The hidden connection between immigration and health care: Our long-term care crisis

At the end of July, Democratic presidential hopefuls have their second chance to impress the public and discuss some of the biggest issues facing the country on a national stage. But if these debates are anything like the first, they’ll also miss the elephant in the room: long-term care.

It’s a bigger problem than many people know. In 2030, when all baby boomers will have reached the age of 65, older Americans will make up 21 percent of the population, up from 15 percent in 2015. And by 2060, one in four Americans will be over the age of 65.

These older Americans will require long-term care. In fact, over the next several decades, more and more of our health care system will be focused on older patients with chronic illnesses, dementias, and numerous medications, all of which may drive up health care costs. We need to re-center the health care debate around long-term care – it’s time our leaders make a plan for that, too.

One of the biggest problems we face is the cost of this care.

As it stands, Medicare only covers medical care, not the activities of daily living such as driving, cooking, cleaning, bathing, and dressing with which many older adults need assistance. In the absence of family members who may be working, caring for children, or live far away, many families turn to paid care. In my research on home care in the Washington, DC area, I met families who were spending tens or even hundreds of thousands of dollars a year to pay for home care workers. That means such care is affordable only to the wealthiest 10 percent of Americans, and even then, for only a few years at the end of their life.

Long-term care insurance would help pay for these extraordinary costs.

The problem is, so far it hasn’t caught on – only 11 percent of those aged 65 or older in 2014 had long-term care insurance policies. Most fail to purchase it because they underestimate the costs of long-term care. The costs of the insurance premiums are also prohibitive for any but the wealthy.

But several countries like Germany, Japan, and Taiwan have found a solution by mandating universal long-term care insurance. Germany’s system has been in operation since 1995, proving its financial viability, funded by a payroll tax of 1.7 percent. In the absence of response at the federal level, some states are moving in this direction too. In May, Washington state passed a Long-Term Care Trust Act, which would provide individuals with a lifetime maximum of $36,500, funded by a payroll tax of 0.58 percent. It’s a step in the right direction, but a far cry from what’s needed to cover the care of someone with a dementia or Parkinson’s disease.

But this isn’t just a health care issue; it’s an immigration issue too.

Our country’s need for long-term care will require an ever-growing workforce of caregivers. The Bureau of Labor Statistics estimates that a million more jobs in home care will be available by 2026 making it the third fastest-growing occupation in the decade between 2016 and 2026. At the same time, the number of women aged 25 to 54—the major population pool from which most care workers are drawn—will remain relatively stable. This is where immigration policy comes in.

At the moment, immigrants already comprise 28 percent of home care workers. Most come from Africa, the Caribbean and Latin America. But despite the demand for their labor, their wages have stagnated. On average, they earn $10.49 an hour, nearly one in five lives in poverty, and nearly one in five lack health insurance despite their risks of injury from lifting patients. A publicly funded system of long-term care would attract and retain much needed workers. Setting these workers up for the long run is especially important, as my research has shown that there’s no replacement for on-the-job experience to develop the emotional intelligence and skills required for dealing with the complexities of dementia and the crisis of death. And providing a legal route of entry for supposedly “unskilled” care workers is necessary to meet the growing demands.

It’s time we see the connections between proposals like Julián Castro’s People First immigration policy and Bernie Sanders’ Health Care for All. Along with climate change, what we seem most unready for is a long-term care crisis, unless we begin to plan and prepare today. Let’s see what the candidates propose at the next Democratic debate.

Cati Coe is professor of anthropology at Rutgers University and the author of The New American Servitude.