Increasing Access to High-Quality Care and Supporting Caregivers, 24669-24676 [2023-08659]

Agencies

• Executive Office of the President

[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 [www.gpo.gov]
[FR Doc No: 2023-08659]



[[Page 24667]]

Vol. 88

Friday,

No. 77

April 21, 2023

Part II





The President





-----------------------------------------------------------------------



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.
                
                
                    (Presidential Sig.)

                THE WHITE HOUSE,

                    April 18, 2023.

[FR Doc. 2023-08659
Filed 4-20-23; 11:15 am]
Billing code 3395-F3-P