Congress has the tools to ease the pressure. Another piece of Mr. Biden’s caregiving proposal would increase the amount of Medicaid funding going toward improving the access to and affordability of home- and community-based care. There are also legislative proposals to provide family caregivers with tax credits for their caregiving expenses and Social Security credits for those who leave the work force to look after loved ones. Other legislation would award additional funding to states that expand access to respite care. Paid family and medical leave and flexible sick leave would allow informal caregivers greater flexibility to deal with loved ones’ illnesses, postsurgical care and emergencies, like the minor falls that are so common yet potentially devastating for older people.
Federal policy is only part of the story; some states are addressing the issue aggressively. Washington State has established a public long-term-care insurance program. Last year Maine announced a pilot program that uses pandemic relief funds to reimburse family caregivers up to $2,000 for related expenditures. Thirteen states and the District of Columbia have established some type of paid family and medical leave, and around 15 allow for flexible use of sick time. Many allow qualified family caregivers to get paid for their duties, mostly through Medicaid. AARP maintains a scorecard of states’ support for family caregivers, tracking the extent to which states have embraced policies such as paid family leave and sick days, unemployment insurance for family caregivers who must leave the work force and spousal impoverishment provisions. States lagging in support policies should be looking to the front-runners for models of what works, and voters should demand it.
With more and more complex duties being heaped upon them, family caregivers also need much more training and education. Since 2014, most states have passed a version of the CARE Act, an important first step. It requires hospitals to ask patients if they have family caregivers and if so, to provide the caregivers with information about the patients’ discharge schedules, along with instructions regarding whatever care the patients will need after returning home. But this measure applies only to people who have been hospitalized, and implementation is uneven, with only perfunctory instruction provided in many cases. More needs to be done. The Better Care Better Jobs Act, for instance, includes incentives for states to make training more available to family caregivers.
The help that caregivers need goes far beyond the nuts and bolts of caregiving and its financial costs. They need better information on how to navigate a health care system that is complex and decentralized, along with help coping with what John Schall, a leader in caregiving advocacy, termed the “psychosocial aspects” of the work — the alienation, isolation, anger, guilt and anxiety that often come with the territory.
Caregiving is essential work in an aging society, and at some point, most of us will have to confront its challenges. No one should have to face them alone.
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Aging Americans Face Bleak Futures Unless We Let New Immigrants Help
There are more than 11 million job openings and only 6 million unemployed workers in the United States, and employers have struggled for more than a year to hire enough people to fill their ranks.
This shortage is having a great impact on our healthcare system. In particular, America’s aging population is exploding and the unmet demand for the caregivers elderly citizens rely on is becoming increasingly pronounced in rural areas and smaller cities and towns where nearly half of all Americans live. The Association of American Colleges (AAMC) predicts a shortfall of as many as 124,000 physicians by 2034, with geriatricians facing a particularly severe shortage. According to a 2021 AAMC report, just 6,124 physicians nationwide specialize in caring for older adults. Per the U.S. Census, “By 2060, nearly one in four Americans will be 65 years and older, the number of 85-plus will triple, and the country will add a half million centenarians.”
Without more immigrants, aging Americans face a bleak future for our ability to age with dignity. And it’s not just our elderly population. We need more immigrants in every aspect of healthcare and the rest of our economy for our country to thrive.
Not only will America’s elderly struggle to find healthcare, but they may also have few choices when hiring help to remain in their homes or securing a position in a residential facility. Today, at least 87 percent of nursing homes in the U.S. face moderate to high staffing shortages, even though most have offered increased wages and bonuses. Representatives from three-quarters of the facilities report a lack of qualified candidates as their biggest obstacle. More than half of all nursing homes fail to comply with daily staffing levels as set by the Centers for Medicaid and Medicare Services. As a result, most nursing homes are limiting new patients, and many face the looming specter of closure over staffing shortages. In Postville, Iowa (pop. 2,400), a residential facility closed earlier this year with little notice, forcing some long-term residents to scramble to secure spots in neighboring facilities.
We can take Iowa as a microcosm of America. The median age for Iowans—like most Americans—is 73. Nearly half of all Iowans live alone and lack retirement income, and a third have a disability. Iowa also has 73,400 job openings for direct care workers, ranking 26 on the national Direct Care Workforce State Index developed by PHI National. Compounding these shortages are low rates of foreign-born workers in the state. Immigrants comprise 7 percent of the workforce in direct care, slightly higher than the 5.5 percent of foreign-born persons statewide.
Nationally, foreign-born workers make up about 25 percent of the direct care workings in the home care industry and 19 percent of direct care workers in the nursing home care industry. In part, this is because the job is incredibly demanding—workers report “chronic understaffing, workplace violence, undue risk of injury or illness, chronic fatigue, and significant mental health strain.” Nursing assistants face heavy workloads that require them to support multiple residents simultaneously per shift, often with insufficient time to meet the needs of those they care for. Demanding workloads and hours lead to stress, injury and burnout, which contributes to high turnover in the field generally. Though raising minimum wage increase may entice more native citizens to work in care facilities, without reform, Medicaid reimbursement wages will always cap salaries. For many citizens, it means they will choose a less demanding minimum-wage job.
Kevin Kincaid sees firsthand the need for immigrants in healthcare as CEO of the Knoxville Hospital and Clinics in Iowa. He tells us, “The immigration process is complicated and expensive. The healthcare system desperately needs these immigrants with the proper training and expertise to carry out our mission. The immigration system makes it very difficult for them, unnecessarily so.” Three immigrants from the Philippines recently arrived and are new members of his staff, Kincaid says. He continues,“We’ve most recently shored up our staffing in the laboratory by using these highly trained immigrant professionals. They come to us with fantastic training and are just great members of our community. We are thankful to have them. We just wish the immigration system would give them (and us) more certainty, be timelier, and be less costly. We need them without a doubt.”
Iowa is leading the nation in utilizing the Conrad 30 program, which helps address the shortage of qualified doctors by incentivizing foreign medical graduates (FMGs) to work for 2-years in medically underserved areas. According to a Niskanen Center report detailing the five-year average use of waivers, Iowa has used every waiver available. Notably, Senator Joni Ernst (R-IA) cosponsored a 2020-2021 Conrad 30 extension bill that would increase the number of waivers from 30 to 35. But this is just a drop in the bucket—many more are needed.
The obvious answer to surplus demand is to increase the availability of labor. Still, the U.S. is taking the opposite approach. In May, the State Department announced that nearly all the available visas for foreign nurses had been filled. Applicants who filed after June 1, 2022—even those with job offers—have to wait for the quota to reset later this year, adding to the growing backlogs. Though International Medical Graduates (IMGs) accounted for 50 percent of geriatric medical providers in 2021, Congress refuses to expand the Conrad 30 waiver program that incentivizes IMGs to practice in areas with high medical need.
Between 1980 and 2017, immigration alone increased the supply of elderly home care in the U.S. and reduced its costs while improving the quality of care. In 2017, more than 30 percent of nursing home housekeeping and maintenance workers were immigrants, but those numbers are falling as fewer immigrants are available to fill increasing numbers of job vacancies. Furthermore, foreign-born workers make up 25 percent of the direct care workers in the home care industry and 19 percent of direct care workers in the nursing home care industry. Approximately 142,000 undocumented immigrants serve as childcare workers, personal care aides, and home health aids.
Iowa isn’t alone in its efforts to expand opportunities for foreign physicians, nurses, and direct care providers. North Dakota recently passed a law creating an entire department dedicated to increasing the immigrant workforce. In support of the law, the President of the North Dakota Long Term Care Association testified that 90 percent of North Dakota’s nursing facilities relied on temporary, contract-staffed nurses, and nearly half of all facilities in the state stopped admitting new patients due to staffing shortages.