Women Caring for Our Aging in Place Seniors Will Lose Out because of U.S. Immigration Policies

ABSTRACT

Most older people experiencing chronic health problems, physical disabilities, and memory losses are still able to age in place in their own homes. However, they often need help from others to enjoy healthy, active, and independent lives. They turn mostly to family members, mainly women and usually their daughters, daughters-in-law or wives. But caring for frail elders has become more demanding and complex, and these family members often feel physically and emotionally overwhelmed and burnt out. They concede that they cannot do it alone. Others find it more difficult to hold full-or even part-time jobs. Hiring home (direct) care workers to assist their loved ones can be an effective solution to ease their caregiving responsibilities. However, these personal care aides, home health aides, and nursing assistants are already in short supply. Moreover, going forward the aging of the baby boomer population will result in an even greater demand for their services even as these jobs are often unattractive to American-born workers and turnover is high. This country’s immigration policies will make it even more difficult for women caring for older persons to hire these workers. Over 25 percent of home care workers are low-skilled immigrants or foreign-born. However, the Trump administration’s policies reduce the number of immigrants entering the U.S. and specifically choke off the various pathways that enable low-skilled persons to be hirable in the home care sector. Female caregivers seeking relief from their caregiving responsibilities will lose out unless we remove these immigration barriers.

KEYWORDS:

• Immigration policy
• informal caregiving
• formal caregiving
• home care workers; women caregivers
• aging in place seniors

Women are the pre-eminent family caregivers of our older population. They are the go-to persons when an elder parent or husband needs help performing their household activities, self-care, and mobility tasks. Their assistance makes it possible for three out of four frail older persons to stay put in their current dwellings and communities rather than transitioning to an assisted living or a nursing home facility (Freedman & Spillman, 2014).

However, caregiving has become ever more demanding and complex (Reinhard, Feinberg, Choula, & Houser, 2015). Aging in place older persons now suffer from difficult-to-manage chronic health problems, physical disabilities, and memory losses. Not all family members have the abilities, time, or even the inclination to help. Others feel physically and emotionally overwhelmed and burnt out. Consequently, even the most well-intentioned women often concede that they cannot do it alone. They seek out paid help to ensure that their loved ones benefit from needed long-term services and supports (Freedman & Spillman, 2014).

Although the connection may not appear obvious, this country’s immigration policies will make it more challenging for older persons and their families to hire these workers. A sizable percentage of home care workers are low-skilled immigrants. However, the policies of the Trump administration curb immigration generally and specifically favor the entry of higher-skilled immigrant workers. These responses are especially untimely because low-skilled home care workers are already in short supply (Gleckman, 2018b, May 10). And going forward, the aging of the baby boomer population will result in an even greater demand for their services (Stone, 2017).

Female caregivers should be justifiably concerned by the enactment of immigration policies that contribute to the shortage of workers so key to their well-being and the well-being of their loved ones. They will be the inevitable losers.

Caregiving challenges

Older persons often have difficulties identifying and acquiring the long-term services and supports they need to cope with their age-related declines. They require help from others to age successfully, that is, to enjoy healthy, active, and independent lives. They typically turn to their families, but gender matters (Lo Sasso & Johnson, 2002; Reinhard et al., 2015). About two-thirds of family caregivers are women, especially daughters, daughters-in-law, and wives (Wolff et al., 2017). While men are stepping into the caregiving role more than in the past, they usually spend 50% less time caregiving than women and help less with intimate hands-on tasks (Family Caregiver Alliance, 2015; National Academies of Sciences & Medicine, 2016). Over 12 years, an Urban Institute study found that 63% of women (ages 51 and older) in this country cared for one or more parents, and 21% cared for a husband (Butricia & Karamcheva, 2014, p. 14).

These caregivers must be jack of all trades filling the jobs of janitor, chauffer, home care worker, counsellor, and nurse. On average they are on duty 24 hours a week over a period of 5 years (Golant, 2015; Reinhard et al., 2015). They take care of routine home maintenance and escort their older family members to supermarkets and doctor appointments. They troubleshoot their financial and legal affairs. They help them bathe, dress, eat, go to the toilet, and get in and out of bed. They manage and coordinate care after a hospital stay, keep track of multiple prescription medicines, check vital signs, change dressings, give injections, and yes, clean bedpans. They keep them from wandering outside their homes (AARP, 2015). They are the major sources of their social and emotional support.

To be sure, these caregivers speak favorably about these responsibilities, but this labor of love comes with a cost. Women feel always on call, are unprepared for their caregiving duties, and fear making mistakes. A wife in her 70s and 80s may lack the vigor to ably assist a frail husband. A middle-aged daughter or daughter-in-law must juggle her time raising younger and dependent children – as part of the sandwich generation. Caregiving also interferes with other life pursuits. Those holding full- or even part-time jobs may have to quit or retire early, turn down a promotion, or cut back on hours. These are financially costly actions and result in lost wages, health insurance, and Social Security benefits. There are health consequences as well. A report from the National Academy of Sciences found that caregivers experience higher rates of chronic disease, musculoskeletal disorders, depression, stress, and sleep problems (National Academies of Sciences, E., & Medicine, 2016).

Relieving the caregiving burden: the home care workforce

How to ease this caregiving burden? Counseling and care education programs help. So do employers who offer paid family leave and flexible work hour options. Moreover, future technological advances – think smart homes that monitor the behaviors of frail elders and alert others when they need help – may lower the demand for on-site personal care (Golant, 2017; National Academies of Sciences, E., & Medicine, 2016; Peek et al., 2016).

However, for many family caregivers, hiring paid workers will be the most effective solution. Some will need only temporary relief – a few hours during the day, or on evenings or weekends. For others, especially those caring for the very frail or those with Alzheimer’s disease, it may mean getting help on a 9-to-5 basis or even around-the-clock.

America’s labor force includes a category of workers able to lessen women’s caregiving burdens. The healthcare industry refers to them as direct care workers, but they are familiarly known as home care workers with job titles such as personal care aides, home health aides, and nursing assistants. The Paraprofessonal Healthcare Institute (PHI) estimates that there are now over 2 million workers helping older persons in their own homes and community-based settings, mostly employed by home care agencies. However, this number does not include a large “gray market” of unlicensed workers hired directly by families (PHI, 2018b).

As of 2017, over 25% of these home care workers were foreign-born or immigrants (compared with 20% in 2005) and hail from 124 countries (PHI, 2018a). For perspective, only 17% of the U.S. labor force is foreign-born (U.S. Department of Labor, 2017). These national numbers may be misleading, however. The immigrant share of the direct care workforce varies by state, ranging from 45% or more in California, Hawaii, New Jersey, and New York to 4% or less in Alabama, Arkansas, Kentucky, Louisiana, Missouri, Mississippi, Montana, Oklahoma, South Carolina, West Virginia, and Wisconsin (Espinoza, 2017b).

Why do immigrants take these jobs? Low hiring barriers are undoubtedly an incentive in light of their limited high school education or work experience requirements (Espinoza, 2017a). However, it may be that immigrants are hungrier or more desperate to earn a living or they are more sympathetic to helping vulnerable persons because of their own stressful lives. It also helps that American-born workers are not beating down the doors for these positions.

Even with the high level of immigrant representation, home care workers are already in short supply (Gleckman, 2018a, December 6; Osterman, 2017; Stone, 2017). Using language such as desperate, dire, challenging, and grim, home care agencies argue that they do not have enough workers to staff all their shifts 24 hours a day, seven days per week (Graham, 2017, April 26; PHI-Paraprofessional Healthcare Institute, 2018b). Employment agencies are unable to come close to filling the requests of their clients (Vais-Ottosen, 2018, May 14). We can only guess at the frustration experienced by families trying to hire these workers directly, but unable to do so because of their limited number.

The growing deficit in caregiving capacity

Experts predict that this gap in care capacity will widen in the future for three reasons. First, even though home care workers will be one of the fastest growing occupational groups over the coming decades, there will be an insufficient supply of workers to fill these jobs. The labor force pool of female applicants (ages 25 to 64) – the typical candidates for these home care jobs – will be smaller than it is now (PHI-Paraprofessional Healthcare Institute, 2018a). Moreover, compared with other low-skilled employment opportunities, home care jobs are less competitively attractive because of their low wages, minimal benefits, stressful job assignments, lack of advanced training programs, unpredictable hours, and poor advancement opportunities (PHI-Paraprofessional Healthcare Institute, 2018b). Because worker turnover is very high, employers must continually fill vacancies (Stone, 2017).

Second, the demand for these workers will skyrocket over the next two decades. Although less than a third of frail elders now depend to some extent on paid help (Freedman & Spillman, 2014), this share will likely increase. Aging baby boomers will result in explosive growth in both the number and percentage of seniors in their mid-70s, 80s, and 90s. These are the age groups with the highest risk of needing caregiving help (Federal Interagency Forum on Aging Related Statistics, 2016). But alarmingly, over this same period, studies predict a sharp decline in the caregiver support ratio – that is, the number of family caregivers available to assist older care recipients (Redfoot, Feinberg, & Houser, 2013). Historically low fertility rates – think fewer adult children available to help – and high divorce rates – think less stable family support networks – will take their toll. However, even if this ratio remained at current levels, the more demanding care needs of this larger chronologically older population are likely to result in higher numbers of family members who feel unable to assume their caregiving obligations.

Whereas these first two influences are not easily controllable, the third reason for predicting a greater shortage of workers most certainly is. It will be a direct result of the current administration’s immigration policies which favor better-educated and more highly skilled immigrants and choke off the various pathways that have enabled low-skilled persons to be hirable in the home care sector (Gleckman, 2018c; Hess & Henrici, 2013; Krogstad & Gonzalez-Barrera, 2018).

To be fair, prior to this administration, the operation of both temporary and permanent employment visa programs limited the availability of foreign nationals to serve as low-skilled home care workers. However, Trump’s proposed or supported immigration policies exacerbate this supply deficit in three ways (Krogstad & Gonzalez-Barrera, 2018; Pierce, Bolter, & Selee, 2018; Sumption & Papademetriou, 2013). First, they sharply reduce the number of legal immigrants entering the U.S. each year. This reduction is accomplished by a more restricted family reunification/sponsored program (aka chain migration), a lower cap on the number of refugees admitted for humanitarian reasons, and by restricting the entry or stays of immigrants who receive or are likely to receive federal government benefits (“public charge” rule). Second, they do not offer immigrants with temporary employment authorization (e.g., DACA – Deferred Action for Childhood Arrivals, or Temporary Protected Status immigrants such as from Haiti, El Salvador, Liberia, and Honduras) a pathway to permanent residence (green card). Third, they increase enforcement and deportation efforts against undocumented individuals, which long-term care expert Robyn Stone especially worries “has created a culture of fear among the population that might be interested in pursuing direct care jobs” (Stone, 2017, p. 98). About 20% of direct care workers are undocumented (Hartmann & Hayes, 2017).

Conclusion

Immigration policies that contribute to the future shortage of low-skilled home care workers do not bode well for the women who care for our frail old. We should not jeopardize their opportunities to hire paid help. We should not make it harder for them to get well-deserved relief from their caregiving responsibilities – their health is at stake. We should not make it more difficult for them to remain in the workforce, thereby crippling their income and career opportunities. They deserve more enlightened public policies. These policies include giving undocumented workers a pathway to legal residency and creating a permanent employment visa program targeting low-skilled home care workers. However, these solutions would be highly controversial and met with stiff legislative opposition. In the meantime, eliminating the aforementioned immigration barriers constructed by the Trump administration would be a start.

Additional information

Funding

None.