At some point in our lives, all human beings depend on the care of others — if not in the present, then certainly in our past and for many, also in our future. Whether from a family member or legal guardian, a medical professional or a care worker, the support of others is an essential precondition for personal well-being and shared prosperity.
When care systems function well, young children have people who provide them with love, learning, and physical safety, working parents have affordable options to support their children’s growth, families do not struggle with overwhelming medical debt, and the elderly can age with dignity.
In a place like California, where we take pride in our strong communities, why do some people still struggle to access essential care services for themselves or their families? And what would it take to move from scarcity to abundance in the care economy, so that people at every stage of life can receive the support they need?
In the summer of 2024, the Possibility Lab invited public policy researchers from across California to share their ideas on addressing these questions. Here, we present reports from three policy experts: Anna Powell (childcare), Leif Haase (healthcare), and Mireille Jacobson (eldercare).
Read the Childcare, Healthcare, and Eldercare memos
Together, these three researchers describe how scarcity in the care economy is not inevitable, but instead is fundamentally shaped by policy design. In their view, achieving abundance requires treating care as a public good, with sustained investment in the workforce and infrastructure that make it possible to provide high-quality care options to all residents. By aligning state-level investments, workforce development, and licensure reforms with local and regional planning, California can expand the supply and accessibility of essential care services for people of all ages.
Moving from Market Failure to Abundant Childcare
In childcare, California’s shortages are widespread. Currently, the state has enough capacity to provide for only one in four children who need care. According to Powell, this reflects a structural market failure. Caring for children is labor-intensive, and mandatory staffing ratios mean childcare centers must have sufficient funds to sustain an appropriately-sized workforce. At the same time, their ‘customers’ — that is, the parents of young children — are often at a point in their lives where they are particularly low on disposable income. Consequently, providers face high labor and operating expenses, but cannot raise their rates without pricing at least some families out. This results in a perpetual squeeze in the childcare sector, where parents cannot afford the options available to them, and care workers cannot afford to stay in their historically under-compensated profession.
Powell’s solution to this predicament is clear: we need sustained public investment to make childcare programs economically viable and widely scalable to every family that needs them. First, Powell argues that expanding supply requires investing in the people who provide care. Because providers must find ways to contain costs so that care options are accessible, wages remain low and turnover high. Improving compensation and working conditions, and reducing barriers to professional advancement, she contends, is essential to retaining and growing a stable childcare workforce. From a people-centered perspective, expanding supply in this way not only increases available childcare slots for families, but also improves economic security for care workers themselves.
Second, Powell emphasizes the need to invest in physical capacity. Even if the childcare workforce stabilizes and expands, the available space in existing care facilities limits how many children can be served. Non-existent profit margins again are to blame, making it difficult for providers to maintain, improve, or build facilities. Powell calls for state investment in a dedicated facilities fund, alongside local financing tools and integration of childcare into housing and land-use planning, particularly in high-need communities.
At the same time, Powell cautions that investments must be paired with broader system reforms, such as aligning subsidies with the true cost of care, developing funding models that provide more predictable revenue for providers, and using a targeted universalism approach that pursues shared, universal goals through needs-based policy strategies. For Powell, the goal is not expansion for its own sake, but a coordinated, system-wide, people-centered effort to maximize public benefit and choice for all families.
Moving from Managing Illness to Fostering Health
Like childcare, healthcare as currently provided falls short. Haase argues that, when it comes to healthcare, California suffers from a gap between abundant medical spending and uneven health outcomes. According to the latest federal data, California spent $405 billion on personal health in 2020. Since 2010, California’s per-capita healthcare spending has grown faster on an annual average basis than both national health spending and the state’s overall economic growth. Despite major coverage gains, many residents — particularly those in rural regions, low-income communities, and communities of color — still struggle to access primary and mental healthcare.
To close these gaps, Haase advocates for a supply-side reform agenda focused on improving access where it is most constrained. Central to this effort, Haase argues, is strengthening and diversifying the primary care workforce.
From his perspective, increasing residency slots, reducing licensure barriers for qualified clinicians, and expanding scope-of-practice flexibility would allow motivated providers to fill care gaps and ease patient competition for limited care appointments. Haase also emphasizes that sustained telehealth expansion can increase availability and reduce geographic inequities, especially in rural communities that lack consistent access to care.
Importantly, Haase stresses that abundant health cannot be achieved through treatment alone. Improving access to housing, nutrition, education, and even broadband — key social determinants of health — is essential to producing better outcomes, particularly for lower-income Californians. Initiatives like CalAIM, Haase contends, demonstrate how integrating health and social services can maximize public benefit while reducing long-term costs, moving California beyond managing illness toward fostering healthier communities statewide.
Moving from Limited Options to Addressing the Missing Middle of Eldercare
Most older adults report that they hope to stay in their own homes as they age, but this is not a reality for many, as health needs and mobility options change. As California’s population ages, Jacobson argues that demand for eldercare is outpacing the system’s ability to respond, exposing deep structural weaknesses in the way society provides for the long-term services and supports that older adults rely upon. Highlighting the state’s leadership in this area through initiatives like the Master Plan for Aging and CalAIM, Jacobson describes how the state could further incentivize and invest in the supply of options for eldercare so that access keeps pace with the state’s growing need.
One of the most pressing gaps, Jacobson argues, is the persistence of a “missing middle” in eldercare provision. Between limited home-based services and costly institutional nursing facilities, low- and middle-income older adults and their families often have few appropriate options. By expanding services and supports for this middle tier, California could better match services to need and increase capacity without leaving families with only the most expensive or restrictive options.
Workforce constraints, Jacobson points out, can further limit access to care as people get older. Similar to the point Haase makes in the broader healthcare domain, she highlights how restrictive scope-of-practice rules prevent trained home health aides from providing routine care (like administering eye drops and medication), thus reducing flexibility in options and increasing costs. From her perspective, streamlining licensure and expanding scopes of practice, paired with appropriate training and oversight, would enable more qualified providers to deliver care for older adults who have limited resources.
Jacobson also calls for broader statewide reform, such as through Medi-Cal policies that align reimbursements with the true cost of care and reduce administrative fragmentation. In this way, she argues, eldercare reforms can address underinvestment and miscoordination in service delivery while better providing for the diverse needs of California’s aging population.
Ultimately, true abundance in California’s care economy will depend on our ability to design people-centered systems. By aligning investment and regulation to expand supply and broaden access, California can reimagine care across generations. This will ensure that essential goods and services are not reserved only for those with the greatest resources, but instead are widespread and can serve as the foundation for economic opportunity, public health, and broader well-being for all.
To learn more, visit the UC Berkeley Possibility Lab’s Abundance Accelerator
