Biden’s Vision for ‘Care Infrastructure’ Needs More Socialism

Nurses are roads and bridges are health care. Photo: Drew Angerer/Getty Images

In recent days, the policy debate in Congress has come to resemble an ontological discourse fit for a hot-boxed dorm room, as red-eyed Congress members ask each other, “What even is infrastructure, man?”

The origins of this semantic conflict aren’t hard to discern. Infrastructure is America’s original “big government” program and one of the few forms of public investment that the Republican Party deems legitimate. Bipartisan consensus has long held that the nation’s roads and bridges are in desperate need of renovation. Donald Trump’s presidency was composed almost entirely of misbegotten “infrastructure weeks.” And Joe Manchin, supreme ruler of the U.S. Senate, has a special affection for infrastructure investment, one that’s led the conservative Democrat to propose giant middle-class tax hikes for the sake of funding “$4 trillion” in public projects.

Thus, Joe Biden had good reason to make infrastructure his first post-COVID priority — especially since a large portion of his climate agenda involves transforming America’s built environment.

But Democrats also have good reason to load up every major spending bill with a cornucopia of unrelated priorities. Congressional Republicans have made it clear that they will condone neither significant new deficit spending nor higher taxes on the wealthy. And that makes passing a sizable infrastructure bill through regular order impossible. Which means that Biden’s plan will ultimately have to be passed through reconciliation, an elaborate and time-consuming legislative process that enables Senate majorities to pass budgetary bills without overcoming a filibuster. Given that reconciliation bills are a finite resource (or at least, were believed to be until recently) and that passing them is an arduous slog, it would be silly for Democrats to break their fiscal agenda into a dozen separate bills for the sake of maximizing the conceptual coherence of each. Rather, the strategic route is the one that Biden & Co. took on the COVID-19 relief bill: Build a festival of spending around a headliner that boasts crossover appeal, then fill the second stages with less-publicized supporting acts.

Biden’s infrastructure bill therefore invests $590 billion into domestic manufacturing, scientific research, and job training — economic initiatives that aren’t conventionally thought of as infrastructure — along with $400 billion into expanding access to at-home care for the elderly and disabled, while improving labor conditions for their caretakers.

There are reasonable arguments for conceiving of these appropriations as forms of infrastructure investment. But the White House didn’t put long-term care into the American Jobs Plan out of a deep-seated conviction that home health aides and bridges occupy the same category of public good; it did so because it believes expanding long-term care is a worthwhile policy goal, and that delivering for the SEIU is an important political one.

Anyhow, these pressures and constraints have yielded some profoundly odd political dynamics. Congressional Republicans rightly interpret the infrastructure bill’s size and scope as an indication that Biden is more interested in policy change than a (likely quixotic) pursuit of bipartisanship. And they are eager to alert the electorate to this reality. So, they’ve spent the past few weeks insisting that they do support infrastructure — but that Biden’s proposal is less of an infrastructure bill than a random grab bag of partisan initiatives. Democrats have responded by arguing that the definition of infrastructure has evolved over time, and that care work is as foundational to our economy as highways and bridges. Put differently: The GOP is warning voters that Joe Biden is secretly trying to expand at-home care for the disabled and elderly, while Democrats are trying to downplay this fact by describing it as a mere supplement to spending on concrete.

Which is pretty weird! At-home care for the elderly is overwhelmingly popular, and voters are much more concerned with “health care” in general than they are about infrastructure. A Morning Consult poll this week found that the American Jobs Plan’s $400 billion investment in long-term care is its third-most popular provision, boasting 76 percent support, making it significantly more popular than spending on broadband infrastructure, airports, or mass transit. Nevertheless, Republican senators are going out of their way to inform their graying base of Joe Biden’s extremely popular plans for making their lives easier.

For Democrats, the politically optimal move here might be to simply rebrand the bill as a “jobs, health care, and infrastructure plan”; or perhaps, a wide-ranging proposal to, say, “build back better.”

This said, the impulse to insist that care work is a kind of infrastructure is a righteous one. Doing so might contradict the common-sense understandings of that word. But it also reflects a noble desire to render devalued, feminized labor more socially visible and politically salient. It isn’t hard to identify distinctions between nurses and bridges. It’s a bit more difficult, however, to explain why the government has a responsibility to supply the latter but not the former.

Both parties consider the provision of physical infrastructure a legitimate public function, on the grounds that well-maintained roads, bridges, waterways, and airports are simultaneously preconditions for a thriving market economy and unlikely to be adequately financed by private actors. The same can be said about child and elder care. Long-term economic growth is impossible if small children are not nurtured. And unless we wish to go “full Soylent Green,” the elderly will need to be looked after in their twilight years.

More broadly, if the economy’s fundamental purpose is to efficiently meet a society’s material needs — rather than to maximize arbitrary measures of aggregate production — then few activities are more economically vital in our aging nation than elder care is. In fact, according to federal projections, no occupation will add more jobs to the U.S. economy over the next decade than “home health and personal aides.” Which is to say: If every American adolescent “learned to code” and/or excelled in school, attended college, and sought a white-collar job in the “knowledge economy,” our country would suffer social collapse. For a very large segment of the working class, the jobs of tomorrow will be — and must be — the mundane task of helping the elderly sustain themselves. And yet, the average annual income among Americans who perform this labor is roughly $25,000.

Our collective failure to provide such “essential workers” with decent compensation has facilitated COVID’s killing spree in nursing homes. As the labor historian Mike Davis explained to Intelligencer last April, “These nursing-assistant jobs pay $10 an hour. The only way people can make ends meet is to moonlight. So a large minority of people who work in nursing homes also work at least part-time in another nursing home. So you have this transmission belt that links all the nursing homes together in a given region.”

The for-profit model of elder-care provision does not require a pandemic to terminate the elderly through malign neglect. Since 2000, private equity firms have increased their collective investment in nursing homes by twentyfold. A recent paper from the National Bureau of Economic Research finds that when a private equity firm acquires a nursing facility, its residents start dying at higher rates. This is partly because private equity’s approach to “rationalizing” the elder-care business involves slashing nursing staff and then compensating for the consequent neglect by pumping residents full of antipsychotic tranquilizers.

Given this context, the Biden White House’s stated ambition is less than radical. The argument is simply: In an aging society, elder care is a top-tier economic need. Right now, neither the private sector nor existing public programs are coming anywhere close to meeting this need, as hundreds of thousands of older Americans cannot access the at-home care they desire — or else, are stuck in poorly managed nursing homes where the quality of service is low. Meanwhile, the care economy’s workforce is both abysmally paid and rapidly growing. Therefore, we are not going to have a thriving working class, or a service sector that meets consumer needs, unless we dramatically increase public funding for elder care and the wages of those who provide it. Just as highways and train tracks were indispensable to achieving shared prosperity in the postwar industrial economy, so long-term care benefits for seniors — and collective-bargaining rights for home health aides — are indispensable for achieving such prosperity in 21st century America. As the economy changes, our conception of “infrastructure” must change with it.

Actually realizing Biden’s normative vision, however, would require radical change. His proposed $400 billion investment in at-home care would make a profound, positive difference in the lives of millions. But it would not come anywhere close to meeting the demand for long-term care. While the proposal aims to extend such services to every qualifying American on Medicaid’s waiting list, it would not extend a universal long-term care benefit to those whose assets or income place them well above poverty. In practice, this means that many older Americans will still be forced to spend down their savings in order to access care (and/or merely end up on waitlist for it). And although details are limited, it’s safe to say that Biden’s proposal will not be sufficient to provide home health aides with the standard of living enjoyed by the unionized proletarians of yesteryear. Simply put, there is no way to make quality elder care a universal right — while also dramatically increasing the costs of providing such a benefit (by turning “health aide” into a middle-class occupation) — without drastically increasing government spending.

This points to a genuine, substantive distinction between conventional infrastructure and the care variety. Well-conceived physical infrastructure projects are (mostly) one-time expenses that yield durable productivity increases and opportunities for profit-making. Care infrastructure, by contrast, is a recurring expense. And although high-quality child care may indirectly increase productivity by aiding “human capital” development, an elderly person who spends their final years warehoused in an underfunded nursing home will be about as “productive” (in official economic terms) as one who spends them at home, in the tender care of a well-compensated personal aide. At the margin, higher public investment in elder care may ease familial burdens on prime-age workers, and thus, make them more economically productive. But this hypothetical benefit to capital accumulation would be dwarfed by the fiscal costs of sustaining a massive, well-compensated elder-care workforce.

In other words: Taken to its logical end point, the rationale for conventional infrastructure investment may justify Biden’s vision for the care economy. But Biden’s vision for the care economy, when taken to its logical end point, justifies something close to socialism.

Which may be why Republicans are so intent on maintaining a conceptual wall between “roads and bridges” and the welfare state.

Biden’s Vision for Care Infrastructure Needs More Socialism