This paper presents the challenges and opportunities of the senior care economy. The demographic trends in the United States show an aging nation. The last two decades have seen the country grow continuously older, resulting in a growing elderly care economy which translates in the creation of a great number of jobs, now and in the future, for senior housing and care options. Home health care workers are estimated to be the third fastest growing occupation.

At the same time, a shortage of paid caregivers has led immigrants to play an important role, both in nursing homes as in-home care, filling the gap. This paper focuses on 3 states where one-fourth of these older Americans live: California, Florida, and Texas, analyzing the trends in senior care, the options available, the costs and the contribution of the immigrants to the labor force.

By 2025, the in-home health care industry is expected to generate $225 billion in revenue and employ close to 3.5 million workers; therefore, the growth of the industry is good news for the economy. The industry provides jobs for a wide range of workers, including nurses, home health aides, as well as individual care aides. The shortage for low and middle skilled home health caregivers is a challenge which also entails an opportunity to provide such services, while promoting economic development and job creation and could be addressed, among other initiatives, by immigration pilot programs for caregivers.

INTRODUCTION

Many studies concur that “In the US, the number of people aged 85 and up will more than double to 14.4 million by the year 2040” (ACL,2020). This means that there will be more demand for senior care in the upcoming years and it is important to navigate about the economic options available for them, while at the same time analysing the impact of these options on the economy. According to several studies, the trends imply that there will be a rising need for senior housing and care options for seniors who need some level of care. However, the future is not all bright. Growing workforce shortages and the resulting increasing cost of labor are leading concerns for the industry, which relies on people to provide services and care at the bedside. The worker shortage will be one of the biggest difficulties in this industry segment.  

Since the 1990s, the number of immigrants in the United States has grown dramatically. Immigrants make up a significant share of the U.S. workforce, and their impact is especially evident in the senior care economy. Studies show that immigrants are more likely than native-born Americans to work in the senior care industry (Butcher et al., 2021). The following case study explores the impact of immigrants on the senior care economy in the United States. Being an international student in the United States for the past seven years, has made me question the impact of immigrants in the economy. In Honduras, my home country, remittances from the US represent close to 20% of the country's GDP, thus being its main source of foreign exchange.

Seniors of different states can see some drastic differences in the average cost of health insurance. Both Medicaid and Medicare are available, but regulations and conditions vary according to the state. Medicaid provides health coverage to low-income people, including elderly adults and is funded by the federal government, and administered by states. Whereas Medicare is a federal health insurance program for those individuals who are 65 or older.

According to Rudowitz, Williams, Hinton, and Garfield in the article “Medicaid Financing: The Basics” Medicaid is a counter-cyclical program, meaning that more people become eligible and enroll during economic recessions; at the same time states may face declines in revenues making it difficult to fund the state share (Rudowitz, 2021). For example, in California, to obtain Medicaid, the senior 65 and older must have a maximum annual income of $18,075 before taxes, if the senior lives by him or herself. This is similar for Florida, however, in Texas for a senior 65 and older living by him or herself to be eligible, his/her maximum annual income before taxes should be $26,909.

In total, over 13 million Californians, one out of three, rely on Medicaid for health coverage. Whereas California's Medicare population grew 11.3% from 5.8 million in 2016 to 6.5 million beneficiaries in 2021. Furthermore, since May 2022, California is the first state in the nation to expand full-scope Medi-Cal (The states’ version of Medicaid) eligibility to low-income adults 50 years of age or older, regardless of immigration status. In California, Medi-Cal can sometimes pay a seniors long-term nursing home and home care costs if they show proof that they can't afford the cost of a nursing home.

Around 15.2% of the population in California consists of adults that are 65 and older, and immigrants are critical contributors to California's health labor force. In California, nearly one in three healthcare workers are foreigners compared to one in six countrywide. This is because of the high share of immigrants among the salaried age population: immigrants in California represent a quarter of all the population, and a third of them are of working age (Ko et al., 2020). A total of 49% of them have a high school diploma and 36% are holding a graduate degree.

Immigrants work in healthcare occupations that include health assistants, registered nurses, and primary care providers who are primarily needed in rural areas. The educational backgrounds of immigrants are essential as most are highly skilled health care workers aged 25 and above. Data in 2017 showed that 35% of registered nurses and 36% of state physicians were born in foreign countries. However, most foreign health care professionals receive training abroad, and those not trained enroll in programs that guide them through the steps required to join the state's healthcare workforce. The programs support the roles in health that take four years to attain a college degree. Hence, these programs encourage low-skilled workers to join the health workforce as they can enroll in health programs and get the skills required to start working.

In California, Medi-Cal sometimes pays long-term nursing home and home care costs if seniors can't afford the cost of a nursing home. Assisted living facilities offer a series of helpful services like housekeeping, medication management, meal preparation, and assistance with dressing and bathing; however, they do not offer skilled nursing care. In 2019, the average cost of an assisted living facility was $4,500 per month. We can compare it to the current cost and the difference is $750 more than in 2019. As it is known the U.S is going through a recession and as mentioned above, According to Rudowitz, Williams, Hinton, and Garfield in the article “Medicaid Financing: The Basics” Medicaid is a counter-cyclical program, meaning that more people become eligible and enroll during economic recessions; at the same time states may face declines in revenues making it difficult to fund the state share.

Immigrants in Texas account for over 20% of the state workforce. However, immigrants are helping meet growing demands for healthcare workers across the skills range (Eckstein & Peri,2018). In 2019, immigrants made up 17.1% of the state's overall population, representing 32.7% of physicians, surgeons at 25.5%, and respiratory therapists in Texas at 18.5%. Hence, immigrants have a significant impact on the healthcare workforce.

Most Texas immigrants are bilingual and communicate in more than one language. Around 71.1% of immigrant healthcare workers in Texas are bilingual. Between 2017 and 2021, the number of job posts needing bilingual skills in Texas rose by 167%. As a result of the job postings, many immigrant healthcare workforces applied for the jobs because of their ability to communicate in different languages.

They also play an essential role in spots like home healthcare assistants, to be specific. The native-born percentage has reduced to 1.5 % between 2012-2022, while the number of work vacancies is rising by 48.5%. As a result, immigrants are likely to hold the job vacancies in Texas as a fifth of health assistants are foreign-born.

In addition, they are considered compassionate caregivers who have respect for the elders. They are also considered hardworking as they are more determined while providing healthcare services given that a lot of them do not have a college degree and learned in their home countries how to take care of their elderly family members. Therefore, they are hired in high numbers to increase the base of potential health workers. Around 13.2% of the population in Texas consists of adults that are 65 and older, and the need for caregivers is essential.

Lastly, Texas depends on foreigners to grow its overall economy, including the senior care economy. The workforce of immigrants in Texas is essential. They contribute a projected amount of $119 billion to the economy annually. This income gained makes up nearly 1 out of 5 of all income dollars in the state. According to Hoyt, the median monthly cost of placing an elderly in a nursing home in Texas is $5,125 for a semiprivate room and $7,092 for a private room. Whereas the median monthly cost of assisted living is $3,998 with an average price of $24/ hour. Paying for this care is not easy, however with the mentioned programs seniors are able to receive care if they qualify through some conditions.

Texas Medicaid will pay for a nursing home, assisted living, or home health care when a patient needs skilled nursing care. To qualify for nursing home Medicaid, the senior must have specific medical needs. Typically, when Medicaid sponsors home care, it does so through a home care agency and pays them directly for all services necessary to keep the recipient thriving in their own home, including help with meals, housekeeping, and activities of daily living.

In Texas the number of individuals who rely on Medicaid grew to 5 million people as of October 2021, according to the latest data from the Texas Health and Human Services Commission. That's an increase of about 1.2 million from February 2020. The number of Medicaid members is- not that far from those that have Medicare given that more than 4.4 million people in Texas have Medicare plans, but that's only a little more than 14 percent of the state's population.

Around 21.3% of the population in Florida consists of adults 65 and older, and of those 19% need care. Employing immigrants in Florida helps to replenish the workforce and strengthen the state’s tax base. However, the demand for healthcare professionals is growing in Florida. The demand is a result of the aging population and patients under insurance. In addition, there is a need for doctors, health experts, and nurses, which has led to the employment of immigrant health workers. Around 67.1% of immigrant healthcare workers in Florida are bilingual, and Latinos are the second-largest racial and ethnic group in Florida at 26% of the population. This helps seniors communicate better with their caregivers and feel more comfortable explaining their needs and wants.

One of the impacts is that the care for the elderly and disabled relies on an immigrant workforce (Zallman et al.,.2019). The immigrants act as healthcare assistants and direct care workforces. In 2017, 18.2% of immigrants were healthcare employees, and 23.5% were formal and informal long-term care sector employees. These immigrants play an essential role in the provision of healthcare, especially for the elderly given that they provide direct care to the elderly in private houses and non-medical housing amenities like older housing. Hence, immigrant employees providing direct care are usually employed by consumer-directed programs or hired by patients and their families directly.

Additionally, one in four direct care employees are immigrants who account for an unbalanced share of housework and upkeep workers in treatment homes. In addition, the role of the non-formal direct care sector provides care for hundreds of people living at home. This kind of care reduces the number of patients seeking institutional care. However, in Florida, these healthcare workers lessen the number of patients at the hospital as they receive care in their own homes. According to Hoyt, the median monthly cost of placing an elderly in a nursing home in Florida is $8,654 for a semiprivate room and $9,627 for a private room. Whereas the median monthly cost of assisted living is $4,000, considering in home care in Florida has an average price of $25/ hour. Florida only guarantees Medicaid for a qualifying nursing home applicant, not an applicant for assisted living or in-home care.

About, over 3.7 million individuals in Florida are on Medicaid for health coverage. On the other hand, Medicare enrollment in Florida stood at 4,797,690 as of November 2021. That's more than 21% of the state's total population, compared with about 19% of the United States population enrolled in Medicare.

By 2025, the in-home health care industry is expected to generate $225 billion in revenue and employ close to 3.5 million workers; therefore, the growth of the industry is good news for the economy. The industry provides jobs for a wide range of workers, including nurses, home health aides, as well as individual care aides. The shortage for low and middle skilled home health caregivers is a challenge which also entails an opportunity to provide such services, while promoting economic development and job creation.

Some countries, such as Canada, have similar situations, and have addressed this challenge with immigration pilot programs for caregivers. The United States could weigh a similar option, staring with California, Florida and Texas. Currently, no visa class has been established specifically for less-skilled medical workers, such as home health and personal care aides. In her article, Zallman also explains that the health care system in the United States is reliant on the work of over three million immigrants, who account for 18.2 % of all health care workers. More than one in four direct care workers are immigrants, including nearly one in three direct care workers in home health agencies. Immigrants also account for a disproportionate share of housekeeping and maintenance personnel in nursing homes as well as in regular households (Zallman et al., 2019). This country without immigrants wouldn’t be as prosperous as it is today, the numbers talk for themselves.

ACL. (n.d.). Home Page | ACL Administration for Community Living. 2020 Profile of Older Americans. Retrieved November 1, 2022, from https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2020ProfileOlderAmericans.Final_.pdf

Butcher, K., Butcher, K., Moran, K., Watson, T., Chinn, M., & Chinn, M. (2021, December 16). Immigrant Workers and care for America's elderly. Econofact. Retrieved October 7, 2022, from https://econofact.org/immigrant-workers-and-care-for-americas-elderly

Hoyt, J. (2022, May 20). Physical therapy for seniors: Elderly physical therapy benefits. SeniorLiving.org. Retrieved November 7, 2022, from https://www.seniorliving.org/health/physical-therapy/

Immigrant Healthcare workers are critical in the fight against covid-19. New American Economy Research Fund. (2020, April 8). Retrieved November 6, 2022, from https://research.newamericaneconomy.org/report/covid-19-immigrant-healthcare-workers/

Kilduff, L. (2021, December 22). Which U.S. states have the oldest populations? PRB. Retrieved November 7, 2022, from https://www.prb.org/resources/which-us-states-are-the-oldest/

Robin Rudowitz Follow @RRudowitz on Twitter, E. W. F. @L. W. on T. (2021, May 7). Medicaid financing: The basics. KFF. Retrieved November 9, 2022, from https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/

Zallman, L., Finnegan, K. E., Himmelstein, D. U., Touw, S., & Woolhandler, S. (2019). Care for America’s elderly and disabled people relies on immigrant Labor. Health Affairs, 38(6), 919–926. https://doi.org/10.1377/hlthaff.2018.05514

Zhang, X., Lin, D., Pforsich, H., & Lin, V. W. (2020). Physician workforce in the United States of America: forecasting nationwide shortages Human resources for health, 18(1), 1-9.