Yale School of Public Health’s Andrew Olenski, PhD. explores who’s working in long-term care today, how foreign-born caregivers have contributed to meeting needs, and why policy proposals have struggled to match the scale of the problem. We also discuss where technology fits (and where it doesn’t), and what to watch next as legislative and funding decisions shape the future of long-term care in the U.S.
Jeffrey Snyder, Broadcast Retirement Network
Dr. Andrew Olenski of Yale University. Dr. Olenski, it’s great to see you. Thanks for joining us on the program this morning.
Andrew Olenski, PhD., Yale School of Public Health
Thanks, I’m happy to be here, excited to chat.
Jeffrey Snyder, Broadcast Retirement Network
Yeah, we appreciate your time. I know you were incredibly busy studying the U.S. workforce, talking about long-term care. Let’s kind of get to the heart of the matter.
You did a recent study, recent research with a group of other researchers. It looks like the United States could come up a little short when it comes to the long-term care workforce.
Andrew Olenski, PhD., Yale School of Public Health
Yeah, so in our new study in the New England Journal of Medicine, we look at population projections, thinking about what demographic change means for the United States and in particular for both the demand and supply for long-term care workers. So I think it’s really no secret that the U.S. population is going through a pretty transformative change. The 85-plus population is projected to roughly double over the next 15 years or so.
And this has pretty profound implications for both the demands for long-term care. The elderly do require more services. And for the supply, the problem is not that the whole population is doubling.
If we were just growing at every demographic point, this wouldn’t be an issue, but instead what we’re seeing is the shift in the age distribution towards the elderly. And so this is potentially a big problem for us if relatively young people provide long-term care services. Well, if they are becoming scarcer compared to the elderly, we’re going to have potentially a profound shortage of long-term care workers.
We project that even under current, under optimistic scenarios, we are looking at something like a 2.5 million long-term care worker shortage over the next 15 years.
Jeffrey Snyder, Broadcast Retirement Network
So count me in that category of people that at some point in the next 30 years, I’m going to be in that 85-year-old range. Hopefully I’ll have a long life. I won’t need as much caregiving, but the reality is we probably will.
We’re going to need some help. So let’s talk about, you know, in terms of the workforce itself, how is it currently comprised? You mentioned maybe some younger workers, you know, nurses, nurse practitioners, staff come into the workforce.
Is that predominantly where the U.S. gets its long-term care and assisted living workforce?
Andrew Olenski, PhD., Yale School of Public Health
Yeah, so we’re thinking about all types of worker, all types of occupations in long-term care settings. So if you work in a nursing home, you could work in assisted living, whether you’re a certified nurse, a nurse practitioner, a registered nurse. We’re thinking about all of these types of workers as all contributing to the production of long-term care.
We’ve got something like one third of these workers are foreign born. Now this consists of some naturalized citizens, but primarily non-citizen workers in these facilities providing this really essential care. And so one of the, I think, concerning trends that we highlight is, you know, if we are seeing a relative aging of the U.S. population, of the native born U.S. population, what this really means is we need to be adding many more foreign born workers to try to fill in the gaps.
Jeffrey Snyder, Broadcast Retirement Network
Well, just as a follow-up, and I should have asked you this at the beginning, but is the U.S. unique in this respect? I mean, are we going to be, aren’t there other countries, China, or I should say in Asia, Europe, that are kind of going through similar demographic shifts and won’t be in competition for those folks to come work here versus work in Europe or Asia?
Andrew Olenski, PhD., Yale School of Public Health
Yes, absolutely. Absolutely. So the U.S. is not unique in this problem. We are relatively richer. And so in principle, this is a problem we can solve, right? We can outbid for workers that would maybe are choosing between coming to the U.S. versus Canada. The problem is that we need the infrastructure to enable these workers to come. And current immigration pathways are really being shut down that would otherwise be open to these workers that come into the country and help provide this essential care that we currently have. We’re already looking at something of a shortage, right?
Nursing homes are already understaffed. Home health agencies are already saying they can’t find the workers they need to provide the care that their patients require. And so we should be able to solve this problem just by bringing in workers from abroad, but we need special visa programs to do that.
Obviously, the current immigration climate is not conducive to the changes that are required.
Jeffrey Snyder, Broadcast Retirement Network
So, doctor, I know that aging, I’m gonna kind of lump this in. I know it’s long-term care, but I’m gonna kind of lump this into aging. We have an aging America.
And I think this is top of mind for the Congress. So this is another piece of the pie, so to speak, right? In terms of policy, you mentioned immigration policy set by the executive branch, but Congress would have a role here as well in terms of setting, like I don’t think our, without getting wading into the politics, I don’t think we’ve really refreshed our policies in quite some time.
This obviously is an important issue. Wouldn’t the policymakers be looking at something like this or am I lost in my practical nature?
Andrew Olenski, PhD., Yale School of Public Health
Absolutely. So there are a handful of bills that have been proposed to try to bring in more caregiving, to bring in more caregivers to expand the long-term care workforce. I would say that overall these bills, while well-intentioned are both, seem to be dead on arrival, right?
There’s very little political appetite for improving them. They’re also an order of magnitude too small, right? We’re talking about maybe bringing in an extra 40,000 visas max, but we need 10 times that, 20 times that.
We need many, many more long-term care workers to be coming in from abroad to possibly fill these gaps. Because if we don’t do that, then these jobs will need to be filled by domestic workers, which is in principle fine, but domestic workers don’t seem to want to do these jobs. If we were to attract domestic workers to these types of settings, well, we would need to one, offer higher wages than facilities are currently able to provide.
And two, a person working in a nursing home, the person not working in say a restaurant or in a warehouse, right? We are potentially extracting people from other parts of the economy that could be providing useful services.
Jeffrey Snyder, Broadcast Retirement Network
So does technology at all play a role? I mean, look, everyone talks about artificial intelligence, the chatbots, does that in any way help mitigate any of this lack of, obviously the world’s gonna change in the next, it could change in the next five years dramatically, the workforce is gonna shift, but does technology allow itself, at least as you foresee it, to mitigate some of these challenges?
Andrew Olenski, PhD., Yale School of Public Health
Yeah, so you can think about the role of technology and technological innovation as providing two potential benefits here. So the first is by decreasing the demands, right? If we could somehow provide more care, if we could somehow provide care more efficiently, right?
Have fewer workers per nursing home resident, let’s say, because they have access to better medicines or better pieces of capital that can help them more efficiently provide the care. This is something that could in principle reduce the gap, we can either increase the supply of workers or we can limit their demands, limit the demand for workers. The second point I’d highlight is, as you pointed out, we are potentially looking at a pretty major transformation of the US workforce, right?
It’s really unknown, I think at this point, what the rise of artificial intelligence means for domestic workers. And so if we’re thinking about who is going to need to change what types of, who’s going to need to change what they do, what types of jobs are most exposed to changes, what types of jobs are most exposed to artificial intelligence? Well, these are potentially workers that might be able to find new employment providing long-term care.
However, we’re really going to need to make sure that this transition is smoothed out in part by providing higher wages in long-term care settings than are currently offered.
Jeffrey Snyder, Broadcast Retirement Network
You know, this is a, you know, again, I kind of labeled this in terms of aging. You know, a lot of conversation over the last couple of weeks about social security, the trust fund, right? I mean, there’ve been several bills.
What’s it going to take to kind of elevate, and I know your research is important, it’s out there. Obviously it’s in the New England Journal of Medicine. That’s not like a small periodical, it’s like the periodical.
But what will it take to kind of elevate this issue? Because the way I see it as a lay person, just a regular American, you know, this trust fund’s important. We need social security to remain fiscally sound.
We need to be able to provide the benefits that people were promised. At the same time, there are other issues around aging, whether it’s getting the right medicines or getting them at the right amount. It feels like this is an issue that is equally as important.
And we actually need, I guess, a national policy, I’ll say this rhetorically, the international policy on aging that would involve all these issues.
Andrew Olenski, PhD., Yale School of Public Health
Absolutely, absolutely. You know, the ability to actually fund this care is a first order policy question, right? I’m thinking right now about the mechanics of who is actually going to provide this care, but whether or not we can actually pay for it in the first place is something that should be top of mind setting for every policy maker.
Jeffrey Snyder, Broadcast Retirement Network
Do you think that, obviously, I was just with another guest on yesterday’s show talking about cryptocurrency, and we were talking about, obviously, there’s an election coming up. It seems like when we have elections, we only can deal with a few issues that only get talked about. I’m not sure this is gonna be one of them.
But do you foresee this being a major policy initiative with the new Congress? Because theoretically, Congress goes on recess, right, in August, and we have the, after Labor Day, everyone’s working on getting reelected or elected. Is this something that with the new Congress could really tackle?
Andrew Olenski, PhD., Yale School of Public Health
There has been some interest. There are some work floating around the Senate now. There’s potentially a renewed interest in reforming the long-term care sector.
But whether or not there’s any traction there, I think is a little hard to say. My suspicion is that with a lot of, as is the case with many issues, this will remain under the radar until the crisis is imminent, until the nursing homes are shutting down because they can’t staff their beds sufficiently. When I have to start calling my congressmen because there are no more nursing homes around, that’s perhaps when Congress will get to the problem.
Jeffrey Snyder, Broadcast Retirement Network
Yeah, it’s pretty, if I do say so rhetorically, it sounds pretty sad. Let me ask you in terms of the follow-up to this research, because research isn’t static. It continues to evolve.
What’s next with you and your colleagues in terms of the next phase of this type of research? I would imagine you’re gonna continue to update the demographics, you’re gonna continue to look at the aging population, but where do you take this research next?
Andrew Olenski, PhD., Yale School of Public Health
Of course. So another, I think, first-order policy issue is thinking about nursing home access. So there has been something of a wave of nursing home closures already.
So nursing homes are already beginning to shut down. We have a, we’re reducing the overall capacity of nursing homes in the United States. Where these patients are going to go, if not to the nursing home, is top of mind.
There are alternative settings for long-term care. We may see some people going to assisted living, other forms of senior housing, home health care, et cetera. But not everyone can go to assisted living.
There are sort of a vertically-ordered set of long-term care settings, and the right patient for assisted living may not be the right patient for a nursing home, and vice versa. So whether or not we have the capacity, the actual physical infrastructure to provide the care for these patients is also something that is going to need to, something that we’re gonna need to take a very careful look at.
Jeffrey Snyder, Broadcast Retirement Network
Well, hopefully, I think you’re gonna be busy for the next 40 years. I don’t know how old you are, but I think if you want it to be, there’s gonna be a lot of research about what to do, what’s projected to happen, and then once we implement it, what the results are. So you have my endorsement for the next grant, Doctor.
Great to see you.
Andrew Olenski, PhD., Yale School of Public Health
Thank you.
Jeffrey Snyder, Broadcast Retirement Network
Great work, as always. Thanks for joining us, and we look forward to having you back on the program again very soon, sir.
Andrew Olenski, PhD., Yale School of Public Health
Looking forward to it, my pleasure.