Presidential DocumentExecutive Order 140952023-08659
Increasing Access to High-Quality Care and Supporting Caregivers
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Published
April 21, 2023
Signed
April 18, 2023
Issuing agencies
Executive Office of the President
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<title>Federal Register, Volume 88 Issue 77 (Friday, April 21, 2023)</title>
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[Federal Register Volume 88, Number 77 (Friday, April 21, 2023)]
[Presidential Documents]
[Pages 24669-24676]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-08659]
[[Page 24667]]
Vol. 88
Friday,
No. 77
April 21, 2023
Part II
The President
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Executive Order 14095--Increasing Access to High-Quality Care and
Supporting Caregivers
Presidential Documents
Federal Register / Vol. 88 , No. 77 / Friday, April 21, 2023 /
Presidential Documents
___________________________________________________________________
Title 3--
The President
[[Page 24669]]
Executive Order 14095 of April 18, 2023
Increasing Access to High-Quality Care and
Supporting Caregivers
By the authority vested in me as President by the
Constitution and the laws of the United States of
America, it is hereby ordered as follows:
Section 1. Policy. High-quality early care and
education and long-term care are critical to our
Nation's economic growth and economic security. Early
care and education give young children a strong start
in life, while long-term care helps older Americans and
people with disabilities live, work, and participate in
their communities with dignity. Access to both types of
care is also critical to our national security because
it helps ensure the recruitment, readiness, and
retention of our military service members.
Throughout this order, early care and education are
collectively referred to as ``child care.'' References
to ``care'' that do not specify the type of care refer
to both child care and long-term care. References to
the ``care workforce'' refer to individuals and
businesses working in the fields of child care and
long-term care.
A sizeable majority of families and individuals in the
United States who require care cannot access the
affordable, high-quality care they need. The markets
for child care and long-term care for persons with
disabilities and older adults who need support in their
homes and communities fail to deliver enough high-
quality care because of a persistent gap between the
costs of providing this care and the prices families
can pay. High-quality care is labor intensive and
requires skilled workers, and providers have limited
ability to reduce costs. As a result, even when high-
quality care is available, it costs far more than many
families and individuals can afford, causing them to
forgo care altogether, seek lower-quality care options,
juggle unconventional shifts at work, reduce their own
paid work hours, drop out of the labor force, or make
other arrangements. Care expenditures represent a
significant and increasing share of families' budgets,
with child care prices growing by approximately 26
percent and some types of long-term care costs growing
by over 40 percent in the last decade. Inadequate
supply is exacerbated by high turnover in the care
workforce. Care workers--disproportionately women of
color--are among the lowest-paid in the country and
often have to rely on public benefits despite working
complex and demanding jobs. Investments in the care
workforce are foundational to helping to retain care
workers and improving health and educational outcomes.
In recent years, more than half of the long-term care
workforce and nearly 20 percent of the child care
workforce turned over each year. And the workforce
remains 8 percent smaller than before the COVID-19
pandemic.
In 2019, more than three in four United States
households that searched for care reported difficulty
finding adequate care for their young children, and
roughly the same share of center-based child care
providers turned families away because they lacked
enough child care slots. Similarly, more than three in
four long-term care service providers have reported not
being able to accept new clients, making it harder for
older Americans and people with disabilities to find
the care they need. Military families consistently cite
access to high-quality child care as an impediment to
military spouse employment and family economic
security. Difficulty accessing care also poses a
challenge for both spouses--and, as data shows,
particularly for women in dual military couples--to
continuing their service if they have
[[Page 24670]]
caregiving responsibilities. The need for long-term
care is likely to become more acute as our Nation's
population ages. By 2060, there will be approximately
twice as many adults over the age of 65 than in 2016,
and projections indicate that there will be around 8
million long-term care job openings over the next
decade.
Family caregivers provide informal, often unpaid, care
to help loved ones live in their homes and communities,
including caring for aging family members, people with
disabilities, and children. At least 53 million people
are family caregivers in the United States--including
5.5 million who are caring for wounded, ill, and
injured service members and veterans--and many face
challenges due to lack of support, training, and
opportunities for rest. Family caregivers include
spouses, parents, siblings, adult and minor children,
grandparents, and other relatives. Family caregivers
reflect the diversity of America's communities, and
people can assume family caregiving responsibilities at
any stage of life. Without adequate resources, family
caregiving can affect caregivers' own physical and
emotional health and well-being and contribute to
financial strain. These negative consequences are felt
most acutely by women, who make up nearly two-thirds of
family caregivers and drop out of the workforce at a
rate three times higher than men.
It is the policy of my Administration to enable
families--including our military and veteran families--
to have access to affordable, high-quality care and to
have support and resources as caregivers themselves. It
is also the policy of my Administration to ensure that
the care workforce is supported, valued, and paid well.
Additionally, care workers should have the free and
fair choice to join a union.
The Congress must provide the transformative
investments necessary to increase access to high-
quality child care--including preschool and Head
Start--and long-term care services, as well as high-
quality, well-paying jobs that reflect the value the
care workforce provides to families and communities.
Such investments include removing barriers and
providing the funding needed for Tribal Nations to
effectively provide high-quality child care and long-
term care.
Nearly every other advanced country makes greater
public investments in care than the United States.
Investing in care is an investment in the future of
America's families, workforce, and economy.
While the Congress must make significant new
investments to give families in this country more
breathing room when it comes to care, executive
departments and agencies (agencies) must do what they
can within their existing authorities to boost the
supply of high-quality early care and education and
long-term care and to provide support for family
caregivers. Through this order, I direct agencies to
make all efforts to improve jobs and support for
caregivers, increase access to affordable care for
families, and provide more care options for families.
Sec. 2. Increasing Compensation and Improving Job
Quality for Family Caregivers, Early Educators, and
Long-Term Care Workers. (a) To increase compensation
and benefits for early childhood educators and long-
term care professionals who are providing federally
funded services:
(i) the Secretary of Health and Human Services, through the Administrator
for the Centers for Medicare and Medicaid Services (CMS), shall issue
guidance to States on ways to use enhanced funding to better connect home-
and community-based workers who provide services to Medicaid beneficiaries;
(ii) the Secretary of Health and Human Services shall implement strategies
to encourage comparability of compensation and benefits between staff
employed by Head Start grant recipients and elementary school teachers;
(iii) the Secretary of Health and Human Services shall expand efforts to
improve care workers' access to health insurance; and
[[Page 24671]]
(iv) the Secretary of Education shall use grant notices for the Child Care
Access Means Parents in School (CCAMPIS) program to encourage grantees to
improve quality in funded programs, including by increasing compensation
and providing support services for early childhood educators who serve
children of students at CCAMPIS colleges using Federal and non-Federal
funding as appropriate;
(v) the Department of the Treasury shall conduct outreach on the Saver's
Match credit, and the Department of Commerce shall conduct--and the Small
Business Administration is encouraged to consider conducting--outreach on
potential Federal resources available to assist small businesses in
offering retirement plans, including a per-employee credit of up to $1,000,
as provided in the SECURE 2.0 Act of 2022 (Division T of Public Law 117-
328), in order to ensure that the care workforce, including individuals and
small businesses, are aware of Federal retirement assistance for which they
may be eligible.
(b) To improve working conditions and job quality
in federally assisted child care and long-term care
programs, encourage providers to establish incentives
to recruit and retain workers, help prevent burnout,
make it as easy as possible for care workers to access
behavioral health services, and thereby improve the
care that individuals receive, the Secretary of Health
and Human Services shall:
(i) consider additional actions--such as providing guidance, technical
assistance, and provider and resident education--and rulemaking on nursing
home staffing transparency to promote adequate staffing at nursing homes,
building on the Department of Health and Human Services' efforts to propose
minimum standards for staffing adequacy at nursing homes;
(ii) consider additional actions to reduce nursing staff turnover in
nursing facilities and improve retention of those staff, advancing the
Department of Health and Human Services' efforts to measure and adjust
payments based on staff turnover; and
(iii) implement strategies to expand mental health support for the care
workforce, including early childhood providers supported through the Child
Care and Development Fund (CCDF) and Head Start.
(c) To expand training pathways and professional
learning opportunities to increase job quality, improve
quality of care, and attract new entrants into the care
workforce, the Secretary of Labor and the Secretary of
Education, in consultation with the Secretary of Health
and Human Services, shall:
(i) encourage recipients of Federal financial assistance to expand
opportunities for early childhood educators and long-term care
professionals through community college programming, career and technical
education, Registered Apprenticeship, pre-apprenticeships leading to
Registered Apprenticeship, and other job training and professional
development;
(ii) make available innovative funding opportunities, develop and evaluate
demonstration projects for care training and educational attainment, and
provide technical assistance to State, local, and Tribal partners to
improve job quality for care occupations; and
(iii) develop partnerships with key stakeholders, including State, local,
Tribal, and territorial governments; unions and labor organizations; State
and local workforce development boards; institutions of higher education
(including community colleges, Historically Black Colleges and
Universities, Tribal Colleges and Universities, and Minority Serving
Institutions); aging and disability networks; and national- and community-
based organizations that focus on care (including professional membership
organizations).
(d) To support family caregivers of beneficiaries
of Federal health care programs and services, and in
conjunction with implementing the 2022 National
Strategy to Support Family Caregivers:
(i) the Secretary of Health and Human Services shall, consistent with the
criteria set out in section 1115A(b)(2) of the Social Security Act
[[Page 24672]]
(42 U.S.C. 1315a(b)(2)), consider whether to select for testing by the
Center for Medicare and Medicaid Innovation an innovative new health care
payment and service delivery model focused on dementia care that would
include family caregiver supports such as respite care;
(ii) the Secretary of Health and Human Services shall consider how better
to evaluate and clearly set expectations for family caregivers in the Acute
Hospital Care at Home program, which allows hospitals to treat in their
homes those who would otherwise be hospital inpatients;
(iii) the Secretary of Health and Human Services shall take steps to ensure
that hospitals are actively involving family caregivers in the discharge
planning process, consistent with CMS condition of participation discharge
planning requirements, including by promoting best practices such as
partnerships with community-based organizations and using resources from
the Administration for Community Living and the Agency for Healthcare
Research and Quality;
(iv) the Secretary of Health and Human Services shall increase beneficiary
communications and support family caregivers by increasing promotion of the
option for Medicare beneficiaries to choose to give family caregivers
access to their Medicare information via 1-800-MEDICARE and the State
health insurance assistance program networks;
(v) the Secretary of Veterans Affairs shall consider issuing a notice of
proposed rulemaking by the end of this fiscal year that would make any
appropriate modifications to eligibility criteria for the Program of
Comprehensive Assistance for Family Caregivers, which provides services and
benefits, including a monthly stipend, for eligible caregivers of veterans
who sustained a serious injury or illness in the line of duty; and
(vi) the Secretary of Veterans Affairs shall develop and implement a pilot
program to offer psychotherapy via video telehealth to family caregivers
within the Program of Comprehensive Assistance for Family Caregivers to
improve their access to mental health services.
(e) To improve and expand opportunities through
AmeriCorps to encourage more individuals to enter early
learning careers, the Chief Executive Officer of
AmeriCorps is encouraged to consider:
(i) expanding access to Segal AmeriCorps Education Awards, which AmeriCorps
members can use to pay for education and training or reduce their student
debt; providing loan forbearance for AmeriCorps members involved in early
learning; and providing other benefits to supplement national service
activities that support early learning; and
(ii) prioritizing applications that propose to implement or expand high-
quality programs focused on early learning and prioritizing projects
intended to prepare AmeriCorps members and AmeriCorps Seniors volunteers to
enter early learning careers.
(f) To improve jobs of domestic child care and
long-term care workers:
(i) the Secretary of Labor shall create and publish in multiple languages,
as appropriate, compliance assistance and best practices materials--such as
sample employment agreements for domestic child care and long-term care
workers and their employers--to promote fair workplaces and ensure the
parties know their rights and responsibilities, and shall identify other
means to promote employers' adoption of best practices;
(ii) the Secretary of Labor shall work with community and other local
partners to expand culturally and linguistically appropriate community
outreach and education efforts to domestic child care and long-term care
workers in order to combat their exploitation; and
(iii) the Chair of the Equal Employment Opportunity Commission is
encouraged to work with the Attorney General, the Secretary of Labor, and
the Secretary of Homeland Security to develop materials addressing the
employment rights of non-citizen domestic child care and long-term care
workers who are legally eligible to work.
[[Page 24673]]
(g) To improve data and information on the care
workforce:
(i) the Secretary of Labor shall conduct and publish an analysis of early
childhood and home care workers' pay in comparison to the pay of other
workers with similar levels of training and skill;
(ii) the Secretary of Labor shall issue guidance to help States and
localities conduct their own analyses of comparable pay rates for care
workers in their respective jurisdictions; and
(iii) the Secretary of Labor and the Secretary of Health and Human Services
shall, in consultation with relevant agencies and external experts and
organizations, jointly conduct a review to identify gaps in knowledge about
the home- and community-based workforce serving people with disabilities
and older adults; identify and evaluate existing data sources; and identify
opportunities to expand analyses, supplement data, or launch new efforts to
provide important data on the home- and community-based care workforce and
ensure equity for people with disabilities and older adults. The
Secretaries shall publicly release the findings and recommendations of this
review no later than April 2024.
Sec. 3. Making Care More Accessible and Affordable for
Families. (a) To increase access to affordable, high-
quality child care and long-term care for workers
delivering federally assisted projects:
(i) Agencies shall identify and issue guidance on which agency
discretionary, formula, and program-specific funds can be used for child
care and long-term care as a supportive service for workers who are being
trained for and working on federally funded projects, and in doing so shall
consider agency funds made available by the bipartisan Infrastructure
Investment and Jobs Act (Public Law 117-58); Public Law 117-169, commonly
referred to as the Inflation Reduction Act of 2022; and division A of
Public Law 117-167, known as the Creating Helpful Incentives to Produce
Semiconductors (CHIPS) Act of 2022.
(ii) With respect to the agency funds identified in subsection (a)(i) of
this section:
(A) Agencies shall consider requiring, where appropriate, applicants for
Federal job-creation or workforce development funds to provide affordable,
accessible, safe, and reliable child care and long-term care for workers
carrying out federally assisted projects (including both construction and
operating phases where applicable), or shall consider preferencing
applicants that use the funds for this purpose or encouraging applicants to
use funds for this purpose. Agencies shall provide implementation guidance
to relevant program staff and collaborate with the Department of Labor to
identify potential support for these actions, including technical
assistance for guidance and funding opportunities.
(B) Agencies shall consider providing technical assistance to help
funding recipients provide access to child care and long-term care as a
supportive service and to connect funding recipients with potential
partners, including care associations, community-based organizations,
Registered Apprenticeship and pre-apprenticeship programs, and labor
unions.
(C) In cases where child care or long-term care is required or
encouraged, agencies shall consider collecting information from funding
recipients on whether and how they will provide access to child care and
long-term care, and how many workers (including apprentices and pre-
apprentices) would be affected.
(iii) The Secretary of Labor and the Secretary of Health and Human
Services, in consultation with the Secretary of Commerce, shall support the
efforts outlined in subsection (a) of this section by issuing guidance and
providing technical assistance with best practices and models for how to
provide supportive services, including child care and long-term care.
(b) To lower child care costs for families eligible
for Federal programs, the Secretary of Health and Human
Services shall:
[[Page 24674]]
(i) consider issuing regulations to pursue policies to reduce child care
costs for families benefiting from CCDF;
(ii) identify potential opportunities to reduce barriers to eligibility for
Head Start and CCDF;
(iii) encourage States, through all available avenues, to increase the use
of Temporary Assistance for Needy Families funds for basic assistance and
work supports for families--including access to child care--and to spend
more funds on cash assistance for families; and
(iv) identify other potential strategies to make child care and Head Start
more accessible for those families most in need.
(c) To help more Federal employees access
affordable care:
(i) the Director of the Office of Personnel Management shall consider
establishing criteria that support equitable and accessible employee
participation in child care programs, to include agencies' adoption of
income thresholds that are aligned with increasing costs of child care;
(ii) the Director of the Office of Personnel Management shall conduct a
review of child care subsidy policy and agency program data to determine
the effectiveness of current child care subsidies within the Federal
Government;
(iii) the heads of agencies are encouraged to expand employee access to
child care services through Federal child care centers, child care
subsidies, or contracted care providers; and
(iv) the Department of Defense shall take steps to enhance recruitment and
retention of the Department's child development program workers and to
improve the affordability of child care for service members by September
2023, in addition to its ongoing efforts as part of the Fourteenth
Quadrennial Review of Military Compensation to assess how child care costs
impact the ability of the military to attract and retain its workforce.
Sec. 4. Expanding Options for Families by Building the
Supply of Care. (a) To provide families with more
options for high-quality long-term, home-, and
community-based care and early learning services:
(i) The Secretary of Health and Human Services shall consider rulemaking to
improve access to home- and community-based services under Medicaid. As
part of any such rulemaking, the Secretary shall consider taking steps to
support provider participation in Medicaid home- and community-based
programs.
(ii) The Secretary of Health and Human Services shall issue policies that
would support child care providers to give families more options to access
high-quality child care providers, and shall update payment practices to
improve provider stability and supply.
(iii) The Secretary of Education shall update a guide for schools and
districts to expand high-quality early learning programming using Federal
funds so that more preschoolers are fully prepared to succeed in school.
(iv) The Secretary of Education and the Secretary of Health and Human
Services shall identify and disseminate evidence-based practices for
serving children with disabilities and their families in high-quality early
childhood education programs, including Head Start. The Secretaries shall
also take steps to ensure that services are inclusive of children with
disabilities and their families; highlight any resources that are available
to aid in that effort, including for preschool-aged children with
disabilities under section 619 of the Individuals with Disabilities
Education Act (IDEA) and for infants and toddlers with disabilities and
their families under Part C of the IDEA; and provide information to support
all early childhood programs in meeting their obligations under section 504
of the Rehabilitation Act of 1973 and the Americans with Disabilities Act
of 1990.
(v) The Director of the Bureau of Consumer Financial Protection is
encouraged to consider developing financial guidance resources that support
families during their care planning.
[[Page 24675]]
(vi) The Secretary of Health and Human Services shall take steps to
streamline processes for Tribes to use CCDF and Head Start funding to
construct and improve facilities, including facilities that are jointly
funded.
(vii) The 12 agencies that signed the October 2022 Memorandum of Agreement
to implement Public Law 102-477 (the ``Tribal 477 Program'') shall increase
the effectiveness of Tribal employment and training programs to ensure
child care can be used as a support for families by reducing and
streamlining administrative requirements, including through consolidation
of budgeting, reporting, and auditing systems.
(b) To expand options for quality home- and
community-based services to veterans:
(i) The Secretary of Veterans Affairs shall consider expanding the existing
Veteran Directed Care Program--which provides veterans who need help with
daily living with a budget to spend on home- and community-based services
including personal care services--to all Department of Veterans Affairs
Medical Centers by the end of Fiscal Year 2024, and shall consider
developing an implementation plan for this expansion by June 2023.
(ii) The Secretary of Veterans Affairs shall consider designing and
evaluating a pilot program in no fewer than five veteran sites or in five
States for a new Co-Employer Option for delivering veteran home health
services. Features of the program may include allowing veterans to choose
who provides their care and to determine when and how that care is
delivered, and connecting veterans with a third-party agency that would
help coordinate administrative tasks and act as an intermediary between
veterans and their home health workers. Should the Department of Veterans
Affairs implement this pilot program, it shall provide an implementation
plan--including cost estimates and evaluation strategy--to the President,
through the Assistant to the President for Domestic Policy, before August
31, 2023.
(iii) The Secretary of Veterans Affairs shall consider expanding the Home-
Based Primary Care program by adding 75 new interdisciplinary teams to
provide care to veterans in their homes.
(c) To increase the supply of providers and options
for families by encouraging greater private financial
protection, support, and technical assistance for care
providers:
(i) the Secretary of the Treasury shall consider providing information to
and sharing industry best practices with Community Development Financial
Institutions to facilitate capital flows and support to care providers;
(ii) the Administrator of the Small Business Administration is encouraged
to consider publishing a guide on how individuals in the care workforce may
start and sustainably operate care businesses locally and through Small
Business Administration programming; and
(iii) the Director of the Bureau of Consumer Financial Protection is
encouraged to consider issuing guidance addressing financial institution
practices that may increase the burden on the care workforce, discourage
their work, and harm their financial well-being.
(d) To build the capacity of local communities to
better coordinate and deliver care:
(i) the Secretary of Health and Human Services shall review existing
policies to identify opportunities--including among Tribal communities--to
increase the capacity of community care entities by providing operational
support to these networks of providers; and
(ii) the Secretary of Agriculture shall use the Rural Partners Network and
issue guidance developed in partnership with the Secretary of Health and
Human Services to promote opportunities--including by hosting workshops--to
increase access to child care and long-term care in rural and Tribal
communities.
[[Page 24676]]
(e) To make the delivery and design of Federal care
assistance and programs work better for families, the
care workforce, and people seeking care, the
Secretaries of the Treasury, Defense, Agriculture,
Labor, Health and Human Services, Education, and
Veterans Affairs shall consider--and the Administrator
of the Small Business Administration is encouraged to
consider--prioritizing engagement with parents,
guardians, and other relatives with care
responsibilities; individuals receiving long-term care;
State and local care experts; care providers and
workers; employers; and labor unions.
Sec. 5. General Provisions. (a) Nothing in this order
shall be construed to impair or otherwise affect:
(i) the authority granted by law to an executive department or agency, or
the head thereof; or
(ii) the functions of the Director of the Office of Management and Budget
relating to budgetary, administrative, or legislative proposals.
(b) This order shall be implemented consistent with
applicable law and subject to the availability of
appropriations.
(c) Where not already specified, independent
agencies are encouraged to comply with the requirements
of this order.
(d) This order is not intended to, and does not,
create any right or benefit, substantive or procedural,
enforceable at law or in equity by any party against
the United States, its departments, agencies, or
entities, its officers, employees, or agents, or any
other person.
<GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT>
(Presidential Sig.)
THE WHITE HOUSE,
April 18, 2023.
[FR Doc. 2023-08659
Filed 4-20-23; 11:15 am]
Billing code 3395-F3-P
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