This file was prepared for electronic distribution by the inforM staff. Questions or comments should be directed to inform-editor@umail.umd.edu. Elder Care What is Elder Care and How Does It Differ From Child Care The following quote, drawn from President Bush's proclamation establishing the 1990 "National Family Caregivers Week," nicely lays the ground work for our discussion of elder care. It highlights both the human elements of why elder care is a sensitive topic, and how it can impact on both employees and employers. "Each day millions of Americans provide various forms of assistance to relatives incapacitated by age, illness, or disability. In addition to home nursing care and companionship, these family caregivers may provide physically impaired loved ones with financial support, transportation, and help with shopping, cooking, and daily household maintenance. Their generous and devoted labors are invaluable to the relative who might otherwise be forced to live in an institutional setting." -30 President George Bush In order to fully understand what elder care is, and why it is of concern to us, it is first important to understand what elder care is not--that is, how it differs from child care. Both elder care and child care are work and family benefit issues because they involve the impact on a work situation of how employees provide care for their dependents. However, the demands placed on people with elder care responsibilities are very different from those with child care needs, as are the outcomes of providing that care. Children grow up and take on increasing independence, thus lessening the need for child care. Elderly people, on the other hand, tend to grow more dependent, especially as their health declines. The consequences of these diverging outcomes were well captured in a recent cover story in Newsweek magazine. It said: ... just when many women on the 'Mommy Track' thought they could get back to their careers, some are finding themselves on an even longer 'Daughter Track,' with their parents, or their husband's parents, growing frail. The average American woman will spend 17 years raising children and 18 years helping aged parents, according to a 1988 U.S. House of Representatives report. As the population ages and chronic, disabling conditions become more common, many more families will care for aged relatives. And because they delayed childbirth, more couples will find themselves 'sandwiched' between child care and elder care. -31 In addition to the differing outcomes of child and elder care, there are fundamental differences in what is involved in actually providing these types of care. For example, most child care "solutions" involve providing some type of supervision to children during part of the day when their parent(s) are working. This is not the case with elder care, as a recent report on elder care in the workplace points out: There is such a service as adult day care which is targeted to frail older people. It is not a question of increasing the supply of this product; it is appropriate for a tiny proportion of the most dependent elderly. Some aging relatives need only a modest amount of help but on a regular basis, others may need intensive support but for a limited time, still others need steadily increasing levels of support over a period of years. That help may be needed suddenly as a result of heart attack, stroke or hip fracture, or the need may develop gradually. -32 This report, prepared by the National Association of State Units on Aging and the National Council on the Aging, Inc., went on to describe some of the other factors which make elder care a complicated and often emotionally trying experience for those responsible for giving or overseeing the care of an elderly person. It said: There are more variations in the situation and condition of the elderly by virtue of their age. Older people are adults, ranging approximately from age 60 to 100. They have lived for years with responsibility for themselves and often for others. They have the authority for their own decision-making and--unless in a protected status determined by the legal system--have the right to accept or reject help arranged for them. Compared to the rest of the population, older people have more health problems. They may or may not be physically able to carry out their personal care and household chores, manage errands and get themselves to doctors and stores. They may need frequent emotional support, information and assistance for the activities of daily living, and/or help in obtaining any of these. Aging relatives may live nearby or at a long distance. Even very dependent relatives may not live with a family member who provides most of the care. Responsibility for providing assistance to an older person may be shared among spouses, children and other family members. -33 Does the Government Need Elder Care Benefit Programs The above-mentioned cover story from Newsweek went on to quote the executive director of the Older Women's League, who said, "We get letters from women who are taking care of their children, and their parents and possibly their parents. They are running from place to place. How do we expect them to do that and stay employed?" -34 Since having their employees "stay employed" is the driving force behind all employee benefits, employers need to know if their employees have elder care problems, and if so, how to address them. Fortunately, it is predictable that certain kinds of employees are more likely to be caregivers than others, given the demographic realities surrounding elder care. For example, employers whose workforce is older than average probably have more caregivers among their workers than employers with a young staff. Similarly, employers with greater than average numbers of female workers may find a disproportionate number of their employees have elder care responsibilities, since as illustrated in figure 4 below, the majority of caregivers are women [Figure 4 unavailable in electronic format due to graphics limitations]. In regard to the Government, it would appear that Federal employees meet at least some of the criteria suggesting above-average elder care needs. Specifically, while the Federal Government employs women at about the same rate as the private sector (43 percent of Federal employees are women, versus 45 percent of private sector employees), Federal employees are older than private sector workers (median age of Federal employees in 1989 was 41, versus a private sector median age of 36). -35 In determining whether and how the Federal Government should respond to the elder care needs of its employees, it is of course important to look at the consequences of acting or not. Issues such as how elder care might affect mission accomplishment, recruitment, productivity, retention, and other goals, should therefore become most relevant. To gauge the extent of this impact, we asked agency personnel directors if they thought elder care responsibilities were having a negative impact on the productivity of employees who were caregivers. In response, 7 agencies said "To a moderate extent," 2 said "To a minor extent," and 13 said "Don't know/Can't judge." We also asked agencies if they had done any research or analysis "... to determine how many of your employees have elder care responsibilities and/or the types of services/benefits which would help employees address these responsibilities?" In response, 7 agencies said "Yes," they had done some research or analysis on elder care, while 15 said "No." Several agencies provided narrative comments as well. Highlights of two of these comments are shown below: "The Office which surveyed for elder care found that 16% of its employees had elder care responsibilities, with the number expected to rise in the future. Of those who had elder care responsibilities, 68% reported some stress, and 20% reported significant stress because of these responsibilities." Department of Energy "... a significant number of families have or expect to have elder care responsibilities in the near future. Employees have requested a counseling/referral service for those providing elder care and the use of sick leave to care for an elderly family member." Department of Justice We also turned to other sources to see what evidence of elder care impacts on the workforce were available. The following extracts are illustrative: * Growing numbers of firms are granting unpaid leaves to employees with family needs. IBM is perhaps the most generous. Full-time employees can take up to 3 years off, with benefits, and find their jobs waiting. 'If we give our employees help in managing their personal lives, it helps us attract and retain the workers we need,' says IBM spokesman Jim Smith. That has proved true at Aetna Life and Casualty as well. When it extended its family leave from a few weeks to as long as a year in 1988, the turnover rate among its female caregivers dropped from 22 to 13 percent. -36 * According to 'Elder care: Its Impact in the Workplace,' which appeared in the July/ August 1989 issue of EAP [Employee Assistance Program] Digest, and a recent national study conducted by [University of Bridgeport Professor Michael] Creedon, employees caring for an elder are 20 percent more likely to see a physician than noncaregivers. Caregivers also report higher rates of depression, sleeplessness, weight gain, and weight loss than noncaregivers. The Creedon study indicates that employees' caregiving burdens can translate into increased company health benefit costs and reduced workplace productivity. -37 Given that they are older than their private sector counterparts, it is likely that increasing numbers of Federal employees are dealing with elder care responsibilities, with or without assistance from their employer. Moreover, it would appear to be in the Government's best interest to assist its employees in meeting their elder care needs, given the demonstrated impact of elder care problems in the workplace. Putting these two conclusions together, the primary elder care question for us to address becomes, "What are the most cost-effective and appropriate elder care benefits for the Government to provide?" What Elder Care Benefits Can the Government Provide Employers, including the Federal Government, are limited in how they can respond to employee elder care needs. There are very few potential elder care "solutions" which employers can appropriately provide directly to elderly dependents. Accordingly, employers are largely limited to assisting employees to do whatever they find necessary in the situation, rather than doing it for them. As a result, the two most common forms of indirect elder care assistance which employers provide are: proactive educational programs which prepare employees for present or future caregiving roles; and resource and referral networks, which assist employees to find the kinds of help or services which their elderly dependents need. Several Federal agencies are currently experimenting with both of these types of programs. While these indirect benefits are helpful, neither solves the most direct problem caregivers typically face -- that is, having the time to arrange for, monitor, or otherwise manage whatever help their elderly dependent needs, or having the time to provide that help themselves. As a result, where it is available, one of the most useful and important benefits an employer can provide to employees with elder care problems is the option of taking additional time off from their jobs when elder care responsibilities require it. If the Government were to offer additional leave time as an employee benefit, it would obviously have to decide whether this was to be paid or unpaid leave. By definition, unpaid leave is less costly than paid leave, although even unpaid leave can be extremely disruptive to mission accomplishment if the caregiver's presence is critical to the work unit. For many employees, however, the loss of income from unpaid leave may make this "benefit" of limited utility. Thus, as the above comment from the Justice Department illustrates, employees typically see paid time off as what is needed to help them fulfill their elder care responsibilities. Paid time off comes in many forms, including some charged to personal leave accounts (e.g., annual leave and sick leave) and others which are not (e.g., holidays and administrative leave). Some employers also offer insurance polices which may replace pay during unpaid leaves of absence (e.g., short-term disability policies), while the Federal Government has recently experimented with a program of leave-transfer and leave banks (discussed in a later chapter of this report). While the Government's annual leave benefits are substantially more generous than many private sector firms (especially in the early years of an employee's tenure), its sick leave benefits are roughly comparable to, or only slightly ahead of, those typically offered by medium and large size private sector firms. Specifically, for those firms offering sick leave plans which have similar characteristics to the Government's plan (i.e., which allow unlimited accumulation of sick leave from year to year, and which do not have a tie-in to sickness and accident insurance), the average number of paid sick days given to full-time employees each year grows from 9.4 days per year at 1 year of service, to 11.4 days at 5 years of service, and to 14.1 days at 20 years of service. -38 The Federal Government provides 13 days of sick leave per year for full-time employees, irrespective of years of service. Use of Sick Leave to Care for Sick or Elderly Dependents Since most Federal employees are limited in the amount of annual leave they can save up for "rainy days," and employees expect to use this leave for other personal and family needs, annual leave is usually inadequate to meet ongoing care demands for sick or elderly dependents. As a result, employees naturally look to sick leave as a potential source of leave--after all, if they are caring for a sick or frail relative, why shouldn't sick leave be authorized? Using sick leave to care for sick or elderly dependents is not without precedent. For example, a study of State governments as employers found that: ... the use of sick leave and extended unpaid leave for the purpose of caring for an aging dependent is widely available as official personnel policy. The quantity of sick leave that can be used for dependent care ranged from 3 to 30 days. One state allows employees to use all accrued sick leave for this purpose and another allows use of advance leave -- that is, what the employee is expected to earn within the fiscal year. -39 From the point of view of some Federal agencies, this is at least a plausible benefit to provide. In response to our questionnaire, 13 agencies indicated that they thought the "ability to use sick leave to care for, or assist, a sick elderly relative" was potentially a cost-effective employee benefit for the Government to offer. When asked if their agency would support a change in sick leave regulations to permit caring for sick relatives (e.g., children, spouses, or parents), however, the results showed sharply divided opinions among the agencies, as table 5 below illustrates: Table 5 Number of agencies choosing the indicated response to: "To what extent would you agency support or oppose a change to the Government's sick leave regulations which would permit an employee to use sick leave if he/she needed to care for a sick relative (e.g., child, spouse, parent)?" 4 Strongly support 2 Minimally support 1 Neither support nor oppose 1 Minimally oppose 4 Strongly oppose 8 Don't know/Can't judge Note: Two agencies did not respond to this question Agencies' narrative comments on the topic were as divided as the above response patterns would suggest. Extracts of representative responses are shown below: "OPM regulations currently allow an employee to use sick leave to care for a family member afflicted with a contagious disease... The Department of the Army (DA) would find it difficult to support any modification of regulations beyond what is currently provided." Department of the Army "Annual leave is not sufficient for elder care needs and current regulations require that an employee with elder care responsibilities exhaust the only category of leave that provides for paid vacations--something that an employee with elder care or child care responsibilities needs. If sick leave is not made available for these purposes, we recommend that employees be allowed to accumulate annual leave without limit to provide for their child or elder care concerns." Department of Justice When we asked OPM about using sick leave to care for sick or elderly dependents, its response began by noting that "the Administration has no stated position on such a proposed change." After explaining how various technicalities in its sick leave regulations (concerning contagious diseases) impact on the question, OPM concluded that it "is studying the entire leave system to determine how well it meets the needs of employees in caring for their families." The statute which establishes an entitlement to sick leave does not prohibit OPM from allowing Federal employees to use that sick leave to care for sick or elderly dependents. In fact, the legal underpinning for the sick leave provided to Federal civilian employees is startlingly simple. Specifically, section 6307 of title 5 U.S.C. provides that: * An employee is entitled to sick leave with pay which accrues on the basis of one-half day for each full biweekly pay period; * Sick leave which is not used by an employee accumulates for use in succeeding years; and * A maximum of 30 days sick leave with pay may be advanced for serious disability or ailment. -40 Beyond these simple provisions, the law does not further define what sick leave is or how it should be used by Federal employees. Rather, Congress provided for OPM (formerly the Civil Service Commission) to issue regulations necessary for the administration of leave (Section 6311 of title 5 U.S.C.). Under this authority, OPM issued the following instruction in section 630.401 of the Code of Federal Regulations: An agency shall grant sick leave to an employee when the employee: (a) Receives medical, dental, or optical examination or treatment; (b) Is incapacitated for the performance of duties by sickness, injury, or pregnancy and confinement; (c) Is required to give care and attendance to a member of his immediate family who is afflicted with a contagious disease; or (d) Would jeopardize the health of others by his presence at his post of duty because of exposure to a contagious disease. While the above regulation is not unreasonably narrow on its face, it has not changed since 1969. In the intervening 22 years, employee needs, societal values and employer-employee relationships have been evolving. Accordingly, it would appear to be timely for OPM to revisit this issue. For its part, OPM appears to be on the threshold of action. In its "Strategic Plan for Federal Human Resources Management," which it published in November 1990, OPM acknowledged that "Benefits are costly and do not meet the needs of relatively new employees, especially those who are family care providers and those who suffer injury or long term illness." In light of this conclusion, OPM committed itself to a strategy which seeks (in part) to "... improve the Federal benefits package by ... considering changes to the leave system, [and] by exploring the feasibility of a more flexible benefits package ..." -41 The time for such changes would appear ripe, especially since Congress itself has recently encouraged a more creative use of sick leave than OPM has traditionally permitted. Specifically, Congress inserted a temporary provision into OPM's fiscal year 1991 appropriations bill (expiring Sept. 30, 1991) which said: Notwithstanding any other provision of law, sick leave provided by section 6307 of title 5, United States Code, may be approved for purposes related to the adoption of a child in order to test the feasibility of this concept during fiscal year 1991. -42 According to OPM's guidance on this change (Federal Personnel Manual (FPM) Bulletin 630-61, "Sick Leave for Adoptive Parents"), the purpose of this provision "is to put adoptive parents on a more equal footing with biological mothers, who are currently allowed to use sick leave for prenatal visits." However, since using sick leave to attend court hearings or meetings with social workers is certainly further afield from the language of OPM's current regulations than using sick leave to care for sick relatives, the precedent value of this Congressionally requested test should not be lost. From the Board's perspective, expansion of Federal sick leave rules to permit at least some usage of sick leave by employees who are caring for sick or elderly dependents makes good sense. This type of benefit could certainly make the Government more of an "employer of choice" for prospective employees, as well as sending a positive message to current employees about the Government's intentions relating to work and family concerns. While in an absolute sense such a benefit may increase the Government's costs (e.g., sick leave employees use for this purpose might have otherwise been forfeited when they resigned or retired), it would not actually be an increase in an employee's entitlement to earn paid leave. Rather, the benefit would simply give employees more flexibility in using leave which they have already earned and are entitled to use (albeit for more limited purposes). Moreover, to the extent that some employees may already be using sick leave to care for sick or elderly dependents (notwithstanding the fact that such use violates current OPM regulations), official sanctioning of this practice obviously would not further increase costs. Finally, it should be noted that, for those employees who use all their sick leave before leaving Government service (e.g., employees who take a disability retirement), any use of sick leave for these expanded purposes would reduce the sick leave used for the employee's own health problems, thus resulting in no net increase in leave usage. Prior to implementation, OPM would obviously need to consider how much discretion agencies should have regarding use of sick leave for nontraditional purposes. Some aspects of this benefit may require standardized criteria (e.g., how much of a person's sick leave may be used for these purposes; can advance leave be granted; what information needs to be tracked by OPM), while others may be more suitable to agency choice (e.g., how specific do the criteria need to be which govern when this type of leave can be granted). It would probably be appropriate to conduct several different pilot programs to test various approaches to this benefit, before determining what final regulations are needed. Even then, final regulations need not be cast in stone -- while a cautious, incremental approach seems prudent at the beginning, it may well be that a more flexible approach will be in order once experience is gained with the concept. Finally, the fact that these changes are capable of being accomplished without the need for further legislation should give added impetus to any effort to make them, since it is always difficult to secure legislative action for a change in benefits. The Board therefore recommends that OPM pursue this issue, and unless unanticipated problems are identified, take action to change its current sick leave regulations.