The Ever-Shrinking Eldercare Workforce

Yves here. We have been keeping tabs on the deteriorating state of US healthcare, between ever-escalating costs, particularly of insurance, and actual care, due to (among other things) a critical primary care physician shortage, closure of rural hospitals, and reliance of often-deficient stand-ins, from nurse practitioners and physicians to AI that is not ready for prime time.

An additional source of stress is increasing demand for what is politely called eldercare, particularly for intensive-need case of dementia patients. The rise in dementia, particularly Alzheimers, is attributed to an aging population, but I suspect there is an environmental component too. Even though historically, average lifespans were low due to childhood diseases and lack of knowledge of how to treat wounds to prevent infection, a fair number still lived to over 80, as did everyone in my father’s gene pool in the 1700s (the genealogy confirmed by grave markers and church birth/death records). Yet if you read histories and literature, there are descriptions of senility, but not much if any of the personality-erasing Alzheimers sort.

A big and unacknowledged driver of the rising need versus the shortfall in care givers is the nuclear family, the necessity to many of a working spouse (who for geographic or time demand reasons can’t provide much care to an aged parent) and the lack of other relatives nearby who might help out in a pinch. So the burden falls on hired help when more in the past across the population would have been taken up by family.

And how is this going to work with Trump driving out low-wage immigrants, now that the US has increasingly designed its workforce around the assumption of relatively cheap help? The article below reports that about 30% of dementia care workers are immigrants. Disgracefully, roughly half of the eldercare work force does not earn enough to get by and also needs public assistance to get by.

Of course, if overall wage levels were higher, there would be more household budget headroom for this sort of support, so one can argue that the same neoliberalism and rentierism that first pushed families to outsource more and more family care activities has now advanced to the point that it has created pressured making that unsustainable. But that’s no answer to the immediate problem. The outcome is likely to be more eldercare facilities that bear a strong resemblance to the old Bedlam.

From IM Doc at the start of the year, whose data points say that the issue is the rentierism, the admin and professional staff being so richly remunerated that it comes at the price of front-line staff being both egregiously underpaid and overworked/overstressed:

Just FYI – The nursing home crash started long ago. It was already in desperate shape when COVID hit – and that and the vaccine mandates put the nail in the coffin. Now, most of them are breathing fumes.

I will never ever forget the absolute mass exodus of staff in and around SEP and OCT 2021. Literally all at the same time. What was interesting was these employees went out into other industries and found work that paid better and they had better hours and the added benefit of not being peed on as well as not being forced to take meds by the same people screaming at them they were all about preserving health care choices for women. They will not be coming back.

Strikingly, all of these female physicians who are so strident in their pro-choice behavior seem to have absolutely zero insight into how absolutely repulsive they are to younger women who are really put off by the hypocrisy of it all. And mind you – the big concern with these shots at the time, as I repeatedly said, was the effects they were having on menstrual cycles in so many of these young women.

The hospital and nursing home corporate C suites have to find the money to pay the tens of millions in salary for their officers – so the employees doing the work get hen scratch.

This past week or so, my life has been really altered because the very exclusive NH here where I live has now gone through 4 medical directors in the past two years or so. There were two 30 something male internists who only wanted to work 4 hour days – there was then a female FP at age 36 – who got pregnant with her 2nd child and not only quit as the director but retired from medicine totally and then a woman internist in her 40s – who it turns out is the exact definition of the mean girl boss and the patients and staff hated her guts. One of the 30 something guys just up and quit about 2 weeks ago as they are so prone to do. He apparently is now working locum tenens over this part of the country – 1 week here and 1 week there – the rest is play time. This is going on all over the place with so many of them – are you not so relieved that the various states and federal government have invested 2-3 million in each of their educations?

This problem is far far more than just foreigners working in the NH.

I was asked to do the temporary duties because they are in red alert mode. I was shocked this past week ( possibly because of the holidays – we will see this next week ) how absolutely threadbare was the situation there. There is a couple of very elderly there, Hollywood elite types, Oscar on the bookshelf….

By Cynthia Lien, a health writer and geriatrician in New York City. She is a fellow in Journalism and Health Impact at the Dalla Lana School for Public Health. Originally published at Undark

avier Erazo remembers lying beside his 93-year-old mother, her small frame helpless as she fell into the late stages of Alzheimer’s disease. He was exhausted from struggling daily to piece together a rotation of paid workers and family caregivers as his mother’s illness spiraled in unexpected ways. “She became more challenging, more confused,” he recalled. But placing her in a nursing home never crossed his mind.

During this time, I was Erazo’s mother’s geriatrician. Through the eyes and voices of caregivers for people with dementia, I have learned the value of consistent, quality care at every stage of the illness. In reality, however, finding such care can be arduous.

For increasing numbers of Americans, caring for their aging parents themselves could become their only option. A tsunami of frail elders is surging ahead just as the primary supply of direct care workers — many of them low-paid, untrained, and undocumented immigrants — is being depleted by political and economic forces.

“We have this level of need that’s coming, that we do not have the workforce or the systems to meet,” said Nicole Jorwic, chief program officer at Caring Across Generations, a national advocacy group that supports the rights of caregivers and care workers. “As a society, it’s the back-burner issue, but we’re running out of time.”

The final wave of baby boomers is approaching 65 and the number of people living with dementia in the U.S. will balloon from nearly 7 million in 2025 to 14 million over the next 35 years. Adults newly diagnosed with dementia are projected to reach 1 million per year by 2060, nearly twice the rate in 2020.

This rapid growth in older adults, chronically ill and care dependent, is poised to push America’s long-term care system to a critical tipping point. Already, before the surge, there were not enough workers to care for the aging population — even if those like Erazo had wished to lean on them.

Families already shoulder the bulk of care for elders with complex needs. AARP and the National Alliance for Caregiving reported that 63 million family caregivers, mostly unpaid and unprepared, are providing “invisible labor,” struggling to balance care for their parents and children while holding down full-time jobs.

Isolated and stressed, they seek relief from direct care workers — about 30 percent of whom are immigrants who form the backbone of dementia care.

Direct care workers, which include nursing and home health aides, continue to face harsh burdens driven by decades of race, gender, and economic inequities. Nearly half of them, mostly women of color, rely on public assistance like Medicaid and the Supplemental Nutrition Assistance Program, according to the Public Health Institute, a national research and advocacy group. More than one-third live in low-income homes or near the poverty line.

At the brink of survival, many choose to leave care work because of low pay and poor working conditions, leading to critical worker shortages and alarmingly high job turnover rates in nursing homes and eldercare facilities. Workplace injury is nearly five times more common among nursing assistants that work in these spaces than for the average U.S. worker, often leading to extended leaves of absence or job transfers and further driving down worker numbers.

This deficit coincides with the explosion in demand for such workers, a need greater than “in any other single occupation in the United States” according to a 2025 Alzheimer’s Association report. The Public Health Institute estimates 8.9 million total direct care job openings from 2022 to 2032, but vacancies will be tough to fill.

Without a steady pipeline to recruit, retain, and grow a sustainable dementia care workforce, the shortage is “only going to get worse,” Jorwic said. “That same pressure is going to get put back onto families.”

While Erazo vowed to never place his mother into a nursing home, such homes are increasingly hard to find. The worker deficit coincides with more than 800 nursing home closures across the nation in the last 10 years, and nearly 600 more may be at risk of shutting down, leaving family caregivers to support older adults in their own homes and communities as dementia care needs escalate over time.

Many people with severe dementia living at home — the phase when care needs are most intense — are themselves ethnic minorities and foreign-born. Families depend on the comforting presence of a care worker who shares the same ethnicity, culture, and language as the elder. America’s harsh and restrictive foreign policies against immigrants could devastate the hundreds of thousands of noncitizen workers supporting elders in homes and facilities, about one-third of them undocumented, threatening an already strained workforce and families that lean on them.

Loss of a care worker due to deportation or being forced to flee the country out of fear could “disrupt a complete family system,” said Jorwic. Without the critical continuity and communication of a trusted caregiver, elders are at risk of hazardous medication errors and hospitalization, said Amanda Bergson-Shilcock, a senior fellow at the National Skills Coalition, an organization that advocates for U.S. worker education and training.

On top of existing challenges, recent federal budget cuts to Medicaid slashed funds to long-term care services that account for nearly one-third of the $781 billion annual cost of dementia care. The cuts instantly overturned moves in the Biden-Harris era that paved the way for better worker turnover rates, training opportunities, and staffing in nursing homes.

Without federal oversight, and the systems and supports to protect them, dementia care workers continue to face escalating burdens while their stories remain unseen. But care should not be a burden, said Jorwic. And for family caregivers, “our goal is to get to a point where there are enough systems and supports where care is a choice.”