[Note: This is Part 1 of “The Weight of Care,” a 3-part series on caregiving, human worth, and the gospel’s different accounting.]

During a congressional hearing this spring, the Secretary of Health and Human Services argued that Medicaid programs paying family members to care for disabled or elderly relatives are “rife with fraud.” Part of the case rested on a phrase caregivers across the country noticed immediately: this is work that families “used to do for free.”

The backlash was immediate. Parents of children on ventilators, spouses of adults with severe traumatic brain injuries, adult children managing the round-the-clock needs of parents with advancing dementia — they came forward to describe what their days actually look like: the medication schedules, the suction equipment, the seizure logs kept through the night, the interventions at 3 a.m. that prevent hospitalizations costing the system ten times what the caregiver’s monthly stipend does. The work they were describing — clinical, sustained, life-preserving — is not what that phrase was built to capture.

But the policy dispute, however legitimate on its own terms, surfaces less than the phrase itself does. “Used to do it for free.” Buried in that framing is an assumption: if something was once done out of love or obligation without compensation, it cannot really be work. And if it is not really work, the question of what it is worth does not quite arise.

The debate over caregiving and human worth runs deeper than Medicaid reimbursement rates. Underneath the policy argument is a question about what our culture believes work is for — and, beneath that, who gets to matter.

The Invisible Labor

The numbers are large enough to be difficult to hold in view. More than 11 million Americans are paid through state Medicaid programs to care for family members who are elderly, disabled, or medically complex.^[1] Millions more provide this care without compensation. Together they form one of the largest labor forces in the country — one that barely registers on balance sheets or in economic conversation, and that surfaces mainly when a government official suggests their labor was supposed to be free.

The parent of a child with a degenerative neurological condition manages feeding tubes, suction machines, and medication schedules that, if missed, produce seizures. She coordinates with a rotation of specialists. She provides the level of care that, in any institutional setting, would require a team of trained staff working in shifts. She works without shift changes, without break rooms, and in many rural communities without any facility that could take her child even if she wanted one.

Or consider the adult child who has moved a parent with advancing dementia into his home — managing behavioral episodes, physical care, and the total supervision that prevents placement in a memory care facility he could not afford even if a bed were available. More than 600,000 Americans are currently on waitlists for home and community-based care services.^[2] In many parts of the country, the family caregiver is not a preference. She is the only option.

The person in this role has typically left the workforce. She has absorbed the financial cost of that departure — the foregone income, the interrupted career, the retirement contributions that did not happen. She may be providing care that would otherwise cost the state far more than her stipend in institutionalization expenses. She is doing work the system cannot adequately staff or fund. And the argument being made about her work is that it should be evaluated in light of what she used to do for nothing.

The assumption beneath the argument is this: work has value only when the market prices it. Labor performed within the bonds of family love or obligation is, by this accounting, not labor at all. It is simply what families do. That framing has consequences — not just for what the caregiver earns, but for how the person being cared for is valued by a society that has decided her care is a family matter rather than a social one.

Caregiving and Human Worth

There is a long history of work that our culture has struggled to see. Much of it has happened in the same places caregiving happens now — in homes, in kitchens, in the hallways and bedrooms where life is sustained rather than produced. The work was real. The economies it made possible were real. But because it generated no income and appeared on no ledger, it had an awkward relationship with the category of work at all.

What a culture cannot see reveals what that culture worships. If the primary measure of work’s legitimacy is its market price, then the labor that falls outside the market disappears from view entirely. The caregiver’s work falls outside the only framework our culture has for measuring it.

The writer of Proverbs 31 describes a woman whose labor is so comprehensive the poem strains to contain it. She rises before dawn. She manages a household, produces clothing, conducts business, cares for those in need, and sustains the people around her. The work is domestic, relational, and largely invisible from the outside. The poem ends not with a wage argument but a verdict: “her worth is far above rubies” (Proverbs 31:10) — a category of value the marketplace is not designed to calculate.

Worth and labor economics are different arguments. Market economies are efficient at pricing goods and services. They are not built to measure what it costs a person to give years of her life to someone who cannot give them back — who cannot, in some cases, recognize her face.

Paul closes his extended argument about resurrection in 1 Corinthians 15 with this: “Therefore, my beloved brothers, be steadfast, immovable, always abounding in the work of the Lord, knowing that in the Lord your labor is not in vain” (1 Corinthians 15:58). The context is resurrection and permanence — the argument that because Christ has been raised, what we do in his name has weight that death cannot erase. The labor Paul has in mind is not limited to formal ministry. It is the labor of faithfulness across all of life’s forms. It carries weight not because the market can measure it, but because it is being watched by someone whose accounting runs deeper than any ledger. That kind of accounting — weight without market equivalence, value without visible output — is precisely what the rest of Scripture keeps returning to.

What the Gospel Sees

In Matthew 25, Jesus describes the final judgment in terms of what the King had seen. The hungry who were fed, the strangers who were welcomed, the sick who were visited, the prisoners who were not abandoned. Those who had done these things did not know they were doing them for the King. They were doing them because these people needed them. The King tells them: “Truly, I say to you, as you did it to one of the least of these my brothers, you did it to me” (Matthew 25:40).

The logic here runs against the logic of the productivity idol. Our culture’s accounting assigns value by visibility and output. The King’s accounting assigns meaning by whom an act serves and whether it was done. Feeding someone who is hungry is, by this accounting, an act the King of the universe identifies with personally. The caregiver sitting with a person who cannot reciprocate, managing the machines that keep her child breathing through the night, is doing work the King has noticed.

Scripture returns to this posture. When Hagar is cast into the wilderness — exhausted and frightened, discarded by the household that had used her — she encounters God in the desert. She names him El Roi: the God who sees (Genesis 16:13). The name she gives him is not a theological abstraction. It is a testimony from someone who had been treated as expendable by every person of social consequence around her, and who found herself counted differently by the One who came looking. The one who was invisible to her world was entirely visible to God.

When Jesus watches a widow drop two small coins into the temple treasury, surrounded by wealthy donors making much larger contributions, he does not rate her gift by its size. “This poor widow has put in more than all of them” (Luke 21:3). The metric he is using is not what a fundraiser would use. His measure is not the size of the gift but what it cost her. By that standard, the caregiver who has given years she cannot recover, serving someone who cannot give them back, has offered something the treasury of the world simply has no category for.

She is not invisible to El Roi. The work is seen. The God who found Hagar in the wilderness, who noticed the widow in the crowd, keeps the same kind of account. And the person she is caring for is not simply a dependent or a patient. By the accounting of Matthew 25, he is someone in whom Christ himself is present.

That does not settle the policy debate or prescribe a reimbursement formula. But it tells us something more fundamental: the framework that assigns worth by market value alone is not the gospel’s framework. A church that has absorbed the market’s accounting without examining it — that cannot name as valuable what the economy cannot price — has lost something essential about the God it claims to follow.

The controversy will move through the normal cycle of political argument. The caregivers will continue their work through all of it. What will not resolve itself in any policy adjustment is the assumption underneath the controversy: that work performed in love, for someone who cannot pay, in a space that generates no income, was never quite real work to begin with.

What the caregiving debate ultimately requires from the church is not a policy position, though that matters. It requires the willingness to look where the economy is not looking — at the caregiver whose labor falls outside every ledger, and at the person in her care whose face Matthew 25 says the King himself is present in — and to name what is there. That is not a program. It is a practice. And the God who named himself El Roi has been doing it far longer than we have.

Questions for Reflection

• Where do you find yourself — consciously or not — assigning worth to work based on whether it generates income or visible results?
• How does Paul’s conviction that “your labor in the Lord is not in vain” (1 Corinthians 15:58) change the way you think about work that goes unseen or uncompensated?
• When you have been in a position of dependency — through illness, grief, or limitation — what did that experience reveal about how you understand your own worth?
• Is there a caregiver in your life whose work you have not named or noticed? What would it mean to see that person the way El Roi sees her?
• What does your community’s response to caregivers — and to the people being cared for — reveal about what it actually values?

Prayer Points

• For Family Caregivers: Pray for the millions of family caregivers — many exhausted, financially strained, and socially invisible — that God would sustain them in their labor, that their communities would see them clearly, and that they would know their work is not forgotten.
• For the Dependent and Vulnerable: Pray for those who require sustained care — the elderly, the disabled, the medically complex — that they would be received with dignity, that the systems meant to support them would be adequate, and that the church would see in them what Matthew 25 says is there.
• For the Church’s Discernment: Pray for wisdom to recognize where the church has absorbed a framework of worth driven by market value rather than the gospel, and for courage to name and resist that framework in concrete ways.
• For Those Making Policy: Pray for those with authority over healthcare and social support systems, that they would exercise that authority with justice and wisdom, and that decisions affecting the most vulnerable would be made in full awareness of the real human lives at stake.

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^[1]“The New Face of Family Caregiving,” ASA Generations, November 19, 2025, https://generations.asaging.org/the-new-face-of-family-caregiving/. (Drawing from Caregiving in the U.S. 2025, which first documented 11.2 million paid family caregivers.)

^[2]KFF, “A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2025,” https://www.kff.org/medicaid/a-look-at-waiting-lists-for-medicaid-home-and-community-based-services-from-2016-to-2025/.