Could immigration policy solve nursing shortages in elder care? : The Indicator from Planet Money Eldercare has been hit extremely hard since the pandemic began. A severe nursing shortage is lowering the availability and quality of care for seniors. What can be done to reverse course?

Who's gonna take care of grandma?

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In some ways, 92-year-old Dorothy Samuelson kind of reminds me of my grandma. She loves good food, laughs easily, and she has these sayings she likes to rattle off.

DOROTHY SAMUELSON: We're here today, and tomorrow's another day.

MA: And also, she has her share of vices.

SAMUELSON: Scratch tickets (laughter).

MA: Say more.

SAMUELSON: I love scratch tickets, and I like to go to the casino.

MA: Have you been keeping track of, like, how much money you win or lose on scratch tickets?

SAMUELSON: Oh, yeah (laughter). I'm not going there for a while.


We're talking with Dorothy inside her room at the Blaire House. It's an assisted living facility in Milford, Mass. It's where she's been living for the past few years. All in all, she says it's been pretty good.

SAMUELSON: I don't have to cook. I don't have to clean. I don't have to do anything if I don't feel like it. They take care of everything.

MA: And yet, behind the scenes at the Blaire House, there's a problem. The company that runs it cannot find enough people to do pretty much everything - nurses, custodians, kitchen staff.


WOODS: They're so short-staffed that Travis Romano, the executive director here, he's been pulling double duty as a cook.

TRAVIS ROMANO: I'm better at chopping vegetables now than I think I ever was. It definitely becomes very exhausting, but, you know, it's what you have to do when you're in health care and you have shortages.



WOODS: And I'm Darian Woods. The eldercare industry is in a bit of a bind. The number of people working in nursing homes since the start of the pandemic has decreased 15%.

MA: And normally, employers responding to a shrinking labor pool would, you know, increase wages, offer bonuses. But for eldercare providers, it's not that simple. Today on the show, we explain why. And we look at how immigration could help.


MA: For more than four decades, Frank Romano and his family have been running various eldercare services in Massachusetts; think nursing homes, assisted living, home care. In a good year, he says, their profit margin is maybe 2- or 3%. But last year was not good.

FRANK ROMANO: We do not have enough revenue to cover our costs. Last year, 2021, was the worst year financially for our little private company in 45 years of running it, and it all had to do with labor costs.

WOODS: Take nurses and nursing assistants - these are the people who help residents with feeding, bathing, everyday things like that. Frank says that the ones that haven't burnt out or retired are increasingly hard to hold onto.

ROMANO: We keep ratcheting up the amount we need to pay. Not once-a-year pay increases, we're doing pay increases quarterly - never did that before.

MA: Nurse assistants, he used to pay 14 bucks an hour. Now, he pays 20. He's raised wages also for other support staff. But he says it's still not enough to keep a lot of people from leaving for better-paying, possibly less-stressful jobs.

WOODS: And as we've been talking a lot about on this show, workers have a lot of choices. There are a lot of industries just crying out for people and offering higher wages. Frank is seeing this in his business, too.

ROMANO: Housekeepers, laundry, kitchen - even here in this building, food service people left to go to work for Amazon.

MA: Frank is not talking rhetorically here. He actually pulls out a map and shows me five Amazon warehouses within a 20-mile radius of the Blaire House.

So this is us, the blue dot.

ROMANO: Right. And that's where all the Amazons are.

MA: OK, wow.

ROMANO: Right here - we are surrounded. So people went to Amazon with a signing bonus and free college tuition. We're just not able to compete with that.

MA: One of the big reasons he says they can't compete is because so much of their revenue depends on Medicaid. That's the state and federal insurance program for people on a low income. Frank says Medicaid reimbursements haven't kept up with his actual labor cost, so raising those reimbursements would be a huge help.

WOODS: And yet, that would still not solve another fundamental problem facing the eldercare industry. As we've mentioned, it's the supply of workers that is needed.

ROMANO: Even when COVID goes, I think the misconception is the problem will go away. It isn't going away. The staffing shortage is still going to be here.

WOODS: States could help by supporting training for nurses and nursing assistants, but that could take years.

ROMANO: We need help very quickly. If not, I believe the nursing home industry, the adult day health industry, homecare are going to begin to close. If a couple of dozen nursing homes close, where are you going to put all those people?

DELIA FURTADO: We could just say, well, maybe we can't provide good quality care for our grandparents. You're on your own. Sorry, you were born in the wrong decade. There's too many of you.

MA: That's University of Connecticut economist Delia Furtado.

FURTADO: But maybe another option is to just have a more open immigration policy.

MA: Delia says she knows lawmakers have been talking about comprehensive immigration reform for, I don't know, decades. But she thinks it might be the answer. When the labor pool is evaporating, immigration is one way to fill it back up. And Delia says that could be accomplished by issuing more employment-based visas for people who want to work here as nurses.

WOODS: But also, Delia says that the U.S. should just increase immigration overall. After analyzing years' worth of data on U.S. nursing homes, she believes that this could actually improve eldercare services.

FURTADO: It's very clear that nursing homes located in areas with lots of immigrants have better quality care measures.

MA: In other words, Delia found when immigrants moved to an area, patients living in nursing homes in those areas were less likely to have a bad fall or develop complications like urinary tract infections or even be restrained - you know, like be strapped to their beds, which can be a sign of an understaffed nursing facility.

What do you think is going on there?

FURTADO: OK, so the short answer is I'm not sure exactly.

MA: But she has some theories, and one of them is nursing home jobs are just hard to fill because, well, as you can imagine, a lot of them are stressful and labor intensive. They often don't pay super well. And Delia says perhaps when more immigrants move to an area, there are more people willing to take those jobs, which means nursing homes are better staffed.

WOODS: Another possibility Delia has considered might have a little bit more to do with culture than economics. She says that some immigrants who take these jobs maybe come from cultures where older folks generally get more respect, and maybe that translates into better care.

MA: Again, these are just hypotheses. But Delia says the pattern is clear.

FURTADO: In most cases, more immigrants, better quality of care.

WOODS: Delia sees the problems in eldercare as really stark.

FURTADO: We need help, and there are people in other countries who are able to help us and at the same time, help themselves and help their families. If we don't have enough workers that are willing and able to do this very difficult - and I would argue very important - job, then we're really letting down the elderly population, the elderly and disabled.


MA: And with baby boomers getting older, with people living longer, that population is only going to get bigger and bigger for decades to come.


MA: Special thanks to Tara Watson, Kristin Butcher and Kelsey Moran. Their research on immigration and home care inspired this story, and it was featured on

This episode was produced by Brittany Cronin with help from Isaac Rodrigues. It was fact-checked by Corey Bridges. Our senior producer is Viet Le. Our editor is Kate Concannon. And THE INDICATOR is a production of NPR.


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