The number of US adults ages 85 years and older is projected to double by 2040, from roughly 6 million in 2026 to more than 12 million. Yet, the working-age population will barely grow during that period, according to a new analysis. The authors say the imbalance raises the question of who will care for an aging population.

The long-term-care workforce in institutional and home-based settings now includes roughly 3 million people, which is already insufficient to meet current needs, with nursing homes routinely understaffed and high turnover rates.

Using census data, the authors compared projected demand for and supply of long-term-care labor through 2040. Holding care intensity fixed at its prepandemic peak, they estimate the country will need 3.4 million additional workers in this sector by 2040, but fewer than 100,000 workers are expected to be added given current employment and immigration trends, resulting in a shortage of about 3.3 million workers.

Even an optimistic scenario, assuming a return to prepandemic employment rates and higher immigration, points to a shortage of 2.9 million workers, roughly the size of the current long-term-care workforce.

The authors identify three possible policy responses: reducing demand through innovations such as dementia treatments and assistive technologies; expanding the workforce through immigration; and increasing wages to attract and retain workers.

They note that foreign-born workers make up approximately 29% of the long-term-care workforce, and that current immigration enforcement policies have led some legally present workers to miss shifts out of fear. Prior research has linked stricter enforcement to reductions in home-care workers and higher institutionalization rates among older adults.

The authors also point to Medicaid, the primary payer for long-term care, noting that projected federal Medicaid spending reductions of approximately $1 trillion over the next decade "will most likely translate into lower wages, fewer hires, and accelerated attrition, at a time when the workforce needs to grow."

"Absent policy changes in these areas, this gap will widen, resulting in fewer staffed beds, reduced access to home-based care, and inadequate quality of care for older Americans," the authors conclude.

To download the abstract of the study, published in the New England Journal of Medicine, click here