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| Why Some Voters Are Saying Yes to Tax Increases, Instead of Facing Aging Costs Alone

| Mark Swartz

| In the fall of 2024, a Washington State ballot measure asked voters to gut one of the most ambitious elder-care programs in the country. The state’s WA Cares Fund, the nation’s first  public long-term care insurance program funded through a small payroll tax, had only recently begun collecting premiums. The measure on the ballot wouldn’t have repealed it outright — it would have made participation voluntary, which advocates say amounts to the same thing.

“A voluntary public program is doomed to fail,” said Howard Gleckman, a visiting fellow at the Urban Institute and the Urban-Brookings Tax Policy Center who has tracked the program for years. Without a mandatory pool of contributors, the insurance math collapses, and Washington families are left, like others around the country, to pay for the full cost of care out of pocket. The WA Cares Fund allocates up to $36,500 per person to use for home care, adult day care, nursing home costs and services like installation of wheelchair ramps.

Hedge fund founder Brian Heywood bankrolled the repeal effort, arguing that tax increases drive entrepreneurs and businesses out of the state. Gleckman expected the tax-cutting measure to pass, but, to the surprise of many onlookers, Washington voters rejected it. The tax and the insurance program stayed in place, and this past July, the fund began paying its first benefits.

This rejection demonstrated the power of SEIU 775, whose members include thousands of long-term care workers, along with other advocates, who defended the WA Cares Fund and worked to persuade voters that it was worth the cost of a 0.58% tax increase. (An employee making $50,000 per year pays $290, or $12.08 per biweekly paycheck.)

Popular support for WA Cares led some to ask a bigger question: Could ballot initiatives be a new tool for voters to compel  states to pay a bigger share for the care of their aging populations? Some observers believe so, as long as advocates understand what makes this particular issue so hard to put in front of voters in the first place.

One Tool in the Toolbox

In a 2020 episode of the Great Battlefield podcast, Chris Melody Fields Figueredo of the Ballot Initiative Strategy Center characterizes this advocacy approach, putting public programs on the ballot instead of asking legislators to pass them, as “a response to broken-ness’; when state legislatures aren’t meeting the needs of the electorate, advocates might choose to take the case directly to voters. It’s a daring approach and can be expensive, especially when it involves raising taxes—which invites the wrath of an array of well-funded opposition, like Heywood in Washington State.

Childcare advocates have had considerable success in harnessing the ballot box to shore up the underfunded care system. Since 2016, according to the Century Foundation, citizens in 20 states have used ballot measures to create at least 38 new voter-approved child care funds, including a tourist tax in Colorado ski towns and a high-earner tax funding preschool in Portland, Ore. Their playbook involves building a public fund tied to a dedicated revenue source, centering the affected community in designing the solution, and assembling a coalition broad enough to survive an attack ad.

Robert Espinoza, founder and CEO of The CareWorks Project, has spent 15 years in long-term care after years in the LGBTQ rights movement, where ballot initiatives were often used as weapons by opponents rather than tools by advocates. His experience underscores that ballot measures are a double-edged instrument: the same mechanism that catalyzes public sentiment for a cause can just as easily mobilize resentment against one. That’s a caution, but not a disqualifier: it means elder-care advocates, like childcare advocates, need message discipline as much as they need a good policy.

Espinoza also notes that ballot initiatives are expensive undertakings. Advertising and on-the-ground promotion cost money, he says, “So you often need a PAC or a major donor and a lot of private money to get it off the ground and be successful.”

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Mobilizing around Care

Long-term care is expensive, and it’s a cost most Americans don’t see coming. A 2022 Health and Human Services study says that more than half of all adults who reach 65 will need significant long-term services and supports, and those who need to pay for care privately can expect to spend more than $250,000 in their later years. Neither Medicare nor private health insurance covers most of it. Medicaid does, but only for people living on low-incomes, or after people have spent down their savings and qualify as low-income.

Marc Cohen, a co-author of a 2020 study on state-level long-term care financing reform for the LeadingAge LTSS Center at UMass Boston, has a theory about why ballot initiatives addressing services and supports for older adults are rare, despite the scale of the problem. “Most ballot initiatives can be summarized really easily,” he says. “Legalize pot, expand Medicaid, raise minimum wage.” Long-term care doesn’t fit that mold. “You have to understand things like caregiving, functional decline, and so on. It requires a little bit more knowledge, and it may be difficult to explain on a ballot.”

Cohen also points to something less visible: unlike teachers or parents, older adults and their caregivers lack a coherent advocacy infrastructure. “It’s more fragmented,” he says. In Cohen’s view, legislators set aging policy with little input from advocates and activists, reflecting a long-standing, largely paternalistic tradition.  While this durable bipartisan support has yielded caregiver tax credits and other gains, it has not led to structural changes to address the realities of an aging population.

That legislative default is where AARP has concentrated its own efforts. “When it comes to caregiving, we’re seeing good momentum to support caregivers in statehouses, and that’s where our focus continues to lie,” says Nancy LeaMond, the organization’s chief advocacy and engagement officer. She points to a wave of state caregiver tax credits that followed Oklahoma’s lead in 2023. “There’s growing recognition among leaders of all political stripes that caregivers — there are 63 million nationally — deserve greater financial support. The roughly $7,200 they pay, on average, out of pocket to support loved ones takes a toll on entire families.”

The statehouse and the ballot box aren’t competing strategies so much as different tools for the same fight.

A Setback in Maine

If Washington shows ballot initiatives can work to help aging families, Maine shows how easily they can fail. In 2018, the Maine Peoples’ Alliance put a universal home-care measure to voters, funded by a tax on income above the Social Security wage cap ($184,500 in 2026). “It was really the most ambitious elder care initiative,” Cohen says, “because it would’ve created a universal home care program for all Maine residents 65 and older and adults with disabilities.” It lost decisively, with 63 percent of voters opposed.

Well-funded opposition played a role. But the 2020 LeadingAge study points to something more instructive: the coalition behind the measure moved to a specific policy solution before building the kind of broad, patient coalition that Washington’s advocates spent years assembling. Washington’s own reform nearly stalled at a similar juncture — a coalition member’s concerns about how family caregivers would be paid and trained led organizers to pull the bill from a vote, address the objection, and reintroduce it a year later. Years of trust between disparate stakeholders arguably produced the adaptability that saved the program when the 2024 repeal effort arrived.

The state of states

None of this is happening in a vacuum. Unlike the federal government, states must, with few exceptions, balance their budgets every year. That means any new long-term care program needs a real, dedicated funding source. And the fiscal room to even consider one is shrinking. Federal Medicaid cuts under H.R. 1 (including $990 billion in Medicaid funding for states over the next 10 years) are pulling state legislatures’ attention toward damage control. “All they’re doing now is they’re trying to play defense,” Gleckman says, describing state officials consumed by new work requirements and other bureaucratic hurdles. “They don’t have the bandwidth to think creatively about other stuff.”

That leaves an opening and an urgency for the ballot box. Cohen believes the financial pressure on middle-income families who don’t qualify for Medicaid but can’t afford private care is only going to grow. “There’s this whole overlooked middle that is now starting to really feel the brunt of this,” he says. “It may very well change. I think there may be higher demand. The question is whether people feel the legislative outlet is responding or not.”

Washington State’s experience suggests an answer to what happens when it isn’t: voters, given a clear enough choice, can be the outlet instead.

Mark Swartz is the publisher of Aging in America News. He lives in Baltimore. Better Life Lab at New America supported the reporting for this story.