The future of U.S.
caregiving: High demand, scarce workers
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[August 03, 2017]
(The opinions expressed here are those of the author, a columnist
By Mark Miller
CHICAGO (Reuters) - If you are hovering
around retirement age today, you will be closing in on your eighties in
the year 2030. With any luck, you will be healthy and mobile - but
imagine for a moment that you are not. Let's say a debilitating illness
requires that you receive care in a nursing home.
It is an unsettling future to imagine. But now ask yourself this - who
will take care of you? The United States is headed toward a severe
shortage of caregivers - paid and unpaid - in the decades ahead,
according to human resources expert Paul Osterman. A professor of human
resources and management at the Massachusetts Institute of Technology's
Sloan School of Management, Osterman is the author of a new book, "Who
Will Care for Us: Long-term Care and the Long-Term Workforce" (Russell
Sage Foundation, 2017), which examines trends in the labor force market
His conclusion? “It’s an absolute train wreck waiting to happen.”
Our aging population will push up demand, although Osterman notes that
roughly half of demand for care will come from younger, disabled people.
He examines the projected rising demand for care in the coming decades,
and then matches up the demand side with trends in the labor force for
paid certified nursing assistants (CNAs) and home care workers,
including the availability of unpaid family and friends - the most
common source of care for many people.
He finds that in 2030 there will be a national shortage of 151,000 paid
direct care workers and 3.8 million unpaid family caregivers. By 2040,
the shortfall will be much larger: 355,000 paid workers, and the family
and friends shortfall will be a shocking 11 million.
"These are conservative estimates,” Osterman said in an interview. “They
assume no changes in immigration policies, and that family members will
be willing to provide care at the same rate they do today - that’s not
likely, due to smaller families and more geographic dispersion.” If
family caregivers become more scarce, that can only put further pressure
on demand for paid care.
DAMAGING IMMIGRATION CRACKDOWN
The Trump administration’s crackdown on immigration in the United States
will only worsen the situation. In 2015, 18 percent of CNAs and 27
percent of home care aides were immigrants, Osterman estimated, citing
Census data. Among immigrant home aides, 24 percent each come from
Central America and Asia, 23 percent come from the Caribbean and 10
percent are from Africa.
But he cautions that the impact of a shrinking immigrant labor pool will
be uneven, due to the huge variation in immigration patterns among the
states. “New York and California have very large immigrant populations,
but it would probably have very little impact in a state like Ohio,” he
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The highest percentages of home care aides who are immigrants are found in New
York (64 percent), New Jersey (47 percent) California (46 percent), Florida (38
percent) and Texas (22 percent). By contrast, just 8 percent of the home care
aide workforce in Ohio are immigrants; in Georgia, the figure is 12 percent.
Osterman also does not believe a crackdown on undocumented workers would affect
the caregiving labor market much. Young men make up a very large part of the
undocumented population and nationally, nearly 90 percent of direct care workers
are female. “Undocumented workers as a group are unlikely to be a dominant
source of labor for these jobs,” he said.
Caregivers earn very low wages - median income for CNAs in 2015 was $20,000, and
home care aides earned a median of $15,000, according to Census data. Normally,
a labor shortage would resolve itself by putting upward pressure on wages -
which would bring more workers into the field. But in this case, the impact on
wages - and the caregiving shortage - will be uneven, Osterman said.
Two-thirds of long-term care in the United States is funded by the federal
Medicaid program, with the remainder paid through private commercial insurance
or out of pocket. Medicaid payment policies vary widely among the states, but Osterman worries that in many states, care facilities funded by cash-strapped
Medicaid programs will not be able to boost wages.
"It’s difficult for wages to rise because they are set bureaucratically
according to Medicaid reimbursement rates,” he said. Meanwhile, wages in the
high-end private payer market will rise, with a corresponding impact on the cost
of care and insurance.
Osterman’s book is not completely doom and gloom. He holds out hope that we can
attract more workers to caregiving by making the occupation more attractive. One
needed change, he said, is attitudinal. Many key actors in the profession -
doctors, hospitals, regulators, legislators and insurance companies - simply do
not demonstrate respect for direct care workers, which is an obstacle to
improving the job.
The second challenge, he writes, is the complexity of our care delivery system
and its financing mechanisms, both of which make reforms difficult to implement.
Osterman also argues for restructuring the roles of caregivers. Currently, new
caregiving workers receive only about two weeks of job training; expanding that
could open the door to broader responsibilities.
"In some states, a caregiver can’t administer eye drops, or help with wound
care,” he said. He thinks caregiving workers could be trained to help with
responsibilities like physical therapy, or coaching people with diabetes on
eating and exercise.
That could attract more workers, he thinks, and save money in the healthcare
system by shifting tasks away from higher-paid workers such as nurses.
“The point of my book is not to be nice,” he said. “It’s really a financial case
for doing this, and an argument for an important social policy.”
(Editing by Matthew Lewis)
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