From lawn care to home care: Elderly living arrangements and immigration

Mockus, Dominikas

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https://hdl.handle.net/2142/117750 Copy

Description

Title

From lawn care to home care: Elderly living arrangements and immigration

Author(s)

Mockus, Dominikas

Issue Date

2022-11-11

Director of Research (if dissertation) or Advisor (if thesis)

Miller, Nolan H

Doctoral Committee Chair(s)

Miller, Nolan H

Committee Member(s)

• Powers, Elizabeth T
• Reif, Julian
• Evans, William N

Department of Study

Economics

Discipline

Economics

Degree Granting Institution

University of Illinois at Urbana-Champaign

Degree Name

Ph.D.

Degree Level

Dissertation

Keyword(s)

• Caregiving
• aging
• disability
• disabled
• elderly
• handicapped
• old age
• senior citizens
• immigrant
• immigrant labor

Abstract

Elderly Americans (those aged 65 and older) express a strong desire to stay out of nursing homes as they age, i.e., to “age in place,” despite increasing potential functional limitations as they age. This is increasing the demand for paid help at home as care provided by family and friends is decreasing. For decades, the long-term care workforce has been facing “staffing shortages,” and it remains to be seen who will support the elderly if these demographic shifts continue. (Undocumented) immigrants play an important role in supporting the elderly who live at home. This dissertation shows that (undocumented) immigration affects aging in place. The American population is aging. FIGURE 1 presents the projected population between 2016 and 2060 for two age groups: The elderly population, defined as those aged 65 and older; and the population most likely to need care, defined as the population aged 80 and older (Redfoot, Fienberg, and Houser 2013). The elderly population is projected to increase from 56 million in 2020 to 83 million by 2045. The population most likely to need long-term care is projected to more than double from 13 million to 31 million over that same time period. FIGURE 2 indicates that the elderly share of the total population will increase from 15% to 23%. The incidence of disability increases with age. Two out of three elderly persons in the U.S. have functional limitations and need help with daily activities (National Center for Health Statistics 2021). While only 5.7% of noninstitutionalized adults aged 18-64 reported severe functional limitations in 2010, 23.1% of noninstitutionalized adults aged 65 and older responded the same. FIGURE 3 displays data from the 2005 American Community Survey (Ruggles et al. 2022) where I report the percentage of 5-year age groups in 2005 not in group quarters reporting either independent living difficulty or self-care difficulty (or both). While only 2% of those aged 20-24 not in group quarters report independent living difficulty or self-care difficulty, this increases gradually to 9% among those aged 65-69, 12% among those aged 70-74, 26% among those aged 75-79, 38% among those aged 85-89, and 55% among those aged 90 and older. Combining the data and statistics in the previous two figures gives the projected population reporting independent living or self-care difficulties. FIGURE 4 presents this projection for the same two age groups as before: The elderly and the population most likely to need care. The elderly population with disabilities is projected to increase from 10 million in 2020 to 18 million by 2045. The population most likely to need long-term care with disabilities is projected to more than double from 5 million to 11 million over that same time period. Despite possible functional limitations, the elderly overwhelmingly desire to age in place and stay out of a nursing home. The American Association of Retired Persons (AARP) has routinely done surveys of the elderly and near elderly to identify their desire to age in place. FIGURE 5 shows the answer to two related questions over time from four such surveys, conducted in years 2010, 2014, 2018, and 2021. The surveys range in size from 1,014 to 2,286. One trend shows the percentage of adults age 45 and older (50 and older in 2010 and 2014) that either agreed or strongly agreed to the statement, “What I’d really like to do is stay in my current residence for as long as possible.” The other trend shows the percentage of adults age 45 and older (50 and older in 2010 and 2014) that either agreed or strongly agreed to the statement, “What I’d really like to do is stay in my community for as long as possible.” More than three-quarters of respondents responded positively throughout the past decade to both the desire to stay in their current residence and the desire to stay in their community. Not only do they want to stay in their own residence, but they want to live alone (or with only their spouse). In 2021, among adults ages 50 and older, 74% reported that they want to stay in their own residence and live on their own, 20% want to stay in their own residence but have a family member or friend move in with them, and only 5% want to move in with a family member or a friend (Binette 2021). In order to age in place, many elderly will need help to maintain their household. Home care use among older adults with disabilities was increasing between 2004 – 2016 (van Houtven et al. 2020). This help may come from family and friends or from paid support. The number of potential family caregivers is shrinking. The caregiver support ratio, defined as the number of people aged 45-64 divided by the number of people aged 80 and older, is used by the AARP to approximate the number of potential family caregivers for every person most likely to need long-term services and supports (Redfoot, Fienberg, and Houser 2013). Using population projections from the US Census Bureau, FIGURE 6 shows the declining caregiver support ratio. The availability of family caregivers is projected to halve from 6 in 2020 to 3 by 2045. As the supply of family care and support decreases, the demand for paid care and support will increase. There are a few pieces of evidence for this. First, FIGURE 7 shows the percentage of Health and Retirement Study (HRS) respondents by year who report having a hired helper. HRS respondents are roughly representative of noninstitutionalized Americans over age 50. The percentage of older Americans reporting having a paid helper has been slightly increasing over the last two decades, from 17% in 2000, to 21% in 2010, to 22% in 2016. Second, FIGURE 8 shows the employment of home care workers using data from the Bureau of Labor Statistics’ (BLS) Occupational and Wage Statistics (OEWS) program as processed by PHI’s Workforce Data Center. The employment of home care workers has monotonically increased 240% from 1 million to 20 million between 2010 and 2020. Third, while the share of Medicaid spending on long-term care has been decreasing over time, the share of Medicaid long-term care spending on home- and-community-based services (HCBS) has been increasing (Thach and Wiener 2018). FIGURE 9 shows that the Medicaid spending on long-term care more than tripled over the five years between 2009 and 2014. FIGURE 10 shows that the share of total Medicaid spending on long-term care has been steadily increasing over the past two decades, from 18% in 1995 to 53% in 2015. Finally, anecdotally, the first two sentences of the trade journal Home Health Care News’ article “How Home-Based Care Providers Are Changing To Meet New Workforce Demands” is “Demand for home-based care continues to rise. Thus, more workers are needed.” This dissertation considers the effect (undocumented) immigration has on aging in place. Previous approaches to identifying the contribution of (undocumented) immigrants to long-term care have tended to focus on workers in direct care occupations (Zallman et al. 2019; Campbell et al. 2021). Campbell et al. (2021) define direct care workers as falling into one of three Standard Occupational Classification (SOC) system codes: personal care aides, home health aides, and nursing assistants. Zallman et al. (2019) document the important contribution of immigrants to the supply of workers in long-term care in America, both at home and in nursing homes. However, it takes more than just direct care workers to help people maintain the household. A household also needs someone to cook and clean and mow the lawn, for example. These tasks might be outsourced before an elderly person needs to hire a direct care worker. In order to capture people employed directly by the household for this sort of household support, this and the following chapter consider all workers in private households as contributing to successful aging in place. This measure includes many direct care workers but also household service workers. The first column of TABLE 1 displays the occupations of workers in private households. A small but significant share (16%) of workers in private households are workers in direct care occupations (2% nursing, psychiatric, and home health aides; and 14% personal care aides). However, the majority (76%) of workers in private households are workers in household service occupations, defined as maids and housekeeping cleaners (50%) and childcare workers (26%). This shows the important contribution of workers other than direct care workers to aging in place. The stylized main equation of interest is given below: Aging in Place_lt=β_0+β_1 〖"Immigration" 〗_lt+μ_l+θ_t+ϵ_lt (1) where 〖Aging in Place〗_lt is a measure of aging in place among the native elderly population in location l in time t, 〖"Immigration" 〗_lt is some measure of immigration in location l in time t, μ_l and θ_t are location and time fixed effects, respectively, and ϵ_ct is idiosyncratic error. The parameter of interest is β_1. Estimating equation (1) using OLS may lead to a biased estimate for β_1. For example, the warm climate of Florida, Texas, California, and Arizona could attract the healthier and wealthier elderly who are willing and able to move to these states. These healthier and wealthier elderly are also more likely to age in place. The proximity of Florida, Texas, California, and Arizona to the southern US border might also simultaneously attract (undocumented) immigrants for reasons unrelated to aging in place. It could also be that (undocumented) immigrants are attracted to places with a large population aging in place because of increased job opportunities. Each chapter in the dissertation proposes a different method of dealing with this endogeneity. The first chapter starts with the empirical fact that undocumented immigrants make up 19% of workers in private households and so play an important role in supporting the elderly who live at home. This chapter estimates the causal effect of changes in undocumented immigration on aging in place. Identification comes from a two-stage least squares (2SLS) research design using the staggered rollout of the Secure Communities (SC) program. The SC program was a county-level mandatory federal immigration enforcement program rolled out between 2008 and 2013 that increased the threat of deportation for undocumented immigrants. The instrument is a measure of exposure to the SC program interacted with an indicator denoting a high level of undocumented immigrants. The instrument compares the effect of the SC program on communities with a high level of undocumented immigrants to the effect of the SC program on communities with a low level of undocumented immigrants. For communities with a high level of undocumented immigrants, the SC program is associated with a 40% decrease in the undocumented labor supply. This change in the labor supply decreases aging in place by 0.4%. Further results support a change in wages as a potential mechanism. The implication of these results is that policies that reduce undocumented immigration will also reduce aging in place at significant cost to the long-term care system. Deporting 10% of undocumented immigrants will cause 59,000 elderly Americans to move into nursing homes, resulting in increased annual expenditures on long-term care by $3 billion. The second chapter starts with the empirical fact that the workforce supporting aging in place has a relatively high share of low-skill immigrants. This chapter examines the impact of low-skill immigration on elderly living arrangements using individual-level data from the 1980-2000 Censuses. Exploiting the tendency of new immigrants to migrate to existing settlements of immigrants from the same birthplace, I use a two-stage least squares (2SLS) strategy to identify the causal effect of immigration on the living arrangements of native elderly. A 1 percentage-point increase in low-skilled immigration increases the probability that an elderly native will age in place by 0.04 percentage points and increases the probability of supported aging in place (aging in place with assistance from someone other than a spouse) by 0.30 percentage points. Consistent with a migration-induced cost reduction in aging in place, a 1 percentage point increase in low-skilled immigration also reduces the wages of all low-skilled workers in private households by 1.03%. My results suggest that low-skilled immigration is an effective way to increase aging in place which may improve quality of life and lower total healthcare costs.

Graduation Semester

2022-12

Type of Resource

Thesis

Copyright and License Information

Copyright 2022 Dominikas Mockus

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