Abstract
The ageing population of the United States is generating an increasing demand for care and foreign-born workers will supply an important part of that demand. This article discusses the ways in which U.S. healthcare and immigration policies affect the supply of the foreign born to professional and lesser skilled, direct care jobs. The U.S. market for long term care is shifting away from hospitals and institutionalised facilities to the direct provision of private services and long term care in homes. A well designed immigration policy would complement the demand generated by the healthcare system. Yet, there are few dedicated avenues of legal admission that select for professional care workers and none at all that target direct care workers. There is concern over shortages of professional workers and a substantial number of unauthorized workers in direct care work that flag deficiencies in immigration policies. Our examination of data, nevertheless, finds that the foreign born play an important role in the supply of workers. In the provision of direct care they are roughly one-quarter of the workforce that provides 80% of all long term care. Among professional care workers they are highly concentrated in the home care industry. These national-level concentrations, however, do not fully reveal the remarkable concentration of immigrants in just a few metropolitan areas.
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Notes
Group quarters are living arrangement for institutional groups with ten or more unrelated persons including, in the case of the elderly, some hospitals, rest homes and, increasingly, nursing homes (IOM IOM Institute of Medicine 2008).
Research partners include the Institute for the Study of International Migration (Georgetown University), the Community Health Research Unit (University of Ottawa), the Irish Centre for Social Gerontology (National University of Ireland Galway), and the Centre on Migration, Policy & Society (University of Oxford), which is the international project coordinator. See http://www.compas.ox.ac.uk/research/labourmarket/migrantcareworkers/. Accessed 17 August 2009.
These estimates do not place a value on the vast amount of unpaid care, including the value of wages forgone by informal caregivers that is estimated to have cost $350 billion in 2006 (Gibson and Houser 2006).
Given that the average age of the informal caregiver is 60, the majority of primary informal caregivers do not hold paying jobs. Among the 31 percent who are in the labor force, two-thirds work full-time. Employed caregivers provide fewer weekly hours of assistance than non-employed caregivers, but they still invest, on average, 18 hours per week. Two-thirds of working caregivers report conflicts between jobs and caregiving that caused them to rearrange their work schedules, work fewer paid hours or take leaves of absence (usually unpaid) from work.
Studies find that when the opportunity is available, from 40 percent to almost 80 percent of participants in consumer-directed programs hire relatives to care for them. Job satisfaction and stress are equal to or more positive for consumer-directed workers than for those who are agency-based (Benjamin and Matthias 2004).
The small Diversity Program aimed to redress the concentration of immigrants from a handful of origin-countries that resulted from the emphasis on family reunification. Diversity immigrants are chosen by a lottery from applicants who must have at least a high school education or its equivalent.
Admission percentages for the year 2008 for a total of 1.1 million individuals admitted. See the Department of Homeland Security’s Yearbook of Immigration Statistics, http://www.dhs.gov/files/statistics/publications/yearbook.shtm
Smaller numbers of primarily professionals enter under other working visas (the O, P, Q and R), as well as classes of admission specified in the North American Free Trade Agreement.
There is also the TN or Trade NAFTA visa, admitting perhaps 20-30,000 predominantly Canadians in 2007, which anecdote suggests includes substantial numbers of nurses. Note too that the EB-3 visa recently developed for Australia has a cap of 10,000 visas but thus far has admitted few workers and an unknown of nurses. Altogether, estimates provided by Passel (see discussion above) suggests that there are about only about 37,000 temporary workers on all possible visas among professional long term care providers (0.70 percent of the professional workforce) and effectively none among direct care providers.
Temporary lifting on the program for J physicians in under-served areas may have accelerated a switch of physicians under the J to the H-1B visa.
Furthermore, their share does not appear to have increased over the last half-decade (see Passel et al. 2006). Note too that these estimates are considered reliable because independent samples indicate that most unauthorised individuals are included in Census samples.
See source for Table 3: American Community Survey (ACS)
Over one-quarter of the American Community Survey (ACS) sample lives in metropolitan areas where central city status is known. Nevertheless, foreign-born long term care workers are twice as likely to live in central cities than are natives out of individuals whose central city residence can be identified—39 versus 18 percent respectively. It is possible that the many elderly living in central cities drive some of the demand that leads many foreign-born workers to also reside and work in central cities.
Pearson correlation = 0.95 between the number of persons aged 65 and over with the total number of direct care workers in metropolitan areas.
Los Angeles and New York are America’s largest cities. During the latter 1980s and 1990s there was significant out migration from both New York and Los Angeles which likely further concentrated their remaining elderly populations. In Los Angeles, foreign-born Latinos also left the city during the 1990s. In New York, the out migration of natives was significant and lasting. An influx of new migrants, particularly from the Caribbean and elsewhere in the Americas, generated rebounding population growth. It is possible that the concentration of foreign-born long term care workers in New York evolved out of these offsetting migratory trends.
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Acknowledgement
Research in the United States was undertaken as part of a collaborative project including the United Kingdom, Ireland and Canada. We wish to express our appreciation to our colleagues in that effort. We also wish to acknowledge the funding of the Nuffield Foundation, the Atlantic Philanthropies, the Social Sciences and Humanities Research Council in Canada, as well as, the German Marshall Fund of the United States, the Rockefeller Foundation, the Alfred P. Sloan Foundation, and the John D. and T. MacArthur Foundation.
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Lowell, B.L., Martin, S. & Stone, R. Ageing and Care Giving in the United States: Policy Contexts and the Immigrant Workforce. Population Ageing 3, 59–82 (2010). https://doi.org/10.1007/s12062-010-9029-x
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DOI: https://doi.org/10.1007/s12062-010-9029-x