Intergenerational Relationships, Family Caregiving Policy, and COVID-19 in the United States

Abstract

Families and intergenerational relationships are important sources of risk for COVID-19 infection, especially for older adults who are at high risk of complications from the disease. If one family member is exposed to the virus they could serve as a source of transmission or, if they fall ill, the resources they provide to others could be severed. These risks may be especially heightened for family members who work outside the home and provide care, or for those family members who care for multiple generations. Policies have the potential to help families bear the burden of these decisions. This essay argues that policies that address health, employment, and other social issues have implications for families, and that policies aimed at families and caregivers can affect the health, employment, and the general well-being of the nation.

Introduction

COVID-19 has spread globally within the period of a few short months, devastating populations and straining healthcare systems in China, Europe, and – more recently – the United States. The virus has demonstrated uneven risks for mortality across different population groups, with severest risks among older adults, those with pre-existing conditions, and racial minority groups (Dowd et al., 2020). Yet one of the most treacherous aspects of COVID-19 is its ability to transmit from person-to-person even when carriers are asymptomatic or show very few indications of infection (Qian et al., 2020). This leads to another axis upon which COVID-19 may differentially impact certain population groups, which has received less attention in the media to date – that of family structure and intergenerational bonds (for an exception from Italy, see Balbo, Billari, & Melegaro, 2020). Families are a central source of many social contacts and daily interactions – and thus a potential source of disease spread – particularly among some of the highest-risk groups for COVID-19 complications (Dorélien, Ramen, & Swanson, 2020).

This perspective examines the implications of multigenerational family relationships for COVID-19 exposure and transmission, with a particular focus on the caregiving roles that “sandwich” generation adults often play, even as they remain active in the formal workforce. Both gender and racial disparities in these caregiving responsibilities, and the risks they pose during the present pandemic, are of central importance.

Caregiving and COVID-19

The United States offers less generous social welfare protections for families and caregivers than most other OECD nations (Organisation for Economic Cooperation and Development, 2011). Social policies and programs that maximize these individual risks also compound racial and gender inequalities that accumulate across the life course (Harrington Meyer & Herd, 2007). Additionally, in part due to this lack of a strong social safety net, as well as due to financial losses during the Great Recession that severely harmed retirement and pension accounts (Newman, 2019), a substantial proportion of older adults remain in the workforce themselves (Toossi & Torpey, 2017). This combination of limited social welfare policies, insufficient retirement savings and support for older adults, and strong “family as caregiver” norms in the U.S. results in older Americans depending largely upon family members – typically spouses or adult children – to provide informal care. This is particularly the case among the oldest-old, those with physical limitations and disabilities, and racial and ethnic minority populations (Harrington Meyer & Herd, 2007).

Indeed, family members are the front-line caregivers in the United States, especially for older adults (Wolff et al., 2016). On average, in the U.S., informal care provided by working age adults for older adults is valued at $412 billion per year; that number rises to $522 billion when accounting for caregivers who are 65 and older (Chari, Engberg, Ray, & Mehrotra, 2015). Even when institutionalized in a nursing home, older adults rely on “care convoys” made up of family members who provide additional care for them (Kemp et al., 2018).

COVID-19 may prevent critical family contact and care from occurring, or could serve as a source of potential exposure for at-risk older adults. This may be especially true for families with “essential” workers, such as those in healthcare, law enforcement, or food/grocery industries, particularly if those workers must balance multiple care duties at work and at home (e.g., Van Houtven, DePasquale, & Coe, 2020). Federal and state governments, alongside major private-sector employers, have encouraged the use of telework options during the COVID-19 pandemic (Hadden Loh & Fishburne, 2020). However, this is not possible for all workers, nor even permitted for those workers deemed “essential” (Hadden Loh & Fishburne, 2020).

Even under normal conditions, the stresses of caregiving – in addition to those of formal workforce participation – can be harmful for health and well-being, especially among the women who inordinately bear those responsibilities (Moen & DePasquale, 2017). Despite increases in women’s formal labor force participation over the course of the last half-century, the burden of informal carework remains highly gendered, with wives, daughters, and other women being more likely to provide any care – and to provide more care – to one or more family members than are men (Patterson & Margolis, 2019). “Essential” workers, in particular, are often caregivers for children or aging parents, and both caregiving burdens and such employment are clustered among women and racial/ethnic minority populations in the U.S. (Robertson & Gebeloff, 2020; Van Houtven et al., 2020). As a recent article in The New York Times noted, “One in three jobs held by women has been designated as essential… Nonwhite women are more likely to be doing essential jobs than anyone else.” (Robertson & Gebeloff, 2020).

Multigenerational Families and Households and COVID-19

The age and family structure of population groups may also be important determinants of COVID-19 spread (Balbo et al., 2020). By sharing resources or providing care, multigenerational families – those that contain family members of various ages and generations – may be a heightened source of potential disease contact (Dowd et al., 2020). For instance, “sandwiched” caregivers, who provide care both for young children and for aging parents may be an especially important population to focus on for pinpointing and isolating spread because the rates of multigenerational care are highest among working age adults, whose caregiving roles can extend across generations (Patterson & Margolis, 2019). Additionally, an increasing number of Americans live in multigenerational households, wherein members of three or more generations live together under one roof, and they in particular may be at higher risk of disease transmission. Under such circumstances, the ability to engage in social distancing or self-quarantine among each generation is unlikely, if not impossible. Moreover, in coresident multigenerational families the eldest generation serves as an important care provider for young children, often in order to allow middle-generation parents to work outside the home (Harrington Meyer, 2020; Luo, LaPierre, Hughes, & Waite, 2012). Populations at high risk for complications from COVID-19, such as racial and ethnic minority older adults, are more likely to live with other family members, including grandchildren (Luo et al., 2012; Cross, 2018).

Multigenerational families and households are particularly important for understanding disease dispersion because COVID-19 generally presents as less severe among children and young adults, making it possible that infected children may transmit COVID-19 to their “sandwich” generation parents or grandparents before anyone is aware that they were even infected (Qian et al., 2020). This risk is particularly grave for racial and ethnic minority groups and lower-socioeconomic status populations, who are more likely to (a) have employment that is contingent, lower-paid, and unable to be performed from home; (b) rely on family networks to provide needed care, whether to young children and/or aging parents; and (c) have underlying health problems and other health disparities resulting from cumulative dis/advantage (Luo et al., 2012; Robertson & Gebeloff, 2020; Sarkisian, Gerena, & Gerstel, 2007; Sarkisian & Gerstel, 2004). Indeed, COVID-19 hotspots have emerged in municipalities with substantial racial and ethnic minority populations, large proportions of residents deemed “essential” employees, and high population density and prevalence of multigenerational households (e.g., Florida, 2020).

A Thin Safety Net for Families

While the U.S. lacks generous family and social welfare policies in general, those that specifically support family caregivers are even more slim. The U.S. does not have a formal federal system that supports caregivers, instead relying on piecemeal state policies, in stark contrast with other peer nations (Organisation for Economic Cooperation and Development, 2011). The widest reaching benefit – the Family and Medical Leave Act (FMLA) – grants only uncompensated time off, though it does apply to all employers in the U.S. The ability to take unpaid leave, however, is not practically available to all caregivers, many of whom may be unable to forego consistent income while providing care to loved ones, or for whom caregiving responsibilities persist over long periods of time.

Congress did pass the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act in 2018 to establish a national strategy to acknowledge and assist family caregivers through policy, infrastructure, and programming. Previously, the National Family Caregiver Support Program was established in 2000 and offers grants to states and territories in order to provide services to caregivers of an older adult, focusing on information and connections to services like respite care (e.g., planned or emergency care provided to caregivers) (see Administration for Community Living, n.d).

Although an important step, more funding is needed to directly help family caregivers, who spend roughly $7,000 per year out-of-pocket on costs associated with caring for an older family member (Rainville, Skufca, & Mehegan, 2016). The current policy landscape thus leaves gaps in care needs, forcing many families to foot the bill themselves (if they can) for extra supports (e.g., respite care; Whittier, Scharlach, & Dal Santo, 2005). Caregivers of Black and Hispanic older adults in particular report challenges in accessing support services, but it is not clear what role the availability, affordability, and/or desirability of services offered play in these choices (Potter, 2018). Caregiving responsibilities and burdens may be intensified during COVID-19 when stay-at-home orders are in place, making access to available supports and services crucial yet difficult to obtain.

Moving Forward: Policy Implications for Family Caregivers

Numerous state governments have imposed social distancing and stay-at-home guidelines for residents, with exceptions for “essential” workers and activities such as grocery shopping and exercise. Yet these guidelines may be limited in influence when it comes to working caregivers, especially those who are economically and socially marginalized, for whom the decision to stay home and protect loved ones from infection may at the same time be a decision to go without pay, forego health insurance coverage, and risk food insecurity or even eviction. For working caregivers, broad-based policies such as paid family and sick leave may be critical for helping families to physically distance when needed, in order to either quarantine or prevent further spread of the virus, while also balancing care roles.

Although there is no federal policy to date, some states have or will soon be implementing paid leave for caregivers, including California, New Jersey, Rhode Island, New York, and Washington (National Partnership for Women & Families, 2019). California implemented a program in 2004 entitled the California Paid Family Leave Program (CA-PFL) and early analyses show that the program is effective in helping caregivers to continue work, especially for some particularly at-risk populations, including middle-aged working caregivers or the near-poor (Kang et al., 2019). This program also reduced the proportion of older adults that required care in nursing homes (Arora & Wolf, 2018). Keeping older adults out of nursing homes is particularly important for protecting against the spread of viral pathogens such as COVID-19, which has been particularly devastating within residential long-term care (Gardner, States, & Bagley, 2020).

We recommend that policy makers keep in mind that families and public health go hand-in-hand, and that policies aimed at workers, caregivers, and older adults can help advance life expectancy and reduce health inequities (Moen & DePasquale, 2017). In such cases, the more universal and accessible these policies are, the more likely they are to benefit caregivers and families in need (e.g., Herd & Moynihan, 2019). Take income support in the context of the current crisis, for example. Unemployment benefits support those who are laid off, but not those who voluntarily quit in order to reduce the risk of infection for themselves and/or dependent family members, nor does it cover workers across all sectors (Badger & Parlapiano, 2020). Further, eligibility and application requirements to access unemployment benefits vary across states, and can create barriers to obtaining benefits in a timely fashion (Badger & Parlapiano, 2020). Conversely, programs such as universal basic income, direct payments to caregivers, or stimulus checks like those proposed and passed in April, can help families provide basic goods like housing and food so that they can focus on their caregiving responsibilities, without restricting eligibility or requiring administrative burdens in order to access needed funds (for instance, those required to file for a dependent tax credit).

Unfortunately, even when supports are available, families are often unaware of them, unable to determine whether they qualify, or simply unable to complete the difficult and time-consuming documentation required (Herd & Moynihan, 2019). It is therefore critical that policies and programs implemented be as broad-based and accessible as possible, without the presence of onerous administrative burdens, in order to maximize the likelihood that benefits will actually accrue to the most marginalized and at-risk populations (Herd & Moynihan, 2019).

Conclusion

Family, caregiving, and intergenerational relationships are important sources of potential exposure to COVID-19 infection. In multigenerational families, the “sandwich” generation adults – especially women – are often care providers to young children and/or older parents, while also being engaged in the formal labor force. This is particularly true among racial and ethnic minority and lower-socioeconomic status populations, who are likelier to live in multigenerational households, and to work in “essential” professions that preclude distance-working alternatives. It is therefore crucial that policies aimed at protecting population health and those intended to support families and caregivers be designed as complementary, and implemented in conjunction with one another. Individual organizations or managers can support workers who are balancing care responsibilities (Plaisier, Broese van Groenou, & Keuzenkamp, 2015). However, policies set at the state and national levels can be much more effective at providing the support necessary to allow caregivers to forego formal work during critical periods in order to focus on caregiving, especially when these policies are free from administrative burdens (Herd & Moynihan, 2019). Intergenerational relationships, family structure, and public health are inseparable, and the most effective public policy regimes and interventions will be those that recognize these intersections and design policies accordingly.

Key Points:

• Families and intergenerational relationships may be an underexplored source of risk for transmission of COVID-19.

• Women and racial minorities are particularly likely to be caregivers for one or more family members of older and younger generations.

• Policies aimed at health, employment, and social welfare should take the diversity of family structure and the importance of family caregiving into account.

• Policies aimed at families and caregivers have the potential to have a positive impact on reducing the spread of COVID-19 through helping family members to balance work and caregiving responsibilities.