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Opinion: The Washington failure that’s making us sick

It’s ironic that a pandemic that has made us hyper-cautious about our families’ physical health has also taken a more insidious health toll on our stress. Many caregivers are feeling increased anxiety, depression, and burn-out. While the pandemic may have pushed more individuals to the brink, none of the structural failures are new — caregivers have long faced inadequate family and sick leave and a patchy, expensive childcare system.

Given the wealth of research linking daily chronic stress to long-term health, it’s worth asking: is our country’s failure to support caregivers making Americans sick? Is caregiver support a health care issue?

As of this writing, Congress is debating President Joe Biden’s Build Back Better plan, which includes historic levels of funding to create a paid family and medical leave program, expand access to childcare and reduce child care costs, and make pre-K universally available. Opposition to this bill has centered on its steep price tag. But no one is talking about how much we could recoup in short and long-term health care costs.
The most expensive family support propositions in the bill — $400 billion for childcare and universal pre-K and somewhere between $225 to $550 billion for paid leave over the next decade — are equal to only about 10% of our annual health care spending. In 2019, the US spent $3.8 trillion on health care costs, far more than other developed nations.
Upwards of 90% of US health care spending goes to chronic and mental health conditions, according to data from the US Centers for Disease Control and Prevention, and decades of research have linked lifestyle stress to long-term risks for these conditions — ranging from heart disease and obesity to depression and autoimmune disorders.
While nearly 3% — or roughly $110 billion– of our health care spending goes to preventive medicine, we have higher rates of mortality from preventable diseases than countries dedicating less funds. If we conceptualize health broadly, and consider the role of stress, the missing piece is clear. Compared to other nations, we have dramatically under-invested in policies that support families and caregivers, like paid family, sick leave and early childcare. For example, the United States is dead last among developed countries in spending on early childhood: countries like Norway, Denmark and Finland spend four times more than we do per child per year. These policies directly affect stress exposure and stress-related illness, especially during windows of change and vulnerability like the transition to parenthood and the transition to older adulthood.
Stress translates into health through pathways like strain on the heart, weakened immune resistance, poor sleep, and even faster brain aging. Stress can have an outsized impact during major life transitions, like the period after the birth of a baby, when hormones are shifting and sleep is disrupted. Stress in older adulthood also compromises health, and the stress of caregiving for sick, elderly, or disabled family members has been linked with increased susceptibility to illness.
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According to Dr. Allison Applebaum, a clinical psychologist who runs a caregiving support clinic in New York City, “I have lost count of the number of caregivers in my clinic who have also become patients. Rates of insomnia are skyrocketing in caregivers. Same with chronic depression, chronic anxiety.” As Applebaum told us, “People are so busy balancing their work with caring for their loved ones that they do not have time to take care of themselves. They often neglect their own screenings and medical care.”

The toll of caregiving without job or income security can spiral into new health care costs for caregivers themselves. Applebaum experienced this firsthand when taking care of her own aging father while working full time. As she recounted, “I took him to the emergency room and I picked up a bacterial infection. I hadn’t been sleeping and hadn’t had the chance to rest or take care of myself, and I ended up hospitalized. My immune system couldn’t fight it because I was so worn down.”

Those most at risk for poor health also stand to benefit most from supportive policies. Research has demonstrated that people of color and low-wage workers start from an elevated baseline stress load due to socioeconomic strain and exposure to systemic racism. Caregiving stress adds an additional layer as these communities are also the least likely to be protected with current policies regarding paid sick time or paid family and medical leave.
In failing to support caregivers with effective policies, we miss the most promising opportunities to promote both adult and child health. If we can reduce stress in the critical windows during the life span — early childhood, the transition to parenthood, caregiving for loved ones of all ages — we may be able to bend the arc of late-life disease trajectories.
Reframing support policies like paid family and medical leave and accessible, affordable childcare as forms of preventive medicine is critical. From a health perspective alone, fixing care support structures is cost-effective. We can potentially save billions in taxpayer dollars that are now devoted to treating stress-related diseases by dedicating a fraction of that funding to support families during key health transitions.

As Applebaum says, “If I had been able to take more paid time off from work to care for my father, I probably wouldn’t have been hospitalized with my own illness.” A few extra weeks, even a few extra days, of paid family leave might have warded off a hefty hospital bill.

As we weigh the cost of new legislation, we need to consider the big picture. Care investments today represent a down payment on tomorrow. We need to step away from siloing policies into categories like “social,” “economic” and “health care” and take a holistic view of our families, our health, and our economy as we craft policies to support caregivers and promote the nation’s health.


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