Executive Summary:
New approaches are necessary to give America’s seniors options beyond Medicaid-funded nursing home placement when they deplete their assets and are no longer able to live on their own. A new model of service delivery based loosely on the “sharing economy” holds great promise for helping seniors “age in place” in the familiarity and comfort of home, assisted by a new type of guest worker.
The United States Department of Health and Human Services (HHS), Congress, and organizations that represent America’s seniors should work collaboratively to develop a “Health Care Guest Worker” (HCGW) initiative that would allow elderly Americans to receive assisted-living services and basic nursing services from foreign-born guest workers in the comfort of the senior citizen’s home.
The Case for a Health Care Guest Worker Program:
Although debates regarding the future of the Affordable Care Act have dominated the headlines in recent years, ensuring high-quality, affordable health care for older Americans should remain a priority for Congress. With 10,000 Americans turning 65 each day, policymakers at the federal level should work expeditiously to ensure that older Americans have access to cost-effective options for the long-term care that they may need—yet struggle to afford—as they age.
New approaches are necessary to give America’s seniors options beyond Medicaid-funded nursing home placement when they deplete their assets and are no longer able to live on their own. A new model of service delivery based loosely on the “sharing economy” holds great promise for helping seniors “age in place” in the familiarity and comfort of home, assisted by a new type of guest worker.
The Department of Health and Human Services (HHS), Congress, and organizations that represent America’s seniors should work collaboratively to develop a “Health Care Guest Worker” (HCGW) initiative that would allow elderly Americans to receive assisted-living services and basic nursing services from foreign-born guest workers in the comfort of the senior citizen’s home.
Such an initiative would be particularly appealing to seniors who have adequate space in their homes to accommodate one or more live-in HCGWs as their mobility and overall health decline.
Just as Airbnb has allowed Americans to monetize extra space in their homes on a short-term basis, a HCGW initiative would allow lower-income and middle-income seniors—many of whom are “house rich and cash poor”—to derive a significant, tangible benefit—in-home health care—at a cost they (and taxpayers) could afford.
To make such an initiative possible, Congress should redefine and dramatically expand the H-1C visa category (which expired in 2009) to include not only nurses, but also lower-skilled caregivers who would assist America’s seniors. The U.S. State Department would identify countries where significant numbers of qualified, English-proficient citizens reside manage recruitment and, in concert with the Department of Homeland Security, conduct thorough background checks on all potential HCGWs.
Just as school voucher programs allow dollars to “follow the child” to a particular school, state and federal policies should allow Medicaid funds to “follow the person” to the physical setting that provides proper care in a cost-effective way. Medicaid demonstration programs have proven the value of the “follow the person” approach, and now is the time to build on those successes on a greater scale. A 2015 profile piece on AARP President Eric Schneidewind conveyed the following regarding AARP’s interest in increasing funding for in-home care:
The organization also is addressing the fact that as people live longer, their odds of requiring long-term care increase. With nursing home-care costs escalating and more people retiring with less savings, AARP is lobbying for home-care programs to receive more state funding as well as Medicaid coverage, which Schneidewind says historically favors nursing homes. “Research shows that allowing a person to be cared for at home with some drop-in support is one-third the cost of moving that same person to a nursing facility. And polling shows that being at home is what people want. So if we can make people more comfortable and get three times the bang for their buck, then that’s a positive approach to a big problem.”[1]
Prospective HCGWs who live in poverty in underdeveloped countries—yet who have learned English and have a strong work ethic—would welcome the opportunity to work in the United States as caregivers to America’s seniors. To keep costs low and to allow broad participation among America’s seniors, wages could be set by federal law well below the standard federal minimum wage of $7.25.
Critics of such a program no doubt will be quick to characterize sub-minimum wage levels as exploitative and unfair. By the standards of the developed world, such wages would indeed be undesirable and insufficient to sustain a middle-class standard of living. However, wages that seem a pittance to those in the developed world would be a small fortune to those in the developing world who eke out an existence not at a wage of $7.25 per hour, but rather $7.25 per day—or per week.
The opportunity to work in the United States—even at sub-federal minimum wage levels—would be highly attractive to English-speaking individuals who live in dire poverty in some of the world’s most underdeveloped countries. Once their terms of employment in the U.S. conclude, HCGWs would return to their home countries having earned more money in a few years than many of their neighbors could hope to earn after decades of work.
Providing in-home care would deliver a cost savings compared to long-term nursing home care, which costs Medicaid around $125 per patient per day. [2] To ensure that HCGWs deliver an adequate standard of care, registered nurses from local hospitals or counties’ departments of public health could visit senior citizens’ homes to monitor the patients’ conditions on a regular basis.
Further, the United States Department of Health and Human Services (HHS) could enter into contracts with local community colleges (and perhaps hospital systems and public and private universities) to provide the HCGWs with job-specific training.
A HCGW initiative would by no means end the need for nursing home care in the United States. Rather, it would relieve some of the cost burden on the federal Medicaid program by ensuring that only those who truly need nursing home care would be placed in such a setting after lower-cost, in-home care becomes infeasible.
Congress could choose from any number of funding models, including the use of a sliding scale that takes into account a senior’s ability to pay for HCGW-related services, as measured by net worth.
Medicaid-eligible (i.e., poor) seniors would pay nothing, moderate-asset seniors would pay a larger portion of the actual cost, and high-net-worth seniors would pay the actual cost of the services provided.
Seniors across the country who want to age in place should have a realistic means of staying in a location that is familiar, safe, and comfortable. HCGWs could be an integral part of the solution.
What You Can Do:
If you support the Health Care Guest Worker concept, would you take a moment to call your members of Congress to register your support? Encourage them to read the Health Care Guest Worker program overview at Healthcareguestworker.org and introduce a bill in the U.S. House or U.S. Senate to make it happen.
A Health Care Guest Worker program will come to fruition only if elected officials know that their constituents want to see such a program implemented. Links for contact information for members of the U.S. House and U.S. Senate are available on Healthcareguestworker.org’s home page.
[1] Spooner, Amy. “Schneidewind, '70: Fighting for the Future at AARP.” The Law Quadrangle Spring 2015, The University of Michigan Law School, 2015. Accessed May 26, 2018. URL: https://quadrangle.law.umich.edu/spring2015/class-notes/schneidewind-70-fighting-for-the-future-at-aarp/
[2] Gleckman, Howard. “Nursing Home Use by Medicaid Seniors is Plunging.” Forbes. Published July 3, 2013. Accessed April 15, 2017. URL: https://www.forbes.com/sites/howardgleckman/2013/07/03/nursing-home-use-by-medicaid-seniors-is-plunging/#42d27cfe5e96