’s ability to make their own decisions about when and if to become parents or expand their families.³² A lack of a care infrastructure makes forced pregnancy more likely and more dangerous for families. The Dobbs decision has already led to significant negative consequences. Millions of people across the country cannot access legal abortions, and many cannot access abortions at all. Moreover, states with restrictions on abortion have seen declines in the supply of obstetricians, gynecologists, and other maternal care specialists as these doctors choose to practice in states where there is less legal risk to do so. As a result, maternal care in states with abortion restrictions has worsened.³³ While state decisions to protect or restrict abortion are not factored into state care report card grades, the legal status of abortion is an important component of a state’s care infrastructure.

State Care Report Card Grades

To date, thirteen states and the District of Columbia have passed paid family and medical leave and fifteen states and the District of Columbia have passed paid sick days policies. These states are some of the highest scoring. Historically, the District of Columbia was the most advanced in terms of child care and early learning policies. The ARPA funds supported other states to make improvements in affordability, stabilize child care supply, and expand pre-K, and even invest additional state dollars into child care and pre-K. However, lagging data means those changes won’t fully show up in the grades. Similarly, ARPA funds supported HCBS expansions in every state, and leveraged additional state dollars, but does not yet fully show up in the grades, including in terms of care worker wages.

Top Five States

The five highest-scoring states in this report card, in order, are: Oregon, Massachusetts, California, Colorado, and Minnesota. Oregon received the highest grade on the report card, a “B+,” while Massachusetts, California, Colorado, and Minnesota were the only states to earn a “B.” Oregon’s strong performance on child care and paid family and medical leave propelled it to the top of the care report card.³⁴ Minnesota made significant investments in paid family leave and paid sick days.³⁵ Massachusetts earned a B in large part due to its improvements in child care. California’s progress on child care, paid sick days, and paid family leave policies helped them score a B. Colorado’s strong paid family medical leave program, and comparative strength in home and community-based services helped it secure a spot in the top five best states.

The fact that no state received an A shows that critical improvements in care policies are possible and needed even among the highest-scoring states.

At the same time, the fact that no state received an A shows that critical improvements in care policies are possible and needed even among the highest-scoring states. For example, California can also maintain its leading edge on care by investing in home and community-based services, implementing a state public long-term care benefit similar to Washington State’s program, and establishing statewide collective bargaining rights for in-home supportive services (IHSS) workers, the largest direct-care workforce in the country. In Oregon, lawmakers failed to pass a bill that would have required the state’s labor agency to adopt the recommended compensation schedule for long-term care workers.³⁶ And in Massachusetts, paid family and medical leave currently can’t be taken to care for what are known as “chosen” family members (loved ones that the leave taker isn’t biologically or legally related to).³⁷ These leading states must continue to take steps to ensure inclusive and equitable investments in care.

Worst Five States

Unfortunately, there are still many states that lack comprehensive care policies. The five lowest-scoring states all had either a D– or an F grade. The lowest-scoring states are: Alabama, West Virginia, Florida, Wyoming, and Idaho. Many of these states lack even basic policies and protections. None of the worst five states have a statewide paid sick day policy or paid family medical leave policy. Florida has a list of over 77,000 people waiting to receive home and community-based services.³⁸ Alabama and West Virginia’s median hourly wages for direct care workers were $12.15 and $12.56 in 2022, respectively, far below the national median of $15.43.³⁹ And many of these states have failed to make progress on affordable child care that’s available to families when and where they need it. For example, in West Virginia there is only one child care slot for every eight children under the age of 6 with all their parents in the workforce, and child care is unaffordable for the typical family.⁴⁰

Map 1

Child Care and Early Learning

Comprehensive child care and early learning policies benefit everybody. They help improve economic prosperity and lead to greater gender, racial, and economic equity.⁴¹ These policies also support healthy child development and improved health, economic, and wellness outcomes that can persist into adulthood and even the next generation.⁴² A robust, high quality, comprehensive child care and early learning system would support family economic security and well-being—supporting the ability of parents to work and advance in their jobs and careers, early educators to be compensated well, child care fees that fit easily within family budgets, and an overall reduction in stress across all households. And in doing so, such a system would grow a state’s economic activity in the form of job creation and support, increased tax revenues, and other economic benefits.

To date, no state has adopted a comprehensive child care and early learning system that ensures families have nurturing child care and early learning options when and where they need them that don’t break the bank and compensate early educators well. As of the 2021 report card, the District of Columbia came the closest with Birth to Three DC and universal pre-K for 4-year olds. In 2022 and 2023, in the wake of the pandemic and unprecedented federal funding, many states made historic strides in dedicating funding to child care and early learning.

For example, the $24 billion in federal child care stabilization funds in the American Rescue Plan Act reached more than 220,000 child care providers across the United States.⁴³ They were used to temporarily pay higher wages through bonuses and stipends, support benefits such as health insurance, and cover non-labor operating expenses such as rent, mortgage, utilities, and supplies. Unfortunately, the stabilization funds expired on September 30, 2023. The abrupt end of funding leaves a child care cliff that will, over time, lead to higher prices, staffing shortages, and child care program closures.⁴⁴

Some states were able to meet the federal funding cliff with their own direct investments in child care programs and the workforce.

Some states were able to meet the federal funding cliff with their own direct investments in child care programs and the workforce. These new state funds will mitigate the harmful impacts of the federal funding cliff, but the positive effects of these new funds and policies may not yet be reflected in the affordability and supply data, which is from 2022. To be clear here, some states are making progress that may not fully be reflected in their grades. For example, legislatures in Alaska, California, the District of Columbia, Illinois, Kentucky, Maine, Massachusetts, Minnesota, New Hampshire, North Dakota, Vermont, and Washington all dedicated state funding for grants to child care providers, programs to support their child care workforces, or other solutions that directly support providers.⁴⁵ In addition, New Mexico became the first state to create a permanent fund for child care through a ballot initiative passed in November 2022,⁴⁶ and has dedicated some of their $150 million in annual child care and early learning funds to stabilization purposes.⁴⁷

Additional states invested federal dollars into stabilization as well. For example, when Wisconsin governor Tony Evers’s multiple attempts to move $365 million from the state’s budget surplus through the state legislature were blocked by legislative opponents, he reallocated $175 million in Federal Emergency Management Agency (FEMA) funds to cover half of the funding gap left by the end of the stabilization funding.45 In addition, Michigan used $30 million in federal funds for projects to strengthen early childhood workforce training, recruitment, and retention; Ohio used $30 million in federal funds in infrastructure grants for child care in underserved parts of the state, and Louisiana used new state funds to stabilize their child care sector.

In addition to the $24 billion in stabilization funds, ARPA and previous COVID-relief bills included nearly $19 billion to supplement the Child Care Development Fund (CCDF), or the Child Care Development Black Grant (CCDBG). This allowed them to expand eligibility, lower costs for families, adopt models that take into account the true cost of providing quality child care, and more. Some of those changes are reflected in the affordability and supply metrics and the child care wages, but due to lagging data, some improvements will not yet be reflected in grades. In addition, for both the stabilization and CCDBG investments, without sustained federal funding, or recurring state funds, states may struggle to maintain the investments they have made in the past two years.

Scoring

To measure states’ progress on supporting a robust, high-quality, comprehensive child care and early learning system, the care report card evaluates states’ on:

affordability for families, measured by family copayments relative to income and income eligibility thresholds in CCDBG;
a diverse supply of options, measured by the ratio of child care slots relative to children under the age of 6 with all parents working;
credentialing supports for early educators; and
progress toward universal pre-K, measured by preschool policies and investments that support pre-K for 3- and 4-year olds.

For more details on these metrics, please reference Appendix 3: Methodology and Data Caveats, below.

Affordability for Families

Child care is simply too hard for parents to afford in the United States. Child Care Aware® of America finds that in forty-one states and the District of Columbia, the average price of child care for two children in a center is more than the average rent or mortgage.⁴⁸ In thirty-two states and the District of Columbia, the average price of child care for an infant in a center is more expensive than in-state university tuition.⁴⁹

Families cannot access child care if it isn’t affordable.

Families cannot access child care if it isn’t affordable. When child care becomes unaffordable, oftentimes parents, and disproportionately mothers, decide to leave the workforce to take care of children.⁵⁰ While some parents may want to make this decision, it should always be a choice, not the result of a lack of options. This is especially true since a majority of children have all of their parents in the workforce,⁵¹ and since employment is tied to other critical benefits, including health insurance and retirement savings. Parents also need child care to attend education and training, to have time to search for a job, and for other purposes.

Ideally, measuring affordability would include how child care impacts all families across incomes. However, since long-standing public policies are restricted to assisting and collecting data for low-income families only, this score only refers to measures connected to CCDBG. Federal benchmarks suggest that families should not pay more than 7 percent of family income for child care. States received points for having copays that were lower than 7 percent for families receiving subsidies. States also received points for having higher income-eligibility thresholds than those specified in CCDBG. The federal law targets resources to low-income families, those earning up to 85 percent of a state’s median income. Despite this, many states’ average price of child care remains out of reach for families seeking care.⁵²

New Mexico and South Carolina had the highest scores for child care affordability, with both states earning the highest possible points by having $0 copays for a family of three at 150 percent of the poverty line and having an income eligibility threshold that exceeded 100 percent of the state median income. Tied for third were California, Georgia, Louisiana, Mississippi, North Dakota, Oklahoma, and Virginia. In a number of states, families paid a lower percentage of their income in copayments in 2022 than in 2021 as a result of ARPA funding. However, some of these were only temporarily reduced and have already reverted to previous levels.⁵³

Even for states doing well on child care relative to other states, improvements can be made to strengthen the child care system currently in crisis. For example, legislation in California that would have waived family fees entirely until an equitable sliding scale was established and that would have changed the way child care funding is estimated to reflect what’s needed to operate high-quality programs with adequate compensation were ultimately vetoed. However, due to the leadership of Parent Voices, the 2023–24 Budget Act permanently revised the family fee schedule to make these payments more affordable. ⁵⁴ California’s high affordability grade reflects this.

Although not in the top three, many states also made recent historic investments in child care affordability.⁵⁵ The CCDBG program—according to the most recent data—only serves one in every six eligible children due to historic underfunding. Including more families ensures they would have assistance paying for child care, thereby making it more affordable.⁵⁶ For example, Maine’s 2023 budget increased eligibility for families from 85 to 125 percent of the state’s median income.⁵⁷ Vermont passed legislation that would improve child care affordability in a host of ways, including expanding subsidies up to 575 percent of the federal poverty line and eliminating copayments for families at or below 175 percent of the federal poverty line.⁵⁸

Diverse Supply of Options

Having a diverse child care supply means that parents can choose a child care option that works for them and their family. Too few parents have access to high-quality care, with many families having to deal with months-long waitlists to access care. Many communities, especially those in rural parts of the country, don’t have access to child care options, with two-thirds of rural families living in a child care desert.⁵⁹ Additionally, the number of family child care homes⁶⁰ has been declining for more than a decade.⁶¹ The American Rescue Plan Act child care stabilization funding slowed this trend and reversed the decline in child care centers. But, the recent expiration of child care stabilization grants exacerbated supply issues, with child care programs closing in states, from Pennsylvania to Wisconsin to North Carolina, as a result of this funding loss.⁶² Building the supply of child care programs is critical to ensure that every family has access to high-quality and affordable child care.

Having a diverse child care supply means that parents can choose a child care option that works for them and their family.

According to analysis of Child Care Aware® of America data, in seven states, there is at least one licensed child care slot per child with all their parents, either solo or coupled, working. These states are Arkansas, Colorado, Delaware, Iowa, Mississippi, Ohio, and Tennessee. Critically, these data are at the state level. It is important to note that the existence of a slot doesn’t guarantee that families can access that slot based on where they live, their child’s age, their budget, or their work hours. As child care is essential for parents’ ability to work, a child care slot that is more than twenty minutes away may not be useful, and this metric doesn’t account for distance and travel time. However, it is an important baseline for ensuring that child care supply sufficiently meets the demand. Another fourteen states had at least three slots for every four children with all of their parents working.

Credentialing

Supporting early educators is integral to supporting child care and early learning. Child care is labor intensive, and supporting educators directly translates to quality early education. The child care sector faces many challenges, chief among them is hiring and retaining early educators. One of the greatest challenges is the low-pay. (Wages for care workers including early educators is discussed further below, in Fair Working Conditions for Care Workers.) There is not a universally accepted definition of quality. While in the 2021 report card used credentialing as a proxy for quality, due to ongoing debates about how to measure quality, this category has been relabeled as “credentialing” for this report card.

This section evaluates support for professional development and other indicators of quality for early educators. Delaware, Georgia, Minnesota, and Vermont were the states with the most supportive comprehensive policies for early educators. All four of these states require Child Development Associate (CDA) credentials of their early educators and include financial support, from scholarships to tax credits, to help early educators attain these credentials. Some states include CDA requirements but do not support educators to attain them. This report card did not credit those states. In addition, all states with education requirements should also offer corresponding wage increases. This report card does not have that data to include that as a scoring factor, unfortunately.

Universal Pre-K

Universal preschool is not only foundational for the early education of children, but it is also a key form of child care for many parents during the day. Preschool is critical for children’s physical, emotional, and social development. It also serves to support the growth of language and literacy skills for children.⁶³ This measure of the report card evaluates states on access to preschool for 3- and 4-year olds, state investments in preschool, and the adoption of quality standards. For this measurement, the report card uses data from an annual report by National Institute for Early Education Research (NIEER), The State of Preschool.⁶⁴ It is the strongest source because it compares the same, detailed information across every state. Unfortunately, the data lags, so it does not reflect the most up to date state investments. For example, in 2022, Colorado also passed universal preschool, which is funded through a nicotine tax, but not reflected in the 2022 State of Preschool report.⁶⁵ Additionally, in 2023, Alabama, California, Delaware, Florida, Georgia, Hawaii, Indiana, Michigan, Missouri, Nevada, New Jersey, New Mexico, and Ohio are among the states that invested more in pre-K programs, which may not yet be reflected in the metrics.⁶⁶

Universal preschool is not only foundational for the early education of children, but it is also a key form of child care for many parents during the day.

Based on the NIEER report, which reflects the enrollment rates of 3- and 4-year olds, state spending levels and meeting standards, District of Columbia, New Jersey, New Mexico, Vermont, and New York lead the nation overall in terms of pre-K. However, other states made significant investments in preschool programs.

Home and Community-Based Services/Aging and Disability Care

Most people want to live and age in their own homes and communities, but are not able to access the services they need. Current investments in aging and disability care continue to undervalue care while leaving care workers underpaid. A robust system of home and community-based services is essential for people with disabilities and older adults to be able to live and age with dignity in their own homes and communities and also support family caregivers who often take time out of the paid workforce to provide care that’s needed.

Most people want to live and age in their own homes and communities, but are not able to access the services they need.

The need for this essential care is only growing. According to the National Academy of Social Insurance, America will experience more than 200 percent growth in the population of people age 85 and over from 2015 to 2050. Furthermore, 61 million adults with disabilities, injury, or illness currently need care provided by a family member or professional caregiver.⁶⁷

Among those age 65 and over today, 70 percent need help with at least one activity of daily living (ADL) such as eating, drinking, bathing, walking, or getting out of bed, and 52 percent have significant need for long-term services and supports (LTSS), indicated by needing help with two or more ADLs and/or a significant intellectual disabilities.⁶⁸ Other examples of long- term services and support include assisting with communication and participation at work, school, and in the community, support with transportation, home modifications, assistive technology for accessibility, and respite services and training for family caregivers.

People receiving care should also be able to choose where and how they receive the supports and services they need. Currently, Medicaid, a state and federal partnership, is the primary source of funding for long-term services and supports, both institutional care facilities and home and community-based services. However, while institutional care facilities are considered a required service under Medicaid, home and community-based care is optional. This imbalance leads to caps on enrollment, waitlists, and limitations for those seeking to live and age in their own homes and communities.

The current underinvestment devalues care and forces reliance on unpaid family caregivers, underpaid care workers, and care recipients who typically are unable to make ends meet in order to access these services. According to the AARP, family caregivers provide an estimated value of $600 billion in unpaid caregiving contributions.⁶⁹ These estimates don’t include other financial challenges, such as lost wages resulting from needing to limit working hours, accumulated debt, and out-of-pocket caregiving costs.

Investing in home and community-based services has significant benefits for economic growth, equity, families, and communities. With a more robust care system in place, family caregivers would be more productive in the economy, increasing economic activity by an estimated $44 billion.⁷⁰ More investment would also improve the quality of caregiving jobs, which are held primarily by Black, Latinx, and immigrant women due to the persistence of historical and present-day discrimination in the labor market. Increased public investment would also help families achieve financial security so they can continue to live and spend money in their communities. And lastly, strong and robust policies can support the inclusion of people with disabilities and older adults’ participation in the community and in the nation’s economy.⁷¹

Scoring

For the scoring of this policy area, the rubric relies on data from the “Innovation and Opportunity” scorecard from the AARP Public Policy Institute, which ranks states based on the following five dimensions:

affordability and access, measured by how easy it is for families to find affordable services, including access to services for low-income families;
choice of setting and provider, measured by wide availability of home and community-based services, including culturally competent services;
safety and quality, measured by adequate staffing and policies that aim to reduce disparities in outcomes;
support for family caregivers, including unemployment insurance for family caregivers and other legal protections for family caregivers; and
community integration, measured by access to other supports like safe and affordable housing.⁷²

The highest-performing states for long term care were Minnesota, Washington, and the District of Columbia. Both Minnesota and Washington spend more than 70 percent of their long-term care dollars on HCBS when comparing the balance of spending between HCBS and institutional care. All three places promote enrollment and affordability for working disabled people by removing barriers to eligibility based on income (Minnesota), assets (District of Columbia), or both income and assets (Washington). They also support direct care workers by directing a specific dollar amount or percentage of Medicaid reimbursement rates to go directly toward worker wages.

Fair Working Conditions for Care Workers

Care work is essential work that is foundational for a functioning economy. Care work includes everything from caring for children, to assisting people with disabilities, to essential household tasks such as cleaning services, laundry, and meal preparation. Care work is the work that makes all other work possible. Care workers—child care workers and direct care workers, including domestic workers—provide life-sustaining care that allows families and communities to thrive. Every care field relies on women of color and mothers to take on caregiving responsibilities for free. Moreover, due to histories and persistence of racism and sexism, professional caregivers’ work is undervalued, with care workers being paid low wages and often working in poor conditions, and care work has often been excluded from the rights and protections offered other workers.

Care work is the work that makes all other work possible.

For example, New Deal-era policies guaranteeing minimum wages, overtime pay, health and safety protections, and the right for workers to join together and form unions, excluded domestic and agricultural workers, occupations held by mostly Black workers. More recently, the 2014 U.S. Supreme Court decision Harris v. Quinn, ruled that Medicaid direct care workers providing home and community-based services for older adults and disabled people could not be required to pay union dues. This was a major blow for workers organizing in the care sector.

Care workers have had a long history of pushing back against this undervaluation by organizing to improve wages, benefits, working conditions, and the quality of services that care consumers receive—from the Atlanta Washerwoman’s strike in the 1880s,⁷³ the Worthy Wage campaign led by child care workers in the 1990s.⁷⁴ In 2010, the state of New York passed the first Domestic Workers Bill of Rights, which laid the foundation for more statewide bills and municipal bills of labor protections. And a national Domestic Workers Bill of Rights policy was introduced in 2021.⁷⁵ Today, ten states, two major cities, and Washington, D.C. have passed domestic workers bills of rights and protections, gaining domestic workers inclusion in minimum wage and overtime protections, anti-discrimination and harassment protections, and other critical rights.⁷⁶

Despite recent progress, care workers as a whole are still underpaid for the critically important work they do. Child care workers—defined as those who attend to children at schools, businesses, private households, and childcare institutions—are paid a median wage of $13.71 an hour nationally.⁷⁷ They also are paid the least out of similar professions, such as preschool and kindergarten teachers.⁷⁸ Direct care workers, which includes home care workers, residential care aides, and nursing assistants in nursing homes, are paid an annual median wage of $15.43 an hour.⁷⁹ And domestic workers—house cleaners, nannies, providers of child care in their own home, and agency-based and non-agency based home care aides—are paid an annual median wage of $13.79 per hour. Even when controlling for demographics and education, domestic workers are paid 25.2 percent less than similar workers in other fields.⁸⁰

Difficulty recruiting and retaining workers, high turnover, and limited support for providers—often small businesses with just a few employees—are just a few of the challenges facing care sectors, and care recipients and family caregivers needing services are left to shoulder the true cost of care. These challenges are not due to a lack of care workers, but rather a lack of good care jobs.⁸¹ If all direct care and child care workers were covered by union contracts, due to the wage-boosting effects of such agreements, these workers would likely see significant wage increases, according to one analysis by the Economic Policy Institute.⁸² They would also be much more likely to have health insurance, paid time off, and equitable pay, since these provisions are often included in bargaining negotiations. Additional federal and state investments are needed to support high quality jobs and access to affordable aging and disability care as well as child care.

Scoring

The care report card looks at three criteria to evaluate progress that states are making to ensure care workers are paid wages that reflect the value of their work and ensure caregivers are working under fair conditions:

progress on passing a Domestic Workers Bills of Rights, which guarantees domestic workers basic rights such as a minimum wage, overtime pay, rest breaks, and safe working conditions, and may also include protections against discrimination, harassment, and retaliation, and in some cases, offer benefits like paid sick days;
progress supporting care worker unions through legislation—unions are a critical source of worker power that help fight for better working conditions and wages; and
progress on setting wages for child care and direct care workers to ensure that care workers are paid a living wage.

Across all these categories, Connecticut, Oregon, and California scored the highest. All three of these states have Domestic Worker Bills of Rights. They join seven other states with similar laws. In Connecticut, direct care workers represented by SEIU 1199NE won a tentative agreement that includes improved wages and benefits.⁸³ Similarly, direct care workers in Oregon represented by SEIU Local 503 ratified a new bargaining agreement that raises wages $1.73 an hour as of January 1, 2024, and another $0.50 an hour January 1, 2025.⁸⁴ However, challenges for fair and safe working conditions remain. In California, for example, SB 686, the Health and Safety For All Workers Act, was vetoed in 2023 by Governor Gavin Newsom, which would have established health and safety protections for domestic workers in the state.⁸⁵

Paid Family and Medical Leave

At some point in life, nearly everyone will need time away from work to recover from an illness or childbirth, provide care to an ill family member, or take care of a new child. Paid family and medical leave (PFML) policies provide wage replacement and job protection so people can take the time they need to recover, or provide care for a family member, without worrying about forgoing income or losing a job. Research shows that paid family and medical leave improves childhood development, public health, and the economic stability for families. If a child is critically ill, either at birth or later, the presence of a parent reduces the length of their hospital stay by 31 percent.⁸⁶ Mothers who take paid leave after childbirth are less likely to experience symptoms of postpartum depression.⁸⁷ Access to paid leave helps cancer patients complete their treatment and better manage any side effects.⁸⁸

At some point in life, nearly everyone will need time away from work to recover from an illness or childbirth, provide care to an ill family member, or take care of a new child.

PFML supports the livelihoods of hardworking people by helping to cover their everyday expenses during a health crisis or after the birth of a child, increasing the financial stability of families and helping caregivers join and remain attached to the workforce. Too many workers currently are forced to risk their financial wellbeing to take time off to care for themselves and others. While the United States has no federal paid family and medical leave policy or paid sick time policy, states have led the way by setting up their own programs.⁸⁹ Workers need both a strong floor for both paid sick leave and paid family and medical leave at the federal level and policies at the state level that build on these policies. Evidence from states with existing paid leave policies, such as California, shows paid leave increases the labor force participation of caregivers.⁹⁰ Studies from California also show that paid leave programs reduce the risk of poverty among mothers with infants, reduced food insecurity in households after childbirth, and increased household income for mothers by 4.1 percent.⁹¹ Paid family and medical leave policies also help employers by attracting and retaining talent and avoiding the cost of turnover, which can be as high as one-fifth of a worker’s salary.⁹²

The lack of access to paid leave exacerbates economic and gender inequality, as care work disproportionately falls to women. This policy shortcoming also has racial implications, as 79 percent of Black mothers and 64 percent Native American mothers are the key or sole breadwinners for their families.⁹³ Furthermore, Black and Brown workers are more likely to work in underpaid jobs that do not provide paid family and medical leave, requiring them to take unpaid time off in response to a medical or family emergency and contributing to racial economic inequities.⁹⁴

Right now, through the Family and Medical Leave Act (FMLA) of 1993, the U.S. federal government requires some employers to provide twelve weeks of unpaid job-protected family and medical leave for eligible employees. Furthermore, the eligibility criteria for FMLA excludes nearly 40 percent of workers, and many who do have access cannot afford to take it.⁹⁵ Given the lack of federal progress on paid family and medical leave, states have begun to step up and offer this crucial protection.

Scoring

To date, thirteen states and the District of Columbia have enacted paid family and medical leave. Since the 2021 report card, four states—Maryland, Delaware, Minnesota, and Maine—have passed new paid family and medical leave laws that will begin paying benefits out to workers in 2026. They join California, Colorado, Connecticut, the District of Columbia, Massachusetts, New Jersey, New York, Oregon, Rhode Island, and Washington.

States’ with paid family medical leave policies received additional points for:

covering all workers;
having an inclusive family definition;
having broad eligible uses for leave including medical and family caregiving needs and military reasons;
offering more than twelve weeks of benefits;
having a progressive wage replacement structure;
sharing contributions between employers and employees;
offering scheduling flexibility;
offering job protection beyond what is required in the Family and Medical Leave Act;
requiring continuing health insurance coverage during leave; and
prohibiting discrimination in ways that go beyond the requirements in the Family and Medical Leave Act.

Minnesota, Colorado, and Maine had the highest scores for their paid family medical leave policies. Of note, Minnesota will offer some of the most comprehensive paid family and medical leave benefits of any state,⁹⁶ which include broadening the eligibility standard, having an inclusive family definition that includes “chosen” family, and ensuring that workers still have health coverage while on leave—areas where other states often fall short. While some states have made important progress, with nearly three quarters of all states still lacking paid family and medical leave policies, many states need to continue working and building off the lessons learned from the places that have successfully implemented PFML. Challenges resulting from the privately administered paid family and medical leave program in Connecticut also make clear the necessity of investing in state agencies to effectively implement paid family and medical leave benefits and ensure all who are eligible are able to access these critical benefits.⁹⁷

Paid Sick and Safe Days

Access to paid sick and safe leave provides workers with the flexibility essential to meeting their own health needs and those of their families without jeopardizing their financial security or health and safety.

Scoring

State paid sick and safe day policies are evaluated on whether they:

ensure that all employees are entitled to at least earn a modest amount of paid sick time for personal health needs, to care for a loved one, or safe time to address domestic or sexual assault;
provide employees with additional paid sick time during a declared public health emergency for health and caregiving needs related to the emergency;
prohibit retaliation against a worker who exercises their rights under this law, including the use of paid sick time to care for themselves or their loved ones; and
dedicate resources for implementation and worker and employer outreach, education, and enforcement.

Colorado, Minnesota, and New Mexico had the highest scores for paid sick and safe days due to their comprehensive policies. Since the 2021 report card, two new states have implemented paid sick and safe leave programs: Michigan⁹⁸ and Minnesota.⁹⁹ Michigan’s law passed in 2018, but has faced litigation affecting the scope of the law. The report card reflects the most current status of Michigan’s law.¹⁰⁰ These states join the fourteen that already had this policy in place.¹⁰¹ In addition to these states passing these protections for the first time, other states have also expanded on the protections offered by their existing state laws surrounding paid sick leave. Starting on January 1, 2024, following legislation passed in October 2023, California increased the minimum number of paid sick and safe days available to workers from three to five.¹⁰² And while not a paid sick days policy for all workers, Georgia made permanent the Georgia Family Care Act,¹⁰³ which allows workers who already receive sick time from their employers to use that time to care for family members, an improvement in recognizing the existence and importance of caregiving needs and responsibilities for workers.¹⁰⁴

In addition, Illinois,¹⁰⁵ Maine,¹⁰⁶ and Nevada¹⁰⁷ enacted paid time off laws. These laws can also help workers have greater flexibility by requiring employers to provide a minimum amount of paid time off to employees. While time off under these laws can be used if a worker is sick, it can also be used for any purpose, and as such these states are not counted as states that offer paid sick time in the report card.¹⁰⁸

Importantly, policies are more effective when they dedicate resources to education and outreach. While the care report card doesn’t grade states on the implementation of their policies, it is worth noting that states can and should work to make sure that their progress in building strong care policies is paired with efforts to maximize the awareness and uptake of these programs. While this is relevant across policy areas, some specific examples include Washington State and New Jersey, which have shown leadership in performing outreach on paid sick days.

Extra Credit: Fair Scheduling

Fair scheduling laws (or “fair workweek” laws) are commonsense policies that help give workers stability, input, and predictability in their work schedules. A predictable and stable work schedule helps families manage the many competing responsibilities they are constantly negotiating, from caregiving to medical appointments. But many employers rely on “just-in-time” scheduling practices that provide workers with little notice or flexibility in their work hours and frequently involve last-minute changes and cancellations. Unpredictable schedules produce unpredictable incomes—and this volatility is linked to both stress and material hardship for workers and their families.¹⁰⁹ Moreover, because unpredictable schedules are particularly prevalent in retail, food service, hospitality, and other hourly service sector jobs, these practices tend to disproportionately harm women, low-income workers, and communities of color.¹¹⁰ For the same reason, fair scheduling policy efforts often focus on targeting the industries in which just-in-time scheduling practices are most widespread.

A predictable and stable work schedule helps families manage the many competing responsibilities they are constantly negotiating, from caregiving to medical appointments.

Since the 2021 report card, no new states have passed a fair workweek law. Recent fair workweek policy efforts have focused on cities; for example, in late 2022, both Los Angeles and Berkeley, California, passed fair workweek laws that are now in effect. A total of nine states and the District of Columbia have some form of fair scheduling policies: California, Connecticut, the District of Columbia, Massachusetts, New Hampshire, New Jersey, New York, Oregon, Rhode Island, and Vermont.¹¹¹

Oregon had the highest score for fair scheduling laws, while California, New Hampshire, New York, and the District of Columbia were all tied for second-highest. Oregon’s fair workweek law, enacted in 2016, is the most comprehensive: it requires employers to provide covered employees with fourteen days’ notice of their work schedules and compensation (known as “predictability pay”) for shifts that are changed or canceled at the last minute, and grants covered employees the right to at least ten hours of rest between shifts as well as the right to request a schedule change without fear of retaliation. California, New York, and the District of Columbia all have “reporting pay” laws that require compensation when an employer cancels or reduces an employee’s shift, but only if the employee has actually reported to work; each of these states also requires “split-shift pay” when an employer schedules an employee for two nonconsecutive shifts in a single day (for example, 10:00am–2:00pm and 4:00pm–8:00pm). New Hampshire has a reporting pay law and provides employees with the right to request a schedule change.

Extra Credit: Supportive Tax Policies

Tax policies are an important mechanism for the federal and state governments to create a more equitable economy and society. The COVID-19 pandemic provided undeniable evidence that expanded tax credits for low-income families can dramatically reduce poverty. There are three primary tax credits at the federal level that are most relevant to care policy: the Earned Income Tax Credit (EITC), the Child Tax Credit (CTC), and the Child and Dependent Care Tax Credit (CDCTC). These credits are progressive by design, offering higher amounts at lower-income levels. The CTC and EITC are also effectively designed to benefit families with low incomes because they are refundable. Refundability means that if what an individual or family owes in taxes is less than the value of the tax credit, the difference is paid out as a tax refund.¹¹² Refundability therefore helps ensure that more families receive the full value of these tax credits, making them more effective at improving economic security for families. Some states have enacted state versions of these tax credits to complement the federal tax credits.¹¹³ States are scored for the size of the tax credit, relative to the federal version, with larger tax credits receiving more points. Additionally, states received additional credit for having a fully refundable tax credit.

The COVID-19 pandemic provided undeniable evidence that expanded tax credits for low-income families can dramatically reduce poverty.

There are also important reforms states can implement to make tax credits more effective and equitable that this report card doesn’t account for.¹¹⁴ Notably, some states, including Minnesota, California, and Maine, have allowed noncitizen workers to receive the credit by making the EITC and/or CTC available to filers using their Individual Taxpayer Identification Number (ITIN) instead of a Social Security number (SSN).¹¹⁵ Expanding eligibility for noncitizens is an important place where states can make improvements beyond the federal versions of these tax credits since the federal versions of these tax credits can only be claimed by filers using SSNs.¹¹⁶

Earned Income Tax Credit

The federal Earned Income Tax Credit is a refundable tax credit designed to support low- and moderate-income families and its value varies depending on total family income, number of children, and marital status.¹¹⁷ While many states made temporary expansions to their state EITCs during the pandemic, a few states made permanent changes that will help expand the number of families who can benefit from the EITC.¹¹⁸ In Utah, the Republican legislature and governor passed and signed a nonrefundable EITC that is 15 percent of the federal EITC. Virginia had a nonrefundable state EITC, but beginning in 2022, the state is offering a refundable version that is equal to 15 percent of the federal EITC. Currently, thirty-two states have EITCs. The District of Columbia’s Earned Income Tax Credit was the most progressive, being both refundable and exceeding 50 percent of the federal credit. Ten other states tied for having refundable EITCs that were at least 25 percent or more of the federal EITC. Those states were California, Colorado, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, New York and Vermont. South Carolina also scored comparatively highly because, although their EITC is not refundable, it does exceed 50 percent of the federal credit.

Child Tax Credit

The federal Child Tax Credit is a refundable tax credit per child under age 17, with the amount of the tax credit varying based on family income.¹¹⁹ Similar to the EITC, some states enacted temporary credits in response to the pandemic. However, two states passed new, permanent, child tax credits: New Jersey passed a CTC of up to $500 per child, with a progressive schedule based on the household’s taxable income, and Vermont passed a CTC of $1,000 per child under age 5, for households earning less than $125,000. Fourteen states overall have Child Tax Credits. However, Colorado, Minnesota, New Jersey, Vermont, and Oregon had the most progressive child tax credits in place.

Child and Dependent Care Tax Credit

The federal Child and Dependent Care Tax Credit (CDCTC) is a nonrefundable tax credit that is designed to help families offset the costs of care for children, adult dependents, or an incapacitated spouse. The amount of the credit varies depending on a family’s care expenses (within a cap per number of dependents) and on family income.¹²⁰ While the federal CDCTC is nonrefundable, and therefore has limited value for families with low and moderate incomes, some states have made their state credits refundable so more low- and moderate-income families can benefit. When the CDCTC was temporarily made fully refundable through the American Rescue Plan Act, hundreds of thousands more families were able to claim the credit.¹²¹

Twenty-nine states have a CDCTC (or tax deduction for care expenses): Arkansas, California, Colorado, Delaware, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Montana, Nebraska, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Vermont, and Virginia.

Of these, Colorado, Minnesota, Vermont, Oregon, New York, South Carolina, and Louisiana had the highest score for their tax credits. These states’ credits are refundable.

Extra Credit: Pregnant Worker Fairness

In 2022, the United States passed the national Pregnant Worker Fairness Act, which guarantees pregnant workers in every state basic protections and reasonable accommodations. In order to acknowledge state leadership, this report card retains extra credit points for states that had in place pregnant worker fairness laws prior to the federal law. As such, Hawaii and California received the most extra credit points for pregnant worker fairness. Tied for third are Colorado, Delaware, the District of Columbia, Illinois, Maine, Rhode Island, Vermont, and Virginia.

Policy Recommendations: Federal and State Opportunities to Build the Care Infrastructure

In July 2020, for the first time in history, as a result of strong advocacy and a response to the COVID-19 pandemic, a presidential candidate announced a care infrastructure proposal: President Biden’s “Plan for Mobilizing American Talent and Heart to Create a 21st Century Caregiving and Education Workforce.” Alongside his paid leave and paid sick days proposals, this proposal called for $775 billion over ten years to expand access to a broad array of long-term services and supports, including HCBS; ensuring access to high-quality, affordable child care and universal preschool to 3- and 4-year olds; and ensuring the care workforce the pay and benefits they need, training and career ladders to higher-paying jobs, the choice to join a union and bargain collectively, and other fundamental work-related rights and protections.¹²²

Despite significant efforts on the part of the organizers, advocates, the Biden administration, and Congressional Democrats, these policies were ultimately left on the cutting room floor and remain the unfinished business of the Biden administration.

Despite significant efforts on the part of the organizers, advocates, the Biden administration, and Congressional Democrats, these policies were ultimately left on the cutting room floor and remain the unfinished business of the Biden administration. In particular, there are multiple current legislative efforts, executive actions, and areas for state progress that reflect these proposals to build the care infrastructure the United States has long needed, as follows.

Child Care for Working Families Act

The Child Care for Working Families Act would lower the cost of child care for families by establishing a sliding scale that ensures no family pays more than 7 percent of household income for child care and would provide free child care to families with the lowest incomes (those earning below 85 percent of the state median income). It would also provide funding to states to make grants to eligible child care providers primarily to cover the costs of operating a child care business, such as wages, benefits, and rent and utility payments. The act would make investments to build the supply of high-quality child care and pre-K options in diverse settings, including during nontraditional work hours. And lastly, it makes investments in the workforce by providing higher compensation and paying workers in a way that supports lower costs for families.¹²³

HCBS Access Act

The HCBS Access Act would ensure that anyone who is eligible for Medicaid HCBS would be entitled to receive it. This would eliminate waiting lists, provide matching federal funds for HCBS to states at 100 percent, support high-quality jobs and competitive wages and benefits for direct care workers, and expand support for family caregivers, including respite care and training opportunities, and make it possible for family caregivers to maintain employment. It would also require states to increase availability of aging and disability care services and support disabled workers by requiring states to improve programs that help disabled workers keep their Medicaid-funded HCBS.

Better Care Better Jobs Act

While the Better Care Better Jobs Act would not make HCBS a required service based on Medicaid eligibility, it would still significantly improve Medicaid funding for HCBS using a permanent 10-percentage-point increase in the federal Medicaid match for delivering HCBS. In addition to provisions that provide support for family caregivers, the bill would take similar steps to support high-quality jobs with family-sustaining wages and benefits for direct care workers. States would also be able to receive additional federal resources for growing and improving HCBS.

Federal Domestic Workers Bill of Rights

The Federal Domestic Workers Bill of Rights would address long-standing inequities experienced by domestic workers by ending exclusions from basic protections on the job such as Title VII coverage for workplace harassment and discrimination protections and by guaranteeing overtime pay for live-in domestic workers. It includes requirements for workers and employers to have clear written agreements describing the terms and conditions of employment as well as protections against retaliation by employers and resources for worker outreach, education, and implementation and enforcement of the policy.

Healthy Families Act

The Healthy Families Act is an earned sick time policy that would guarantee eligible workers the right to earn paid, job-protected time off for when they or their loved ones are sick, hurt, or getting medical care, as well as for needs in connection with sexual or domestic violence. Employees would be able to earn one hour of sick time for every thirty hours they work, up to a maximum of fifty-six hours per year—equivalent to seven workdays. In addition to caring for oneself or one’s family, The Healthy Families Act also allows workers to take time off to care for “chosen family”—loved ones they may not be biologically or legally related to, but that are like family.¹²⁴

Family and Medical Insurance Leave Act

The Family and Medical Insurance Leave (FAMILY) Act would establish a national paid family and medical leave program through a shared fund that would make paid leave affordable for employers of all sizes and for workers and their families. It would provide workers with up to twelve weeks of paid leave for taking care of their own serious health conditions, including pregnancy and childbirth recovery, as well as taking care of the health of their loved ones. The lowest-paid workers would earn up to 85 percent of their usual wages and ensure that they have a job to return to following their leave. The program would be funded by small employee and employer payroll contributions—two cents per $10 in wages, or less than $2.20 per week for a typical worker.¹²⁵

Federal Rulemaking

There have been many executive actions and proposals for federal rulemaking in 2023 that have the potential to give states the tools and incentives to improve their policies impacting aging and disability care and child care. While they do not negate the need for robust federal funding, they do create a blueprint for incremental progress.

Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers

In April of 2023, the Biden administration issued an executive order with over fifty directives that powerfully utilize the administration’s clear authorities to strengthen care infrastructure.¹²⁶ It is the most expansive set of executive actions on care in history, outlining goals to bolster child care and aging and disability care. The executive order highlights actions for improving wages for child care and direct care workers, ensuring domestic worker rights, supporting family caregivers, and creating opportunities for more people to enter the care workforce while also emphasizing the need to engage care recipients such as older adults and people with disabilities, family caregivers, and care workers. This executive order also laid the groundwork for several subsequent proposed rules from federal agencies discussed below.

Improving Child Care Access, Affordability, and Stability in the Child Care and Development Fund

In July 2023, the U.S. Department of Health and Human Services, Administration for Children and Families (ACF) announced a Notice of Proposed Rulemaking (NPRM) to amend the Child Care and Development Fund (CCDF) regulations.¹²⁷ The rule was finalized in February. CCDF is the federal–state child care program that serves low-income families via CCDBG. The changes are designed to lower families’ child care costs, improve child care provider payment rates and practices, and streamline eligibility and enrollment processes.¹²⁸ The rule requires and encourages states to improve practices, including requiring them to:

cap family copayments at 7 percent of household income (this is the floor, not a ceiling);
post current information about copayment sliding fee scales on their consumer education sites, including waived copayment policies and estimated copayment amounts;
provide more services through grants and contracts as one of many strategies to increase the supply and quality of child care for infants and toddlers, children with disabilities, and nontraditional-hour care;
implement payment practices that are consistent with the private-pay market, including paying prospectively and reimbursing based on enrollment instead of attendance; and
implement eligibility policies that minimize disruptions to families and lessen the burden on CCDF administrative requirements on families, which may include best practices like using an online application, basing applications off the 2022 model application, and developing screening tools.

State policymakers can build on the proposed CCDF rule changes and further support equitable child care policies by:

increasing funding reimbursement rates for child care to providers, which would improve access and affordability to child care for families, increase wages for child care workers, and support high quality programs;
supporting the stability of the child care workforce by providing the benefits workers and families need to thrive, such as health insurance, retirement contributions, affordable childcare, paid sick time, and paid family and medical leave;
supporting child care workers to join and form unions with strong collective bargaining agreements, and;
developing and implementing a cost model that reflects the true cost of care, engaging parents, workers, and providers to assess what it would take to operate a high-quality, culturally competent program with adequate staffing and resources, including living wages for child care workers.

The expiration of the federal child care relief funds at the end of September 2023 creates additional barriers to access, affordability, and family-sustaining wages and benefits for child care workers. Action must be taken on the state and federal level to prevent programs from closing, families from losing child care, and workers from losing pay, or employment altogether.

Ensuring Access to Medicaid Services

The Ensuring Access to Medicaid Services (Access Rule) is one example of a proposed rule that would help stabilize the direct care workforce by directing a specific proportion of Medicaid HCBS payments directly toward compensation for workers, making payment rates publicly available, and reviewing rates regularly while engaging key stakeholders.¹²⁹ The proposed rule supports reporting requirements detailing how many people are on waiting lists to receive home and community-based services as well as the length of the time people must wait, waiting time for services following approval, and a standardized set of quality measures, allowing for improved comparisons across states. The rule also reinforces the need to incorporate “person-centered “practices for home and community-based services that are responsive to the priorities and preferences of people receiving care.

Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting

This proposed rule would for the first time establish minimum staffing standards in nursing homes, requiring a registered nurse to be on-site twenty-four hours a day, seven days a week, and meet a minimum number of registered nurses and nursing aides for each resident on a daily basis.¹³⁰ The proposed rule also includes requirements to collect data regarding how Medicaid payments are used, improving pay transparency.

Discrimination on the Basis of Disability in Health and Human Service Programs or Activities

This proposed rule strengthens Section 504 of the Rehabilitation Act of 1973, which provides protections against discrimination based on disability in programs and services that receive federal funding. It includes strengthened provisions to promote accessibility in communications with disabled people, prevent discrimination when providing medical treatment, and clarifies the legal obligation to provide home and community-based services, affirming community living as a civil right.

State policymakers can further strengthen HCBS by:

increasing state investments in Medicaid reimbursement rates, requiring that this increase be used to increase pay for direct care workers, and establishing a meaningful floor for wages; and
creating a state-based long term care public benefit program for those not eligible for Medicaid HCBS and allowing people receiving services to self-direct their own care, including hiring a family member as their caregiver.

State Progress

Care is a public good, and in order for older adults, disabled people, family caregivers, and care workers to thrive, the care economy will require significant additional investments from federal and state governments to support what’s needed for affordable and accessible child care, aging and disability care, and paid leave. The federal government should set a strong standard for equitable and inclusive policies and investments in care infrastructure. At the same time, states also have the opportunity to make critical investments to support care, develop innovative policies, and pave the way for transformative investments at the federal level.

States have the opportunity to make critical investments to support care, develop innovative policies, and pave the way for transformative investments at the federal level.

Specifically, states can raise their grades and make significant care progress by enacting new laws, investing state dollars, and implementing finalized federal rules. More states can adopt paid family and medical leave, paid sick and safe days legislation, and a Domestic Workers Bill of Rights. States have invested their own funds in child care and home and community-based services following the ARPA investments. These and future investments can be used to (1) improve the wages of the care workforce; (2) provide the benefits workers and families need to thrive, such as health insurance, retirement contributions, affordable childcare, paid sick time, and paid family and medical leave; (3) support training and credentials that are accessible to current and future workers, demonstrate cultural competency, and prioritize skills and knowledge informed by person-centered care approaches; and (4) invest in resources and materials needed for child care programs and for home modifications, assistive technology, meal delivery, transportation services, caregiver training, and respite services.

States can also take action to support the formation of unions with strong collective bargaining agreements. For LTSS, states can develop an inclusive and equitable state public insurance benefit to provide affordable long term services and supports, especially home and community-based services for people with disabilities and older adults. In addition, across care issues, states can establish task forces of key community members representing care recipients, family caregivers, and care workers responsible for (1) developing recommendations to advance equity, inclusion, and access; (2) monitoring outcomes; and (3) supporting public engagement and transparency.

Moving Forward

The movement for care is only growing, as ongoing campaigns bring together workers alongside disabled people, older adults, parents, and other family caregivers to build momentum for investments in care infrastructure. While there is still a significant gap between what is needed and where states are, many states have made improvements and investments to strengthen their care infrastructure over the past two years. These changes come amid unprecedented federal investment in state economies and care policies. States used the opportunity presented by these investments to prioritize families. As states continue to be laboratories of innovation it is crucial for the federal government to pass the foundational protections that advocates have long sought to support families and the economy.

Acknowledgments

The authors are tremendously grateful for the careful review and feedback offered by Reena Arora from the National Domestic Workers Alliance; Elizabeth Gedmark and Cassandra Gomez from A Better Balance; Kristina Haynie from Child Care Aware® of America; and Amy Matsui, Laura Narefsky, Karen Schulman, and Julie Vogtman from the National Women’s Law Center; as well as insights from Lauren Hogan from the National Association for the Education of Young Children and Stephanie Schmit from the Center for Law and Social Policy.

Appendix 1: Glossary

advance notice. Advance notice are fair scheduling provisions that require employers to provide employees with a certain amount of advance notice of their schedules. Some provisions also require employers to provide estimates of schedules and minimum hours before an employee begins employment.

care. The range of services and supports needed to meet needs related to age, disability, health, or illness. Care can be provided by loved ones, institutions, or professionals. Other terms for care include family care (commonly used by research or advocacy organizations) and dependent care (commonly used by government entities).¹³¹

child care and early learning. The care of children, including infants, toddlers, and school-aged children. Early education is an important component of child care that involves teaching and fostering healthy brain development. Common child care employment options include center-based child care, family child care, and home-based child care.

Domestic Workers Bill of Rights. National and state legislation that establishes rights for home care workers, nannies, and house cleaners to ensure safety and dignity at work.

home and community-based services. Home and community based services (HCBS) provide opportunities for people who need assistance with the activities of daily living to receive services in their own home or community rather than institutions or other isolated settings.

long-term services and supports (LTSS). The range of services and supports used by individuals of all ages who need assistance with activities of daily living because of disabling conditions or chronic illnesses, including older adults care. LTSS is also known as long-term care.

paid family and medical leave. Paid family and medical leave policies provide wage replacement and job protection so people can take the time they need to recover, or provide care to a family member, without worrying about forgoing income or losing a job. It may be provided by a state government, employer, or insurance company.

paid sick and safe days. These days consist of time that a worker accrues over hours worked that can be taken in hourly or daily increments to recover from a personal illness, take care of a sick family member, respond to a public health emergency, or a matter arising from an incident of domestic or sexual abuse.

predictability pay. Predictability pay provisions are fair scheduling provisions that require employers to pay employees a certain number of hours of compensation, in addition to payment for any time actually worked, when employers make last-minute changes to employees’ shifts, including additions or reductions in hours and cancellations of regular or on-call shifts.

pregnant worker fairness. Pregnant worker fairness policies require employers to provide employees with needs due to pregnancy, childbirth, and related medical conditions with reasonable accommodations in order to allow employees to safely continue working during their pregnancy. Some examples include longer or more frequent breaks, allowing the worker to sit in a chair while performing their duties, temporary transfer to a less strenuous or hazardous job, modified work schedules, assistance with manual labor, and access to a non-bathroom private lactation area.

reporting pay. Reporting pay provisions are fair scheduling provisions that require employers to pay employees for some portion of their originally scheduled shifts when employees report for work but are then told that their shifts have been canceled or reduced. Laws and regulations requiring repeating pay typically predate, and are more limited than, those requiring predictability pay.

right to request. Right to request laws protect employees who want to request flexible working arrangements or other changes to their schedules by granting them the express right to do so free from retaliation by their employers.

right to rest. Right to rest provisions are fair scheduling provisions that require employers to provide a minimum amount of rest time between shifts and to pay employees who consent to work without the rest time at a higher rate.

split-shift pay. Split-shift pay provisions are fair scheduling provisions that require employers to pay employees additional wages as compensation for any day on which they are required to work shifts in which they have a gap or gaps between scheduled hours in the same day.

Appendix 2: Detailed State Grades

In the 2021 care report card a state needed a minimum of 13.5 points in order to earn an A grade. For this current report card, given minute methodological changes, the cutoff for an A grade is 14.67 points. Table A2.1 lists the cutoffs for each grade.

Table A2.1. Grading Rubric

A	14.67+
B+	13.59–14.66
B	11.41–13.58
B-	10.33–11.4
C+	9.24–10.32
C	7.07–9.23
C-	5.98–7.05
D+	4.89–5.97
D	2.72–4.88
D-	1.63–2.71
F	0–1.62

Table A2.2 lists detailed scores for each state including their total points, letter grade, and relative ranking.

Table A2.2. Detailed State Scores

STATE	Total Score	Letter Grade	Ranking
Alabama	0.96	F	51
Alaska	3.31	D	29
Arizona	5.64	D+	19
Arkansas	3.39	D	27
California	12.28	B	3
Colorado	11.86	B	4
Connecticut	10.71	B–	8
Delaware	7.44	C	16
District of Columbia	10.58	B–	10
Florida	1.58	F	49
Georgia	2.60	D–	35
Hawaii	6.31	C–	17
Idaho	1.78	D–	47
Illinois	6.04	C–	18
Indiana	2.49	D–	38
Iowa	4.19	D	23
Kansas	2.64	D–	33
Kentucky	2.24	D–	41
Louisiana	2.60	D–	34
Maine	7.81	C	15
Maryland	9.70	C+	11
Massachusetts	12.32	B	2
Michigan	4.68	D	20
Minnesota	11.58	B	5
Mississippi	2.26	D–	40
Missouri	2.20	D–	42
Montana	2.05	D–	44
Nebraska	4.42	D	22
Nevada	2.75	D	32
New Hampshire	2.93	D	31
New Jersey	10.85	B–	7
New Mexico	9.69	C+	12
New York	11.31	B–	6
North Carolina	1.78	D–	46
North Dakota	4.18	D	24
Ohio	3.39	D	27
Oklahoma	2.33	D–	39
Oregon	13.82	B+	1
Pennsylvania	3.70	D	25
Rhode Island	9.63	C+	13
South Carolina	2.56	D–	36
South Dakota	1.80	D–	45
Tennessee	2.50	D–	37
Texas	2.10	D–	43
Utah	3.27	D	30
Vermont	8.16	C	14
Virginia	4.62	D	21
Washington	10.67	B–	9
West Virginia	1.38	F	50
Wisconsin	3.46	D	26
Wyoming	1.71	D–	48

Appendix 3: Methodology and Data Caveats

To create a report card that reflects the trends and status of state progress on care policies across every state and the District of Columbia required decision-making about which data sources to use and how best to use them. Wherever possible, this report card used the same data sources and methodology as the 2021 report card. This included using single sources of data for all fifty states and the District of Columbia wherever possible. The upside of this is that it is much easier to compare states on a level playing field and dig in on a variety of data points. The downside is that this data sometimes lags, and may not reflect the most up to date occurrences. In 2023, state activity on child care and pre-K in particular was more robust than it has been historically, based on a combination of states using federal funding to improve their programs and investing new state dollars. This report card aimed to find a balance between using single sources of data and the same sources as 2021, and complementing that data with some additional information from 2023 sources.

Changes in the 2024 Update

The 2024 update to the care report card was designed to maintain as many equivalent metrics as possible to the 2021 report card to make state progress easier to evaluate. There were a few key changes made in an attempt to have more timely data and metrics that better evaluate the true state of care investments in the states. Those changes are listed here. First, in the previous care report card, for paid family medical leave, states either received a baseline of 0.5 points for having only expanded eligible workers under the Family Medical Leave Act (FMLA), or 1 point for having a paid family medical leave (PFML) law. Because FMLA expansion is distinct from PFML, the 2024 update allows states to earn a baseline of up to 1 point if they have both PFML and FMLA expansion, and FMLA expansion alone is worth 0.25 points. All other scoring metrics for PFML remain the same.

Second, a new source has been used to evaluate the supply of child care options. Our new metric uses data from Child Care Aware® of America because the previous source for this metric, The Center for American Progress’ Child Care Deserts report, has not been updated. Third, a few changes were made to the methodology for this report card to ensure that each core care policy area (child care, home and community-based services, fair working conditions for care workers, paid family and medical leave, and paid sick and safe days) was equally weighted, resulting in scoring adjustments. In the previous care report card, child care was weighed significantly less than other policy areas, such as paid sick and safe days and paid family medical leave. Now, the maximum possible score for each core policy area is 3 points, and the maximum possible score for each extra credit category is 1 point. This resulted in slightly different scores for different metrics and therefore makes it challenging to compare overall scores from year to year. Lastly, to compensate for the scoring changes, grade cutoffs were adjusted to make the range of 2024 letter grades comparable as possible to the 2021 report card.

Child Care and Early Learning

The information available about state child care policies can help demonstrate states that have done better and worse, but do not reflect the full picture of how children, families, providers, and early educators are experiencing the child care and early learning systems in their states. State progress on child care and early learning was historic in 2023, but still lags behind what is truly needed, and remains at risk without new federal funding. In places where we were not able to include the most up to date state actions in our metrics, we included them in the narrative.

Affordability of Child Care and Early Learning

For example, measuring affordability by state is complicated. Child Care Aware® of America annually reports data on the price of child care in each state and how it compares to median family incomes, which could be useful. However, this data on its own does not provide enough information. Less-expensive programs may be of poor quality, so the lower price tag does not necessarily make it better; just as more-expensive programs may be paying early educators better and therefore serving children better. In addition, the price of care does not reflect state policies. Therefore, we did not use the price of child care.

Instead, the affordability metric looked at family copayments and the share of families that were eligible and states could earn a maximum of 1 point total. For copayments, the scoring relied on data from the National Women’s Law Center’s report on state child care assistance policies, specifically their data on the average monthly mean family copayment as a percent of family income for a family of three at 150 percent of the federal poverty line. The most recent data available was from 2022, which was used for this report. The scoring was based on the average copayment as a percentage of income for families that do have copayments. States where the average copay was $0 for such a family received 0.50 points. States where the average copayment as a percentage of income (not including $0 copayments) was below 5 percent received 0.25 points. States received 0.1 points if the average copayment was between 5 and 7 percent. This is one key area where data lag, and therefore does not reflect all of the 2023 progress on waiving and lowering copayments.

Even though 7 percent of income is the affordability measure according to the U.S. Department of Health and Human Services, since the families included had income that is at most only 85 percent of state median income (SMI) and the majority were between 100 percent and 150 percent of the federal poverty level, the rubric used a lower percentage as a more accurate sign of affordability.

To ensure that low copays aren’t coming at the expense of fewer families served, states also received credit for having eligibility standards that exceeded the federal eligibility for standards. This helps measure which states are working to make sure that as many families as possible are receiving subsidies. To measure this, states received 0.5 points if their income eligibility threshold is above 95 percent of the state median income. States received 0.25 points if the income eligibility threshold is above 85 percent of SMI and 0.1 points for an eligibility threshold above 75 percent SMI. Data from the National Women’s Law Center were also used for this metric.

Accessibility to a Diverse Supply of Options

In the previous care report card, we looked at data from the Center for American Progress from 2018 to look at the share of families living in child care deserts to measure the availability of child care options.¹³² To capture the most recent data available, this report card has looked at a different data set—data from Child Care Aware® of America (CCAoA). In both datasets, the information available reflects only licensed child care, which does not include family, friend and neighbor care—a type of child care that is also widely used by many families but difficult to track. We compared the number of licensed child care slots relative to the number of children under the age of 6 with both parents working in each state. For this reason directly comparing care report card grades on the supply of options from the previous iteration to this iteration isn’t recommended. However, while this data is slightly different from the previous report card, it should be a more nuanced and reliable metric moving forward.¹³³

Additionally, it bears mentioning that many states want to build their supply but face challenges from insufficient funding and a labor shortage in child care workers that is the direct result of failing to publicly invest in child care in the way that is necessary to support high-quality programs for providers, family sustaining wages and benefits for child care workers, and affordable, accessible child care for families.¹³⁴ At the same time, advocates in many states have successfully fought to secure additional funding during legislative sessions to help build the supply of child care.

To evaluate access to child care options the scoring rubric relied on data from Child Care Aware® of America on the number of child care slots by state. The data from CCAoA includes licensed capacity from both centers and family child care homes. CCAoA did not have data available for every state in the most recent year. When possible, licensed capacity data from 2022 was used. If a state did not report data in 2022, then the most recent year’s data was used. To fill in the remaining gaps, supply data was used from the Bipartisan Policy Center, which has state supply data for a select number of states. Lastly, for the other states where data wasn’t available in either of those sources, the scoring rubric relied on market rate surveys, which provided data on the number of child care slots.

These data were then compared to data on the universe of children under the age of 6 who have all of their parents working. The data on children, which is reported on in the American Community Survey, includes single parents and coupled parents. The number of slots per child is represented as a ratio. The better the ratio, the higher score a state received. States with at least three slots per four children received the minimum score of 0.3. States with one slot per child or more received an additional 0.7 points, resulting in a maximum possible score of 1 point. There are other factors that impact whether child care supply is sufficient, including measures on quality and availability during nontraditional hours that this report card doesn’t account for.

Credentialing

Ideally, the child care sector would have a standard, agreed upon measure of quality. Without such an agreement, the scoring rubric narrowly looked at the Child Development Associate (CDA) credential and support for achieving it. Most states have their own quality rating and improvement system (QRIS), but few of these systems take into account teacher and staff wages and working conditions, which can have the biggest impact on the quality of a child’s experience. And some advocates feel that existing quality measures have been developed without a cultural sensitivity or consideration for racial equity.¹³⁵

In terms of using the CDA specifically, CSCCE researchers write, “For early care and education, experts . . . recommend that lead teachers and program administrators acquire degrees and specialization equivalent to those working in elementary schools and that others working with young children, like assistant teachers or aides, attain foundational knowledge, such as a Child Development Associate (CDA) Credential. However, unlike K–12, these recommendations by and large have yet to be implemented in state requirements for early care and education.” Debate remains about whether a CDA is enough, or if early educators should also have an Associates or Bachelors degree.¹³⁶ Some advocates feel that experience with children and being a consistent, stable presence is enough, while others feel that more education is needed. The scoring rubric gives states credit (0.2 points) for having a CDA requirement but does not give any additional credit for requirements above a CDA. It further gives states credit (0.2 points) for providing support for pursuing and achieving a credential or additional training in the form of scholarships, apprenticeships, stipends, or tax credits and bonuses.

Additional credentialing requirements must also come with an increase in compensation. This policy was not measured as part of the data set this report card used, but it is important to note. (In addition, additional scoring based on early educator wages is included in a later section.) There are also other priorities for high quality child care that are particularly hard to measure, such as how states are faring in terms of cultural competency and supporting dual language learners, how they are supporting parents and children with disabilities, how they are addressing racial justice and racial and economic integration, and how they are including diverse stakeholder voices in decision making.

In addition, this report card does not include measure of how states are investing in after school and summer programs, but acknowledges that these are also essential programs.

Success in Achieving Universal Pre-K

States could earn a maximum of 0.6 points for progress on universal pre-K. The scoring rubric for pre-K for this report card assigned 0.2 points to the top ten states in terms of access for children age 4; 0.15 points for states 11–25; 0.1 points for states 26–39; 0.05 for states 40–50; and 0 for those that did not have any program at all. The rubric assigned the same scores again for states according to pre-K access for children age 3, although many fewer states had a program in place that served that age. Since NIEER created a way to measure whether state preschool policies meet ten quality criteria, the scoring rubric used that scale for the report card. States that met NIEER’s maximum of 10 on the quality checklist received 0.1 points; those that met 6–9 received 0.05; and those that met 1–5 received 0.025. Finally, the rubric used the NIEER ranking of state spending per child on preschool to assign scores there. States in NIEER’s top ten received 0.1; those ranked 11–25 received 0.05; and those ranked 26–50 received 0.025; states without a program received 0. Unfortunately, due to data lags, we know there is significant state progres on preschool that has not been accounted for in this rubric.

Paid Family and Medical Leave

The analysis draws from two state-level policy data sources compiled by the National Partnership for Women & Families and A Better Balanced on paid family and medical leave in each state. Data on states with expanded FMLA comes from the National Partnership for Women & Families.

This measure uses model legislation to identify ideal policies. While the model legislation identifies twenty-five areas for advocacy, this analysis uses only the ten criteria that most connect to the principle that every worker who needs to take time away from work for family or medical reasons can do so. Some aspects of an ideal paid family and medical leave policy that would impact access to leave, such as minimal unpaid waiting periods or specifications on the minimal increments of leave, are not included here to maintain focus on the key provisions that impact access. Outside of benefits duration, this report does not evaluate the quantitative specifications, such as the amount of wage replacement or specific work-hour or earnings eligibility criteria. Additionally, due to data limitations, the rubric does not evaluate aspects of the policy related to paid leave implementation, such as education requirements for public agencies and employers that help workers learn about the benefits that are available to them.

States received 0.25 points for having expanded on FMLA. They received 0.75 points for having a paid family medical leave law in place. States then received an additional 0.2 points for each of the following components:

covering all workers,
having an inclusive definition of family,
having broad reasons for use of leave including medical and family caregiving and military reasons,
offering more than twelve weeks of leave,
having a progressive wage replacement scale,
funding the program through shared contributions between employer and employees,
allowing for intermittent leave,
offering job protection that exceeds those in FMLA,
requiring continuing coverage of health care benefits during the leave period, and
prohibiting discrimination beyond FMLA.

This makes the total maximum points possible for paid family leave laws to be 3 points.

Paid Sick and Safe Days

This analysis uses eight criteria that most connect to the principle that every worker who needs to take time away from work for family or medical reasons can do so. It draws from model legislation as well as two state-level policy data sources compiled by the National Partnership for Women & Families and A Better Balance on paid sick and safe leave in each state. States received 1 point for having a paid sick leave law in place. They received an additional 0.25 points for each of the following components:

covering all workers,
offering more than five days of leave in a calendar year,
including safe days,
having an inclusive definition of family,
allowing for sick days to be used in the event of a public health emergency or school closure,
having a minimum accrual rate of one hour per thirty hours worked,
having a private right of action, and
allowing days to be used immediately without a waiting period.

Domestic Workers Bill of Rights

One key data limitation in this policy area is the level of enforcement or adherence to the law. Some states require workers’ rights and home policies to be provided in writing to their employee, but there is no data to determine whether it’s common practice. In states that don’t require written notice, it’s unclear how many workers or employees know about these policies at all. Another unknown, and opportunity for further research, is the difference in adherence and enforcement for home care workers that work for agencies versus those who are hired directly by a household employer.

States received 0.9 points for having a Domestic Workers Bill of Rights in place. They received an additional 0.1 points for each of the following components:

requiring overtime pay for working more than forty hours a week;
having access to paid sick leave, paid family leave, and other forms of PTO;
protections against discrimination, harassment, and retaliation by employers;
requiring the minimum wage;
requiring a layoff notice or severance;
requiring time off for meal breaks; and
using state budget funds for overtime pay for home care workers.

Care Workers Unions

There is no comprehensive source on the number of care workers covered by union contracts by state, sector, or occupation. These data would be useful in understanding how comprehensive state laws are in terms of the percentage of care workers actually covered, and the impact on their wages and working conditions. As a result states received 1 point for having a law protecting care worker unions.

Care Worker Wages

The scoring for ware worker wages started with the median wage for direct care workers and child care workers for each state, Which was then evaluated against a number of metrics. First, states earned 0.1 points if the median wage was at least 50 percent of the living wage for one adult and one child. States earned an additional 0.2 points if the median wage was 80–99 percent of the living wage for one adult and one child, and an additional 0.3 points if it’s more than 100 percent of that living wage. Because median wages for care workers are lower than they should be due to the undervaluing of women’s work, states earned an additional 0.2 points if they met the sufficient wage benchmark for workers set by economists for the Economic Policy Institute.¹³⁷ This benchmark provides state-by-state levels for what direct care worker wages would be if they accounted for the full value of their labor, including by eliminating wage gaps and accounting for education levels. These benchmark wage levels were inflation-adjusted to 2022 levels to be comparable with median wage data from 2022. No state has yet met this wage benchmark.

Home-and Community-Based Services

For the scoring of this policy area, the rubric relies on data from the “Innovation and Opportunity” scorecard from the AARP Public Policy Institute, which ranks states based on five dimensions. Each dimension includes a number of indicators. States were ranked in order and received a maximum score of 3 for the highest ranking state. Each subsequent state’s score decreased by 0.06 points. For greater detail on the AARP’s scorecard please consult their report for extensive information on indicators and definitions of key terms.¹³⁸ Some of the key indicators for the five dimensions in the AARP scorecard are:

“Affordability and Access” includes metrics on home care costs, nursing home costs, long-term care insurance, and Medicaid HCBS presumptive eligibility.
“Choice of Setting and Provider” includes metrics on spending on HCBS, assisted living supply, home health aide supply, and LTSS worker wage competitiveness.
“Safety and Quality” includes a number of quality benchmarks in HCBS and home health hospital admissions, staff turnover, quality ratings, and staffing levels.
“Support for Family Caregivers” includes metrics on nurse delegation, family responsibility protected classification, unemployment insurance for family caregivers, and state caregiver tax credits.
“Community Integration” includes metrics on the employment rate for people with disabilities, multisector plans for aging, and access to housing assistance for people with disabilities.

Tax Policy

This scorecard does not capture the full extent of the progressivity or adequacy of tax credits in place. Some states have progressive taxation, in that lower-income recipients receive a higher benefit relative to the federal benefit. However, the bend points and cutoffs vary from state to state. This report card did not attempt to identify whether those bend points and cutoffs are adequate based on poverty levels and cost of living in each state, or if the benefits get individuals and families closer to a living wage. As a result, for each tax credit evaluated, states received 0.5 points for having the tax credit in place. They received an additional 0.25 points if their tax credit was refundable. States received 0.25 points if the tax credit was at least 50 percent of the federal benefit, or 0.1 points if it was less than 50 percent but greater than 25 percent of the federal benefit. States total tax credit scores are aggregated and divided so the maximum possible extra credit points possible for tax credits is 1 point.

Notes

Julie Kashen and Amanda Novello, “Care Matters: A Report Card for Care Policies in the States,” The Century Foundation, September 22, 2021, https://tcf.org/content/report/care-matters-a-report-card-for-care-policies-in-the-states/.
Ibid.
Julie Kashen et al., “The Top Six Lessons from ARPA’s Care Economy Investments,” The Century Foundation, October 11, 2023, https://tcf.org/content/commentary/the-top-six-lessons-from-arpas-care-economy-investments/.
Julie Kashen et al., “Child Care Cliff: 3.2 Million Children Likely to Lose Spots with End of Federal Funds,” The Century Foundation, June 2023, https://tcf.org/content/report/child-care-cliff/.
Karen Schulman, “Precarious Progress: State Child Care Policies 2022,” National Women’s Law Center, June 2023, https://nwlc.org/wp-content/uploads/2023/06/State-of-Child-Care-2023-FINAL.pdf.
Julie Kashen and Kim Knackstedt, “How Three States Made Covid-Relief Investments in Improving Home and Community-Based Services,” The Century Foundation, September 2022, https://tcf.org/content/report/how-three-states-made-covid-relief-investments-in-improving-home-and-community-based-services/.
“Strengthening and Investing in Home and Community Based Services for Medicaid Beneficiaries: American Rescue Plan Act of 2021 Section 9817,” Centers for Medicare and Medicaid Services, https://www.medicaid.gov/medicaid/home-community-based-services/guidance-additional-resources/strengthening-and-investing-home-and-community-based-services-for-medicaid-beneficiaries-american-rescue-plan-act-of-2021-section-9817/index.html.
“Overview of State Spending under American Rescue Plan Act of 2021 (ARP) Section 9817, as of the Quarter Ending December 31, 2022,” Centers for Medicare and Medicaid Services, https://www.medicaid.gov/sites/default/files/2023-12/arp-sec9817-overview-infographic_0.pdf.
George Fenton, “Gains from Expanded Child Tax Credit Outweigh Overstated Worker Worries,” Center on Budget and Policy Priorities, June 2023, https://www.cbpp.org/research/federal-tax/gains-from-expanded-child-tax-credit-outweigh-overstated-employment-worries.
Chuck Marr et al., “American Rescue Plan Includes Critical Expansions of Child Tax Credit and EITC,” Center on Budget and Policy Priorities, March 12, 2021, https://www.cbpp.org/research/federal-tax/american-rescue-plan-act-includes-critical-expansions-of-child-tax-credit-and.
Margot Crandall-Hollick, “The Child and Dependent Care Tax Credit (CDCTC): Temporary Expansion for 2021 Under the American Rescue Plan Act of 2021 (ARPA;P.L. 117-2),” Congressional Research Service, May 10, 2021, https://crsreports.congress.gov/product/pdf/IN/IN11645.
Kashen et al., “Investing in the Care Economy Works: Learning from the American Rescue Plan,” The Century Foundation, February 2023, https://tcf.org/content/commentary/investing-in-the-care-economy-works-learning-from-the-american-rescue-plan/.
Erica Meade and Sarah Gilliand, “Bolstering State and Local Care Infrastructure with Federal Recovery Funding,” New America, April 2023, https://www.newamerica.org/new-practice-lab/briefs/state-and-local-care-infrastructure-federal-recovery-funding-arpa/.
“Nebraska Home and Community-Based Services (HCBS) Spending Plan: Quarterly Update—FFY 2024—Q1,” Nebraska Department of Health and Human Services, July 18, 2023, https://dhhs.ne.gov/Documents/Nebraska-HCBS-Spending-Plan-Quarterly-Update.pdf.
Claire Caine Miller and Alicia Parlapiano, “ The U.S. Built a European-Style Welfare State. It’s Largely Over,” New York Times, April 2023, https://www.nytimes.com/interactive/2023/04/06/upshot/pandemic-safety-net-medicaid.html.
Sharon Parrott, “Record Rise in Poverty Highlights Importance of Child Tax Credit; Health Coverage Marks a High Point Before Pandemic Safeguards Ended,” Center on Budget and Policy Priorities, September 2023, https://www.cbpp.org/press/statements/record-rise-in-poverty-highlights-importance-of-child-tax-credit-health-coverage.
Karen Lynch and Conor Boyle, “What is the Child Care Funding Cliff?” Congressional Research Service, September 2023, https://crsreports.congress.gov/product/pdf/IN/IN12243.
Alicia Burns et al., “Payment Rates for Mediaid Home- and Community-Based Services: States’ Responses to Workforce Challenges,” Kaiser Family Foundation, October 24, 2023, https://www.kff.org/medicaid/issue-brief/payment-rates-for-medicaid-home-and-community-based-services-states-responses-to-workforce-challenges/.
Julie Kashen, “How Congress Got Close to Solving Child Care, Then Failed,” December 12, 2022, The Century Foundation, https://tcf.org/content/commentary/how-congress-got-close-to-solving-child-care-then-failed/.
“The Build Back Better Framework,” The White House, https://www.whitehouse.gov/build-back-better.
Rep. Jerry Nadler, “Making the New Pregnant Workers Fairness Act Work for Women and Families,” The Hill, November 1, 2023, https://thehill.com/opinion/congress-blog/4286704-making-the-new-pregnant-workers-fairness-act-work-for-women-and-families/; Dina Bakst, Opinion, “Pregnant and Pushed Out of a Job,” New York Times, January 30, 2012, https://www.nytimes.com/2012/01/31/opinion/pregnant-and-pushed-out-of-a-job.html.
“Winning the Pregnant Workers Fairness Act: An Inside Story and Lessons Learned from the Decade-Long Fight for Justice, Fairness, and Equality,” A Better Balance, June 2023, https://www.abetterbalance.org/winning-pwfa/; Gillian Thomas and Vania Leveille, “The Historic New Law Protecting Fairness for Pregnant Workers,” American Civil Liberties Union, June 27, 2023, https://www.aclu.org/news/womens-rights/the-pregnant-workers-fairness-act-how-we-got-here.
Equal Opportunity Employment Commission, “Regulations to Implement the Pregnant Workers Fairness Act,“ Federal Register, August 11, 2023, https://www.federalregister.gov/documents/2023/08/11/2023-17041/regulations-to-implement-the-pregnant-workers-fairness-act#h-32.
Ibid.
“The Pregnant Workers Fairness Act: What You Should Know,” A Better Balance, November 14, 2023, https://www.abetterbalance.org/resources/pregnant-workers-fairness-act-explainer/.
Author email exchange with National Partnership for Women & Families, May 2023, and with A Better Balance, January 2024.
Ibid.
FLSA Protections to Pump at Work,” U.S. Department of Labor, Wage and Hour Division, https://www.dol.gov/agencies/whd/pump-at-work.
“The PUMP for Nursing Mothers Act: What You Should Know,” A Better Balance, January 27, 2023, https://www.abetterbalance.org/resources/pump-for-nursing-mothers-act-explainer/.
Becca Damante, “5 Facts about the PUMP for Nursing Mothers Act,” Center for American Progress, January 26, 2203, https://www.americanprogress.org/article/5-facts-about-the-pump-for-nursing-mothers-act/.
Dobbs v. Jackson Women’s Health Organization, 597 U.S. 215 (2022).
“Reproductive Justice,” In Our Own Voice: National Black Women’s Reproductive Justice Agenda, 2023, https://blackrj.org/our-causes/reproductive-justice/.
Sheryl Gay Stolberg, “As Abortion Laws Drive Obstetricians From Red States, Maternity Care Suffers,” New York Times, September 6, 2023, https://www.nytimes.com/2023/09/06/us/politics/abortion-obstetricians-maternity-care.html.
“Fighting for Our Families,” Family Forward Oregon, 2023, https://familyforwardoregon.org/our-wins/.
“Governor Walz Signs Paid Family and Medical Leave Bill into Law,” Office of Governor Tim Walz and Lt. Governor Peggy Flanagan, May 25, 2023, https://mn.gov/governor/newsroom/press-releases/?id=1055-579303; “FAQs: Earned Sick and Safe Time,” Minnesota Department of Labor and Industry, https://www.dli.mn.gov/business/employment-practices/faqs-earned-sick-and-safe-time-esst.
Daniel Hauser, “Missed Opportunities of the 2023 Oregon Legislative Session,” Oregon Center for Public Policy, July 25, 2023, https://www.ocpp.org/2023/07/25/missed-opportunities-legislative-session/.
“Comparative Chart of Paid Family and Medical Leave Laws in the United States,” A Better Balance, January 2, 2024, https://www.abetterbalance.org/resources/paid-family-leave-laws-chart/.
“Medicaid HCBS Waiver Waiting List Enrollment, by Target Population and Whether States Screen for Eligibility,” Kaiser Family Foundation, 2023, https://www.kff.org/medicaid/state-indicator/medicaid-hcbs-waiver-waiting-list-enrollment-by-target-population-and-whether-states-screen-for-eligibility/.
“Workforce Data Center: Direct Care Worker Median Hourly Wages Adjusted for Inflation, 2012 to 2022,” PHI, https://www.phinational.org/policy-research/workforce-data-center/#var=Wage+Trends&states=.
“Child Care Costs in the United States: The Cost of Child Care in West Virginia,” Economic Policy Institute, October 2020, https://www.epi.org/child-care-costs-in-the-united-states/?gclid=CjwKCAiA98WrBhAYEiwA2WvhOszM3MiMkCtLgOKfSRAkD9IdJlFtHNfoQSkC9FP3mCOSPE3EQL5SohoCTUQQAvD_BwE#/WV.
Julie Kashen, “The Case for Child Care and Early Learning for All: Economic Prosperity,” The Century Foundation, August 12, 2021, https://tcf.org/content/commentary/case-child-care-early-learning-economic-prosperity/.
Julie Kashen and Halley Potter, “The Case for Child Care and Early Learning for All: Healthy Child Development and School Readiness,” The Century Foundation, September 2, 2021, https://tcf.org/content/commentary/case-child-care-early-learning-healthy-child-development-school-readiness/.
“American Rescue Plan Child Care Stabilization Program,” Administration for Children and Families, Office of Child Care, https://www.acf.hhs.gov/sites/default/files/documents/occ/National_ARP_Child_Care_Stabilization_Program_Fact_Sheet_Sept_2023.pdf.
Julie Kashen et al., “Child Care Cliff: 3.2 Million Likely to Lose Spots with End of Federal Funds,” The Century Foundation, June 21, 2023, https://tcf.org/content/report/child-care-cliff/.
Julie Kashen and Laura Valle-Gutierrez, “With Arrival of Child Care Cliff, Some States have Stepped in to Save the Sector,” The Century Foundation, January 17, 2024, https://tcf.org/content/report/with-arrival-of-child-care-cliff-some-states-have-stepped-in-to-save-the-sector/.
Casey Parks, “In N.M. child-care funding win, providers nationwide see road map,” Washington Post, November 10, 2022, https://www.washingtonpost.com/dc-md-va/2022/11/10/new-mexico-child-care-fund/.
Casey Park, “In N.M. child-care funding win, providers see national roadmap,” Washington Post, November 10, 2022, https://www.washingtonpost.com/dc-md-va/2022/11/10/new-mexico-child-care-fund/.
“Annual Price of Care: 2022 Child Care Affordability,” Child Care Aware® of America, https://www.childcareaware.org/catalyzing-growth-using-data-to-change-child-care-2022/#:~:text=CCAoA%20found%20that%20the%20national,afford%20this%20national%20average%20price.
Ibid.
Robert Paul Hartley, Ajay Chaudry, Melissa Boteach, Estelle Mitchell, and Kathryn Menefee, “A Lifetime Worth of Benefits: The Effects of Affordable, High-quality Child Care on Family Income, the Gender Earnings Gap, and Women’s Retirement Security,” National Women’s Law Center and Center on Poverty and Social Policy at Columbia University, March 2021, https://nwlc.org/wp-content/uploads/2021/04/A-Lifetimes-Worth-of-Benefits-_FD.pdf.
Leila Schochet and Rasheed Malik, “2 million Parents Forced to Make Career Sacrifices Due to Problems with Child Care,” Center for American Progress, September 13, 2017, https://www.americanprogress.org/article/2-million-parents-forced-make-career-sacrifices-due-problems-child-care/.
“Annual Price of Care: 2022 Child Care Affordability,” Child Care Aware® of America, https://www.childcareaware.org/catalyzing-growth-using-data-to-change-child-care-2022/#PriceofCare.
Karen Schulman, “Precarious Progress: State Child Care Assistance Policies 2022,” National Women’s Law Center, May 2023, https://nwlc.org/wp-content/uploads/2023/06/State-of-Child-Care-2023-FINAL.pdf.
Laura Pryor et al. , “Mending Harmful Family Fees: Expanding Possibilities for California Families,” California Budget and Policy Center, July 2023, https://calbudgetcenter.org/resources/mending-harmful-family-fees-expanding-possibilities-for-california-families/.
Diane Girouard, “State Session Round Up: Summer 2023,” Child Care Aware® of America, September 14, 2023, https://info.childcareaware.org/blog/state-session-round-up-summer-2023?emci=89c66cef-f55e-ee11-9937-00224832eb73&emdi=6f21f863-cd63-ee11-9937-00224832eb73&ceid=9877058.
Alycia Hardy and Stephanie Schmit, “What a $4.38 Billion Increase in CCDBG Annual Discretionary Funding Could Mean for Your State,” Center for Law and Social Policy, April 19, 2023, https://www.clasp.org/publications/fact-sheet/what-a-4-38-billion-increase-in-ccdbg-annual-discretionary-funding-could-mean-for-your-state/.
Diane Girouard, “State Session Round Up: Summer 2023,” Child Care Aware® of America, September 14, 2023, https://info.childcareaware.org/blog/state-session-round-up-summer-2023?emci=89c66cef-f55e-ee11-9937-00224832eb73&emdi=6f21f863-cd63-ee11-9937-00224832eb73&ceid=9877058.
Ibid.
Maureen Coffey, “Rural Communities Need Federal Child Care Investments,” Center for American Progress, May 17, 2022, https://www.americanprogress.org/article/rural-communities-need-federal-child-care-investments/.
A family child care provider is a person who uses a residence other than the child’s home to provide paid care, on a regular basis, for one or more children who are not related to the person.
“Addressing the Decreasing Number of Family Child Care Providers in the United States,” National Center on Early Childhood Quality Assurance, March 2020, https://childcareta.acf.hhs.gov/sites/default/files/new-occ/resource/files/addressing_decreasing_fcc_providers_revised_march2020_final.pdf.
Nate File and Lynette Hazelton, “Day-care owners are fighting for survival as federal funding runs out this month,” Philadelphia Inquierer, September 23, 2023, https://www.inquirer.com/news/pennsylvania/childcare-funding-american-rescue-covid-daycare-philadelphia-20230923.html; Chabeli Carrazana, “The death of a day care: When a child care center closes, an entire community is affected,” The 19th, August 31, 2023, https://19thnews.org/2023/08/child-care-centers-closing-pandemic-era-funding-communities/; McKenna Leavens, “NC Health Dept: 7 Western North Carolina child care centers to close, lack of funding,” Asheville Citizen Times, October 23, 2023, https://www.citizen-times.com/story/news/local/2023/10/23/child-care-centers-close-down-in-wnc-leaving-kids-without-care/71255415007/.
“What Do Children Learn in a High-Quality Preschool Program?” National Association for the Education of Young Children (NAEYC), https://www.naeyc.org/our-work/families/what-do-children-learn-preschool-program.
Allison H. Friedman-Krauss, Ph.D. W. Steven Barnett, Ph.D., et. al, “The State of Preschool 2022,” Rutgers University, 2023, https://nieer.org/wp-content/uploads/2023/09/YB2022_FullReport.pdf.
Erica Meltzer, “Gov. Polis signs Colorado universal preschool bill into law,” Chalkbeat Colorado, April 25, 2022, https://www.chalkbeat.org/colorado/2022/4/25/23041861/colorado-free-universal-preschool-polis-bill-signed/.
“State Child Care and Early Education Updates 2023: Continuing Progress,” National Women’s Law Center, January 9, 2024, https://nwlc.org/resource/state-child-care-and-early-education-updates-2023-continuing-progress/#.
“The Case for Action: Long-Term Services and Supports,” National Academy of Social Insurance, June 16, 2019, https://www.nasi.org/wp-content/uploads/2019/06/NASI_Infographic_LTSS_061619_01.pdf.
Ibid.
Susan Reinhard et al., “Valuing the Invaluable 2023 Update: Strengthening Supports for Family Caregivers,” AARP Public Policy Institute, March 8, 2023, https://www.aarp.org/ppi/info-2015/valuing-the-invaluable-2015-update.html.
Dan White et al., “The Economic Impact of Caregiving,” Blue Cross Blue Shield, June 1, 2021, https://www.bcbs.com/the-health-of-america/reports/the-economic-impact-of-caregiving.
Ibid.
“Innovation and Opportunity: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers,” AARP Public Policy Institute, September 28, 2023, https://ltsschoices.aarp.org/scorecard-report/innovation-and-opportunity.
Jennifer Guglielmo, Michelle Joffroy, and Diana Sierra Becerra, “The 1881 Washerwomen’s Strike,” A History of Domestic Work and Worker Organizing, https://www.dwherstories.com/timeline/the-1881-washerwomens-strike.
Peggy Haack, Rosemarie Vardell, and Marcy Whitebook, “Who Were the Worthy Wagers,” Center for the Study of Child Care Employment, May 3, 2021, https://cscce.berkeley.edu/blog/who-were-the-worthy-wagers/.
National Domestic Workers Alliance, “National Domestic Workers Bill of Rights,” https://www.domesticworkers.org/programs-and-campaigns/developing-policy-solutions/domestic-workers-bill-of-rights/national-domestic-workers-bill-of-rights/.
Ibid.
“Occupational Employment and Wages, May 2022: 39-9011 Childcare Workers,” U.S. Bureau of Labor Statistics, https://www.bls.gov/oes/current/oes399011.htm.
C. McLean, L. J. E. Austin, M. Whitebook, and K. L. Olson, Early Childhood Workforce Index—2020 (Berkeley, Calif.: Center for the Study of Child Care Employment, University of California, Berkeley, 2021), https://cscce.berkeley.edu/workforce-index-2020/report-pdf/.
“Workforce Data Center: Direct Care Worker Median Hourly Wages Adjusted for Inflation, 2012 to 2022,” PHI, https://www.phinational.org/policy-research/workforce-data-center/#var=Wage+Trends&tab=National+Data&natvar=Wage+Trends.
Asha Banerjee et al., “Domestic Workers Chartbook 2022,” Economic Policy Institute, November 22, 2022, https://www.epi.org/publication/domestic-workers-chartbook-2022/#occupationsdefined.
Justin Schweitzer and Rose Khattar, “It’s a Good Jobs Shortage: The Real Reason So Many Workers are Quitting,” Center for American Progress, December 7, 2021, https://www.americanprogress.org/article/its-a-good-jobs-shortage-the-real-reason-so-many-workers-are-quitting/.
Elise Gould et al., “Care workers are deeply undervalued and underpaid,” Economic Policy Institute, July 16, 2021, https://www.epi.org/blog/care-workers-are-deeply-undervalued-and-underpaid-estimating-fair-and-equitable-wages-in-the-care-sectors/.
“Home Care,” SEIU 1199NE, https://www.seiu1199ne.org/connecticut-2/home-care/.
“Calculate your new raise!” SEIU503, October 2, 2023, https://seiu503.org/member_news/calculate-your-new-raise/.
Gaving Newsom, Letter to the Members of the California State Senate, Office of the Governor of the State of California, September 30, 2023, https://www.gov.ca.gov/wp-content/uploads/2023/09/SB-686-Veto-Message.pdf.
“Expecting Better: A State-by-State Analysis of Laws That Help Expecting and New Parents,” National Partnership for Women & Families, August 2016, https://www.nationalpartnership.org/our-work/resources/economic-justice/expecting-better-2016.pdf.
“Expecting Better: A State-by-State Analysis of Laws That Help Expecting and New Parents,” National Partnership for Women & Families, August 2016, https://www.nationalpartnership.org/our-work/resources/economic-justice/expecting-better-2016.pdf.
“Meeting the Promise of Paid Leave: Best Practices in State Paid Leave Implementation,” National Partnership for Women & Families, 2019, https://www.nationalpartnership.org/our-work/resources/economic-justice/paid-leave/meeting-the-promise-of-paid-leave.pdf.
“Comparative Chart of Paid Family and Medical Leave Laws in the United States,” A Better Balance, January 2024, https://www.abetterbalance.org/resources/paid-family-leave-laws-chart/.
Ibid.
Kathleen Bryant and Kathleen Romig, “A National Paid Leave Program Would Help Workers, Families,” Center on Budget and Policy Priorities, April 2021, https://www.cbpp.org/research/economy/a-national-paid-leave-program-would-help-workers-families.
“Paid Family and Medical Leave: Good for Business,” National Partnership for Women & Families, September 2018, https://www.nationalpartnership.org/our-work/resources/economic-justice/paid-leave/paid-leave-good-for-business.pdf.
“America’s Women and the Wage Gap,” National Partnership for Women & Families, September 2023, https://nationalpartnership.org/wp-content/uploads/2023/02/americas-women-and-the-wage-gap.pdf.
“Paid Family and Medical Leave: A Racial Justice Issue—and Opportunity,” National Partnership for Women & Families, August 2018, https://www.nationalpartnership.org/our-work/resources/economic-justice/paid-leave/paid-family-and-medical-leave-racial-justice-issue-and-opportunity.pdf.
“Paid Leave,” National Partnership for Women & Families, accessed September 2021, https://www.nationalpartnership.org/our-work/economic-justice/paid-leave.html.
Dana Ferguson, “‘A much more inclusive safety net’: Minnesota House passes paid family leave program,” Minnesota Public Radio, May 2, 2023, https://www.mprnews.org/story/2023/05/02/a-much-more-inclusive-safety-net-minnesota-house-passes-paid-family-leave-program.
Bria Lloyd and Jim Haddadin, “CT Paid Leave Authority to withhold $375,000 from claims company for missing performance goals,” Connecticut Public Radio, February 10, 2023, https://www.ctpublic.org/news/investigative/2023-02-10/ct-paid-leave-authority-to-withhold-375-000-from-claims-company-for-missing-performance-goals.
“Overview of Paid Sick Time Laws in the United States: Michigan,” A Better Balance, January 30, 2023, https://www.abetterbalance.org/paid-sick-time-laws/michigan/.
“Minnesota Session Laws—2023, Regular Session, Chapter 53, Article 12: Earned Sick and Safe Time, 181.032 Required Statement of Earnings by Employer; Notice to Employee,” Minnesota Legislature, Office of the Revisor of Statutes, https://www.revisor.mn.gov/laws/2023/0/53/laws.12.1.0#laws.12.1.0.
“Fighting to Defend Michiganders’ Hard-Won Paid Sick Time Rights,” A Better Balance, November 28, 2023, https://abetterbalance.org/fighting-to-defend-michiganders-hard-won-paid-sick-time-rights/.
Arizona, California, Colorado, Connecticut, District of Columbia, Maryland, Massachusetts, New Jersey, New Mexico, New York, Oregon, Rhode Island, Vermont, and Washington also have paid sick days.
Lynn La, “California workers will get more paid sick days,” CalMatters, October 5, 2023, https://calmatters.org/newsletters/whatmatters/2023/10/sick-days-california/; California Senate Bill No. 616, 2023, https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240SB616.
“Georgia’s Family Care Act is Now Permanent,” A Better Balance, April 3, 2023, https://www.abetterbalance.org/georgias-family-care-act-is-now-permanent-law/.
Ibid.
“Employment (820 ILCS192.) Paid Leave for All Workers Act,” Illinois General Assembly, https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=4351&ChapterID=68.
“S.P. 110-L.D. 369: An Act Authorizing Earned Employee Leave,” Maine Legislature, https://legislature.maine.gov/legis/bills/getPDF.asp?paper=SP0110&item=4&snum=129.
“Chapter 608—Compensation, Wages and Hours,” Nevada Legislature, https://www.leg.state.nv.us/nrs/nrs-608.html.
“Paid Sick Days Statutes,” National Partnership for Women & Families, October 2023, https://nationalpartnership.org/wp-content/uploads/2023/02/paid-sick-days-statutes.pdf; “Overview of Paid Time Off Laws in the United States,” A Better Balance, January 8, 2024, https://www.abetterbalance.org/resources/overview-of-paid-time-off-laws-in-the-united-states/.
Elaine Zundl et al., “Still Unstable: The Persistence of Schedule Uncertainty During the Pandemic,” Shift Project, January 2022, https://shift.hks.harvard.edu/still-unstable/; “Collateral Damage: Scheduling Challenges for Workers in Low-Paid Jobs and their Consequences,” National Women’s Law Center, September 2023, https://nwlc.org/resource/collateral-damage-scheduling-challenges-workers-low-wage-jobs-and-their-consequences/.
Ibid.
“State and Local Laws Advancing Fair Work Schedules,” National Women’s Law Center, September 2023, https://nwlc.org/resource/state-and-local-laws-advancing-fair-work-schedules/.
“Key Elements of the U.S. Tax System: What is the difference between refundable and nonrefundable tax credits?,” Tax Policy Center Urban Institute and Brookings Institution, May 2020, https://www.taxpolicycenter.org/briefing-book/what-difference-between-refundable-and-nonrefundable-credits.
“Momentum Grows for State Tax Credit Programs with Key Legislative Wins,” Economic Security Project, December 19, 2023, https://economicsecurityproject.org/resource/momentum-grows-for-state-tax-credit-programs-with-key-legislative-wins/.
In order to align with the previous care report card, and given data availability, state tax credits that are available to filers with ITINs were not included in the scoring metric for tax credits.
Aidan Davis and Neva Butkus, “States are Boosting Economic Security with Child Tax Credits,” Institute on Taxation and Economic Policy, Septemer 12, 2023, https://itep.org/states-are-boosting-economic-security-with-child-tax-credits-in-2023/; “State Earned Income Tax Credits,” Urban Institute, https://www.urban.org/policy-centers/cross-center-initiatives/state-and-local-finance-initiative/state-and-local-backgrounders/state-earned-income-tax-credits.
Samantha Waxman and Iris Hinh, “States Can Enact or Expand Child Tax Credits and Earned Income Tax Credits to Build Equitable, Inclusive Communities and Economies,” Center for Budget and Policy Priorities, March 3, 2023, https://www.cbpp.org/research/state-budget-and-tax/states-can-enact-or-expand-child-tax-credits-and-earned-income-tax.
“Policy Basics: The Earned Income Tax Credit,” Center on Budget and Policy Priorities, April 28, 2023, https://www.cbpp.org/research/policy-basics-the-earned-income-tax-credit.
Samantha Waxman, “A Record 14 States, Territories Created or Improved EITCs to Respond to COVID-19,” Center on Budget and Policy Priorities, October 14, 2021, https://www.cbpp.org/blog/a-record-14-states-territories-created-or-improved-eitcs-to-respond-to-covid-19.
“Policy Basics: The Child Tax Credit,” Center on Budget and Policy Priorities, December 7, 2022, https://www.cbpp.org/research/policy-basics-the-child-tax-credit
“Child and Dependent Care Tax Credit,” Tax Credits for Workers and Families, https://www.taxcreditsforworkersandfamilies.org/federal-tax-credits/child-dependent-care-tax-credit/.
“The Child and Dependent Care Tax Credit Helps Working Families with the High Cost of Child Care,” National Women’s Law Center, April 2021, https://nwlc.org/wp-content/uploads/2021/04/CDCTCFactSheet.pdf.
Joe Biden, “The Biden Plan for Mobilizing American Talent and Heart to Create a 21st Century Caregiving and Education Workforce,” Medium, July 21, 2020, https://medium.com/@JoeBiden/the-biden-plan-for-mobilizing-american-talent-and-heart-to-create-a-21st-century-caregiving-and-af5ba2a2dfeb.
“Senator Patty Muray and Rep. Bobby Scott’s Child Care for Working Families Act,” Office of Senator Patty Muray, https://www.murray.senate.gov/wp-content/uploads/2023/04/The-Child-Care-for-Working-Families-Act-Summary.pdf.
Molly Weston Williamson, “Getting to Know the Healthy Families Act,” Center for American Progress, September 5, 2023, https://www.americanprogress.org/article/getting-to-know-the-healthy-families-act/#:~:text=The%20Healthy%20Families%20Act%20would%20guarantee%20employees%20the%20right%20to,with%20sexual%20or%20domestic%20violence.
“The Family and Medical Insurance Leave (FAMILY) Act,” National Partnership for Women and Families, November 2023, https://nationalpartnership.org/wp-content/uploads/2023/02/family-act-fact-sheet.pdf.
Joseph R. Biden, “Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers,” The White House, April 18, 2023, https://www.whitehouse.gov/briefing-room/presidential-actions/2023/04/18/executive-order-on-increasing-access-to-high-quality-care-and-supporting-caregivers/.
“Improving Child Care Access, Affordability, and Stability in the Child Care and Development Fund (CCDF) [Proposed Rule, RIN 0970-AD02],” Federal Register, July 13, 2023, https://www.federalregister.gov/documents/2023/07/13/2023-14290/improving-child-care-access-affordability-and-stability-in-the-child-care-and-development-fund-ccdf.
“Proposed Amendment to CCDF Regulation,” Child Care Aware® of America, https://info.childcareaware.org/hubfs/NPRM2023SummaryofChanges.pdf.
“Medicaid Program; Ensuring Access to Medicaid Services [Proposed Rule, RIN: 0938-AU68],” Federal Register, May 03, 2023, https://www.federalregister.gov/documents/2023/05/03/2023-08959/medicaid-program-ensuring-access-to-medicaid-services.
“Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting (CMS 3442-P),” Centers for Medicare AND Medicaid Services, September 1, 2023, https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid.
Dyvonne Body, “The True Cost of Caregiving,” Aspen Institute, June 2020, https://www.aspeninstitute.org/publications/the-true-cost-of-caregiving/.
Rasheed Malik and Katie Hamm, “Mapping America’s Child Care Deserts,” Center for American Progress, August 30, 2017, https://www.americanprogress.org/article/mapping-americas-child-care-deserts/
Note that neither metric includes unlicensed child care, which includes family, friend and neighbor care that many families rely on to provide culturally affirming care or needed during nontraditional work hour.
U.S. Department of the Treasury, “Remarks by Secretary of the Treasury Janet L. Yellen on Shortages in the Child Care System,” September 15, 2021, https://home.treasury.gov/news/press-releases/jy0355
“Quality Improvement in California,” Letter from Child Care Resource and Referral Network, Parent Voices and Child Care Law Center, August 14, 2020, https://rrnetwork.org/assets/general-files/Master-Plan-QRIS.pdf.
Some advocates feel that experience with children and being a consistent, stable presence is enough, while others feel that more education is needed.
Cassandra Robertson et al., “All States Must Set Higher Wage Benchmarks for Home Health Care Workers,” Economic Policy Institute, June 2, 2022, https://www.epi.org/publication/state-home-health-care-wages/.
Susan Reinhard et al., “Innovation and Opportunity: A State Scorecard on Long-Term Services for Older Adults, People with Physical Disabilities and Family Caregivers, 2023 Edition,” AARP Public Policy Institute, September 28, 2023, https://ltsschoices.aarp.org/sites/default/files/documents/doi/ltss-scorecard-2023-innovation-and-opportunity.doi.10.26419-2Fppi.00203.001.pdf.

Tags: care workers, child care, paid family leave, care economy, home and care community based services