Immigrants take on brunt of caregiving
The work can be daunting and low paying
PHOENIX – Marlene Carrasco takes care of aging adults in their homes, a job she has done for nearly 30 years.
The challenging and low-paid work often falls to immigrants like Carrasco, who play an outsize role in caring for older Arizonans, an analysis by The Arizona Republic and the Migration Policy Institute shows.
But unlike workers employed in other immigrant-heavy industries such as construction and hospitality, immigrant workers who care for aging Arizonans remain largely invisible.
The workers who care for aging adults are already in short supply. The need for workers like Carrasco will become more critical as Arizona’s already large population of older adults soars in the coming years, the analysis found. But with Arizona’s immigrant population as a share of the total population shrinking, there may not be enough immigrants to help fill the gap without action by local, state and federal officials, experts say.
“The U.S. population is aging. People live longer. And the population in need of these services is growing. Hence, the projections show that the workforce needed” to care for the aging population “will be growing much faster,” said Jeanne Batalova, a senior policy analyst at the Migration Policy Institute who assisted with the data.
That is especially true in Arizona, where the share of people older than 65 is growing faster than in the U.S., Batalova said.
Without enough immigrants to help care for the growing aging population, family members may have to shoulder more of the responsibility.
Meanwhile, federal immigration solutions that could help Arizona and the U.S. meet the growing demand for workers to care for the aging population are not even on lawmakers’ radar amid the political chaos in Washington.
“It’s not in our national policy conversation because immigration reform is just nowhere on the table,” said Julia Gelatt, associate director of the U.S. Immigration Policy Program at the Migration Policy Institute.
The lack of interest by lawmakers in addressing immigration solutions means that many of the immigrants who care for the elderly will remain undocumented, which could make aging people vulnerable to liability issues or elder abuse, caregiver advocates say.
How many caregivers will Arizona need?
There is already a shortage of workers such as Carrasco who care for aging adults in the U.S. The shortage is expected to worsen in the coming years, especially in Arizona, where the population is growing fast, and the population of older adults is growing even faster.
People over 65 made up 19% of Arizona’s population in 2022, up from 14% in 2010, the data shows. In the U.S., the population of people over 65 makes up 17% of the population, up from 13%.
More than 51,000 new direct care workers will be needed in Arizona by 2030 to care for older people, according to PHI, formerly the Paraprofessional Healthcare Institute, a national research and workforce solutions organization. In 2021, there were just under 85,000 direct care workers in Arizona, according to the group.
Direct care workers include home health aides, personal care aides and nursing assistants. They are the workers who care for aging adults and people with disabilities in their homes or other residential settings such as assisted living facilities.
The need for direct care workers is projected to grow from 2021 to 2031 at a pace that is more than twice as high as total employment growth, 40% versus 17.2%, according to estimates by Batalova of the Migration Policy Institute.
The direct care worker industry depends heavily on immigrants such as Carrasco. Immigrants make up about one in four direct care workers in Arizona, according to Batalova’s estimates based on U.S. Census Bureau and Arizona Commerce Authority data. In comparison, immigrants make up about 16% of the overall workforce – about 1in 6 workers, Batalova said.
The share of direct care workers who are immigrants, however, is most likely an underestimate, Batolova said. A significant number of immigrants who care for the elderly are undocumented or are paid in cash and, therefore, might not have been counted in official data, Batalova said. Others are recently arrived refugees and asylum seekers with permits that allow them to work legally temporarily.
There are several reasons why immigrants are overrepresented in the workforce that cares for aging adults, Batalova said. Similar to taking care of children, taking care of older adults provides an opportunity for immigrants to enter the workforce because the job does not require a college degree, highly specialized skills, or even the ability to speak English well, she said. Poor working conditions, the lack of health insurance, low pay and other factors often associated with the caregiver industry are often a deterrent to Americans with better job options, creating opportunities for immigrants, she said.
Immigrants will be needed to meet impending caregiver challenge
Recruiting and retaining enough workers to care for Arizona’s fast-growing aging population will be challenging without the help of immigrants to help bridge the gap, experts say.
Between 2021 and 2031, nearly 9.3 million job openings in direct care nationwide will need to be filled, including new jobs and job vacancies created when workers leave the field or labor force, said Robert Espinoza, executive vice president of policy at PHI. At the same time the need for more direct care workers is growing, the industry is losing workers due to poor working conditions, the lack of advancement and low pay, Espinoza said.
His organization has proposed several immigration solutions to help meet the demand for direct care workers. Among them:
● Expanding caregiver visas to allow temporary workers from other countries to come to the U.S. and take care of aging Americans.
● Enacting the Citizenship for Essential Workers Act. The proposed legislation would provide a pathway to citizenship for undocumented immigrants who worked through the pandemic as essential workers, including direct care workers.
● Improve working conditions by providing legal services to immigrants working in sectors with chronic shortages of workers, including the direct care workforce. “How do we create better workplaces and help people understand their labor rights?” Espinoza said.
● Partner with resettlement agencies to recruit refugees and asylum seekers to become caregivers.
● Devote resources to learn more about the direct care workforce. “For many people, it’s an invisible issue. The more we study it and the more we draw public attention to it, the more people understand what a big part of the sector immigrants are,” Espinoza said.
Federal immigration reforms would benefit immigrants and aging Americans who depend on them for care, said Zach Shaw, secretary, and Seth Layman, president, of the Arizona In-Home Care Association. The nonprofit organization works to improve standards for the private home care industry. They also run an agency that provides home care to older adults, Affordable Home Care.
“Immigrants are vital” to the caregiver industry, Shaw said.
However, undocumented immigrants willing to work for lower pay drive down wages, which contributes to the shortage of caregivers, they said. Undocumented immigrants who work as caregivers often lack workers’ compensation and professional liability insurance, which puts people who receive care at risk of being held liable in the case of an injury, they said.
“So if they’re providing one-on-one care to somebody without any of these insurances and they injure themselves at that elderly person’s home, who do you think is going to be liable for their medical bills?” Layman said.
Shaw and Layman pointed out that caregivers who receive payment through Medicaid must be licensed by the state.
But the private in-home care industry in Arizona is not regulated. The lack of oversight makes older people who need care vulnerable to unscrupulous caregivers, they said.
Caregivers and clients: ‘We become very attached’
Carrasco is originally from Monterrey, the capital of the state of Nuevo Leon in northeast Mexico. She and her husband, Raul Carrasco, 55, came to Arizona in 1994 as visitors to attend a wedding and then stayed as undocumented immigrants. They are now legal permanent residents authorized to work legally in the U.S.
During an interview at their Phoenix home, Carrasco said she and her husband began taking care of aging adults little by little, almost by accident.
After first arriving in Phoenix, they cleaned houses for a living and rented a casita from an aging couple who lived in the larger house in front. After the husband was hospitalized, Carrasco and her husband offered to run errands for them and help around the house. Eventually, they became the couple’s full-time caregivers.
After the couple passed away, Carrasco and her husband began caring for other aging adults. They found their clients mostly through word-of-mouth referrals, Carrasco said.
“We’ve taken care of four best friends and their wives,” Carrasco said as an example of how word spreads.
They registered their business, Caring Companion Assistance, with the Arizona Corporation Commission in 2016 and have workers’ compensation and professional liability insurance, Carrasco said.
Carrasco placed a scrapbook on the dining room table filled with photos of some of the 50 or so clients they have taken care of over the years. Although Carrasco and Raul are immigrants, most of their clients are not immigrants, Carrasco said.
“The vast majority have been Americans, Anglo-Americans,” Carrasco said in Spanish, adding: “It’s very beautiful work. At the same time, it’s sad” because when clients pass away, “it hurts. It hurts because we become very attached.”
Caregiver agencies have difficulty competing with other employers
Arizona’s shortage of caregivers, including workers who care for aging adults, has already reached a crisis.
“When counting new jobs and job openings created as workers leave the field, employers in the state will need to fill nearly 130,000 paid caregiver jobs openings from 2016 to 2026,” a 2021 PHI report found.
Although there is growing demand for caregivers, they have been underpaid historically. The median hourly wage for paid caregivers was just $12 in 2019, a decline from nearly $13 in 2009 after adjusting for inflation, the report said.
Nearly 50% of the workforce lives in or near poverty, and over half rely on some form of public assistance to make ends meet, the report said.