“We Were All Children. We Will All Become Adults”: A Conversation with Regina Seo

Caregivers perform vital work that keeps our society and economy running. All of us may be caregivers at some point in our lives, and all of us receive care throughout our lives. Earlier this month, I spoke with Roosevelt Institute Fellow Regina Seo about her research into the experience of care providers, both formal and informal, in the US today. Focusing on her working paper “Caring for Parents and Spouses: How Paid Leave Shapes Caregivers’ Work and Well Being,” we dig into the necessity of paid leave for caregivers and the future of the care economy. Seo is a lead economist at the Research and Innovation for Social and Economic Inclusion (RISEI) Lab at Northwestern University. As a fellow in Roosevelt’s Worker Power and Economic Security program, she researches and writes about structural barriers to aging in place.

This conversation has been edited and condensed for clarity and length.

Ijeoma Ogbonna: Regina, thank you for joining me today. I’m curious to know what brought you into this work, and what, to you, feels most overlooked about the experience of family caregivers in our policy conversations today?

Regina Seo: While I was training at American University for my PhD in economics, we had a big program on gender economics and a big profile of feminist economists working on this issue and how caregiving affects caregivers at home, especially women. That was how I got introduced to the care economy. And although my interest in it started really intellectually—as an economist, I was curious about what drives people’s decisions to participate in the labor market and what drives their incentives—I think that as I’ve studied it more and more, my personal life experiences have been really informing my scholarship as well. I just gave birth, so I’ve been studying how maternity leave and paid family leave affect mothers’ labor force participation. But now I’m really experiencing this and having conversations with a lot of middle-aged workers also who are engaging in elder care work. So I have a lot of personal curiosity invested in it as well.

In general when we talk about care and the care economy, it’s viewed as a niche area of policy that just a number of scholars are interested in. So I think what’s being overlooked is that care is actually very, very universal to the experience of being human. We will all engage in some kind of care at some point, as parents or as children or any loved ones, or even yourself. You’re caring for yourself. You might receive care at some point. And so care is a crucial backbone in our economy, and without it, there is no labor market production. People cannot be productive in the way that we typically measure productivity and output and economic activity without care being provided by someone. And, usually, in the US’s case and worldwide, but especially in the US, care is being provided in an invisible manner—in an unpaid manner in the home, usually by family members or friends. So it’s not just a niche policy area. I think it should be something that is universal, and we should really be trying to create a care infrastructure because it affects all of our economic activities.

Ijeoma: You put it so beautifully, about how care is an essential part of not just worker productivity and hard economic output, but indexed into being human. I think that gives a great segue into our next question: You have a working paper connecting paid leave and caregiving, particularly on caregivers’ well-being. In that paper, you found that taking on elder care, specifically, can pull people out of the workforce and increase stress and depression. Can you walk us through what those impacts might look like on the ground for caregivers?

Regina: There has been a lot of research that shows providing this kind of informal elder care reduces people’s labor supply and worsens people’s mental health. Informal caregivers tend to be disproportionately female, so we see a big impact especially on women caregivers. They’re reducing their work hours, they might be shifting from full time to part time, they might be taking on [fewer roles], or shifting into lower-paid jobs. And especially when that care work is high intensity and the care recipient requires more intensive care and you’re living with them, that would really increase the labor market effects.

But it’s not just women. We are seeing a smaller but increasing proportion of male caregivers as well. And although they’re less likely to be providing elder care when they do, they have a larger labor market penalty and are more likely to exit the labor market entirely. So in terms of the labor market, it just looks like slower wage growth: missed promotions, employment gaps, and things like that. For mental health, we also see higher levels of stress and depressive symptoms for elderly caregivers. And this strain is really driven by the time pressure of juggling elder care with working. It could also be the financial insecurity and lack of quality formal support that give people no choice but to engage in elder care themselves. We see evidence that supports this, we have a lot of lived experiences that also speak to the evidence that elderly caregiving is really having an impact on people’s labor supply and mental health.

Ijeoma: Given what you’ve seen in data about the experiences of caregivers, how does the relatively short support provided by state paid family leave (PFL) leave gaps for these individuals?

Regina: State-level paid family leave policies can be very helpful in many cases, especially for short-term and predictable life events. For example, [in terms of] giving birth, there’s a set timeline for how the child develops and what kind of care they require. But for elder care, it’s very different in that, well, first of all, it’s very unpredictable. You don’t know when it’s gonna happen. And even when it happens or when it begins, you can’t plan for how long they will need care and what kind of care they’ll need. And it tends to be very long term. So state-level paid family leave policies can be helpful to delay labor market exits, but it can’t entirely prevent it because paid family leave policies were designed for short-term predictable life events. And so it might not be the best policy to support working individuals with elder care needs.

Ijeoma: What would you say needs to be reformed in our current care infrastructure to better address caregiver outcomes? Are there 2–3 changes you’d propose to the current system that would make the biggest difference for working families?

Regina: So although I said paid family leave might not be the most suitable for other care needs, it’s definitely still helpful. As you probably know, the US is one of the only countries in the whole world that doesn’t offer paid family leave at the federal level, so the number one thing is just to enact paid family leave at the federal level. Alone, it’s not sufficient, but it’s absolutely necessary support.

In terms of elder care policies, we know that people really want to age in place, meaning they want to grow old in their own home or in their own community with the people they love. At the moment, nursing homes and institutional care are required to be supported by Medicaid, but our home- and community-based services (HCBS) are not required to be supported [by Medicaid]. It’s optional at the state level. I would really like to see that being a guaranteed benefit at the federal level as well. If we have a federal floor for HCBS, it will eliminate the long wait lists that people are in to receive [institutional] services. And it will also eliminate disparities, because it’s different based on where you live. The current system disproportionately affects our low-income, rural, and black and Hispanic communities, [leaving them] to receive less of these services that people want. So HCBS having a federal floor or having states use waivers to access these programs will really reduce the unpaid caregiver’s burdens and help caregivers be more attached to work. I think it’s important to reframe that these policies shouldn’t just be seen as aging-specific or disability-specific policy. I think it’s more helpful to see them as a labor market and gender equality policy. It can have a larger impact on people’s abilities to be more productive at work.

Ijeoma: This has been a very generative conversation. Whose work should people follow if they want to better understand the landscape of care policy and the future we could build with stronger public investment? And what are your hopes and dreams for the future of care infrastructure?

Regina: Because I’m an economist, I’ve read a lot of work by economists who study caregiving and the impact of caregiving on labor market outcomes and health outcomes. One of them is Courtney Van Houten from Duke. Another one is Norma Coe from the University of Pennsylvania. An agency that also provides a lot of evidence on this area is the Institute for Women’s Policy and Research, or IWPR. They’ve put out a lot of evidence on the economic costs of unpaid caregiving and the impact it has, especially on our female labor force.

As a society we’ve figured out how to medically treat people and how to delay death. But I don’t think we as a society talk deeply about what it means to age with dignity and be taken care of at our most vulnerable stages of life.

In terms of big thinkers, someone that I’ve found inspiring is Ai-Jen Poo. She wrote the book Age of Dignity: Preparing for the Elder Boom in a Changing America, which I really liked. She’s the president of the National Domestic Workers Alliance, so she represents the voices of people who are working in the formal care space. But she has a lot of good ideas about linking the care workforce and how we as a society value care work. Not just unpaid care work being done at home, but also the formal care space and compensating our care workers and acknowledging that it’s a valuable part of our economy. She has a lot of great methods on some political strategies and building movements around that.

In my ideal world, we would be thinking about care not just as one labor policy issue or just one health issue, but as a foundational backbone to our economic infrastructure. Another person that I found to be really inspirational is Atul Gawande. He’s a physician who wrote the bestselling book Being Mortal: Medicine and What Matters in the End. He comes from a medical perspective as a medically trained doctor, but as he was seeing his patients and dealing with death and aging, he realized that the most important things that he needed to talk about with his patients weren’t things that he was trained for in medical school. He was taught, of course, about the medical aspects of how to treat and extend people’s lives, but not necessarily how to have that conversation about if that’s what these patients want and how they would like to age with dignity. I think that was a really interesting framework that we all need to think about, because we are all going to age and die at some point. As a society we’ve figured out how to medically treat people and how to delay death. But I don’t think we as a society talk deeply about what it means to age with dignity and be taken care of at our most vulnerable stages of life. I think his book is really helpful with thinking about aging and care by shifting away from that medical perspective toward a quality of life and autonomy perspective.

And I think that leads back to the emphasis on home- and community-based care. I really think that, if you ask anybody, they would say that nobody would voluntarily want to go into an institution or a nursing home. Of course, that’s a very good option. But the reality is we don’t have enough quality institutional care and institutional care is very expensive. So we need to think hard about how we can build an infrastructure that allows everyone to age with dignity in the community that they would like to stay and age in. When I think of the ideal scenario, people can age with confidence and relief that there is an infrastructure in place that will allow them to age in a way that aligns with our values rather than the current lack of infrastructure, where there’s a lot of uncertainty and a lot of financial strain when people think about aging and their health declining with age.

Ijeoma: Thank you so much for that. I want to highlight your point about aging with dignity specifically. I think that’s the perfect way to package it not only to the general public but even to policymakers, especially in the conversation around paid family leave and connecting it to care. We have the idea of the private family, which became popular and helped explain why we don’t have a substantial care infrastructure in the first place. I think this is a good counter message—asserting this right to age with dignity.

Regina: Speaking as a trained economist, the way that we economists and policymakers make decisions is very telling, because we count the working-age population (ages 16–64) as the most productive population. And the rest, under-16 children and those over 65, are a cost burden to our economy. So the rest of the working-age population needs to produce enough to support those people. But we were all in that bracket; we were all children. We will all become adults. They’re all part of our society. We’re all born very vulnerable. We all need help and support when we come in, and then we all need support at the end of our lives. I think it’s kind of a beautiful life stage. And so while we need to make the most out of what we’re producing while we’re the most productive, the invisible part is that even for us to be productive in our working age, we are probably still receiving and giving a lot of care. We’re doing a lot of housework at home, a lot of cooking, taking care of children and the elderly, etc., that will allow us to be productive.

Our traditional economic models and policymaking make a lot of assumptions where the economic actor is usually a male who has a wife or mother who’s cooking for him and doing all the housework. So these models did not have to take caregiving into account, because it’s readily available. But money is not the only resource. Doing these activities also requires time. Now that we have a lot more economic actors in the economy, it’s a lot more diverse. We have more female workers who are providing so much valuable production in the economy. So we need to think more about how we change our traditional ways of thinking and all of our models and policymaking in a way that acknowledges the value of these things that we did not value before, and make it possible for us to be productive members of society.