As the U.S. population ages, demand for assisted living and skilled nursing care is sure to grow. But there’s an obvious problem that care providers must solve: a chronic and growing shortage of workers to fill positions as critically-needed caregivers. 

Industry executive Cliff Porter was quoted in an early-2025 article from trade source Provider magazine with this bleak prediction. “The reality is that there simply aren’t enough nurses and nurse aides to meet the demand, and we desperately need meaningful workforce solutions to grow our pipeline of qualified caregivers.” The article stresses the need for better pay, more professional training, and a better worklife balance to attract new workers. 

This week we read this article on the topic from NextAvenue, written by freelance reporter Karen Fischer. She profiles two young sisters who work in long-term care, and love it. But she also makes it clear that these enthusiastic young women represent “a bright spot” in a troubled industry.  

What’s more, for those trying to anticipate their care needs five or ten years from now, we couldn’t help wondering whether the problems institutions are having with hiring qualified staff might be a compelling argument for more in-home care provided by professional agencies. Let’s examine some of the issues raised by Fischer’s report. 

Two Sisters Who “Absolutely Adore” Working in Long-Term Care 

Meet Katie and Mary Leppert. “The sisters, aged 28 and 24, respectively, really, really like each other,” Fischer writes. “They live together, and work in the same long-term care (LTC) facility in Cincinnati. Before that, they worked together at Subway and were residential cleaners.” 

The Leppert sisters started as housekeepers in the same LTC facility where they work currently. They stepped into the role of activity coordinators when they discovered that they wanted to spend more time with the residents, some of whom are there for temporary rehabilitation while others live there full-time.   

Katie and Mary adore the LTC industry and want to stay in it for the long haul. “You learn something new from [residents] every day,” Mary says. “You see them meet their goals . . . and make sure they’re not alone . . . It’s very rewarding. They’re like our little family.” 

Industry Faces Chronic Problems with Hiring, Retention 

Fischer calls the Leppert sisters “a bright spot” in a fraught industry struggling with chronic staffing and retention difficulties. She writes, “According to a March 2024 analysis of long-term care facility staffing by the American Health Care Association, 90 percent of 441 surveyed nursing homes said they had increased their wages in the previous six months, and 72 percent said their current workforce remained below their pre-pandemic staffing levels. Nearly half of respondents said they’d had to turn away new patients because their nursing homes did not have the space or workers to support them.” 

Then, several months later in November 2024, the National Center for Health Workforce Analysis forecast that the demand for LTC workers would increase by 39 percent between 2022 and 2037.  

This begs the question, posed for us by Fischer: while so much of the US economy has bounced back to close to pre-pandemic levels, why is this not reflected in the LTC industry?  

Reliance on Government Funds Makes Care Facilities Vulnerable 

Funding is a major element in this conversation. Fischer explains, “Nursing homes and LTC facilities are notoriously dependent on public insurers, such as Medicare and Medicaid. In 2024, Medicaid was the primary payer for three out of every five beds in nursing homes and LTC facilities.” 

Medicare, on the other hand, generally covers the cost of medical services, but it’s limited and temporary. As an example, Fischer notes that Medicare will cover physical therapy if a resident is recovering from a fall, but does not pay for the day-to-day cost of living in an LTC-style facility. Medicare only pays for limited periods of rehabilitative care. 

“Private health insurers often do cover LTC, but many older people no longer work, so they no longer have private insurance,” Fischer writes. “If they do still work and have private insurance, they belong to the age demographic where health care costs, such as premiums, are the highest.” 

Many Medicaid-Dependent Facilities Can’t Afford Higher Wages 

This discrepancy creates a hierarchy of payment. Fischer explains, “Medicaid tends to reimburse at the lowest rate versus other insurers. Let’s say they reimburse a nursing home $10 for a service. Medicare will reimburse slightly more, say $15. Private insurers will reimburse substantially more than both, to the tune of perhaps $50.” 

Therefore, LTC businesses that receive the bulk of their revenue from Medicaid and Medicare struggle to afford the higher wages that attract and retain workers. “In February, the American Health Care Association (AHCA) found that Medicaid pays about 82 cents of every health care dollar spent in a nursing home, and about one-third of adults 65 and older are economically insecure, and cannot pay for services out of pocket if there are substantial Medicaid cuts,” Fischer writes.  

Workers Say LTC Jobs Offer Rapid Advancement, Good Training 

Currently the Leppert sisters earn between $17 to $18 per hour, and while they wouldn’t be opposed to higher wages, they believe that attendance bonuses and holiday pay often make up for it.  

And there are other benefits to working in the LTC industry. One is the relatively streamlined path for entry-level employees to work their way up the career ladder into more advanced roles, whether clinical or administrative. Many facilities also help their employees with education and further training by reimbursing them for classes and reducing the burden of student debt.  

Employees Cite Flexible Scheduling and Ample Overtime  

There are other benefits, too, such as flexible scheduling. This can make it easier for single parents to coordinate their work around their children’s school schedules, for example.  

Opportunities for overtime also abound. Peter Murphy Lewis is a documentarian from Kansas currently shooting a docuseries on day-to-day life and work in LTC called People Worth Caring About.  He interviewed a worker recently who clocked 177 hours in two weeks, or 97 hours of overtime.  

“At the Leppert girls’ wage, that alone is over $2,600 pre-tax,” Fischer adds. “It’s notable because few jobs offer opportunities to flex and earn more when you can.” 

Even Before Recent Crackdown, Immigrants Faced Major Roadblocks 

The healthcare industry employs immigrants at a very high rate, with one in five nurses in the U.S. recorded as foreign-born as of 2022. The LTC and homecare industries see an even higher concentration, where about 28 percent and 32 percent of the workforce are immigrants, respectively. More specifically, about 12 percent of the LTC workforce in 2023 was of Hispanic descent.  

Fischer writes, “Pushes to deport undocumented workers, or urge them to self-deport, may inevitably be exacerbating existing workforce shortages throughout the industry without a concrete plan on how to improve staffing.” 

Lewis, the documentarian, has also observed a high concentration of first- and second-generation immigrants in the LTC industry, and says that part of it might be inherently cultural. “Immigrants from developing countries are culturally already taught the language of love and caring,” he says. “[These are] collective societies that are less individualistic than the U.S. . . . That’s why it’s less difficult for them than other cultures.” 

Multiple Visa Types, Restrictions, Requirements, and Delays 

Lewis observes that every LTC leader he’s spoken to for the series has been in a near decade-long staffing crisis, and immigration visas are a huge source of the problem.  

“There is a plethora of visa types for foreign health care workers seeking to work in the U.S.; the visas all have different completion tracks and timelines. They generally take about a year to complete from beginning to end,” Fischer writes. “But it’s not as simple as that: Nurses from the Philippines, for example, who want to work in the U.S. often have to work with a placement agency to help with the worker visa application process, which includes stringent education and documentation requirements.” 

And, she adds, there are also ample fees associated with this process. 

Other Medical Facilities Tempt Workers with Higher Wages 

Cross-industry competition is another problem. Hospitals and other medical entities can often pay immigrating employees more than LTC facilities can.  

Many of the LTC administrators Lewis has spoken to have been working to bring nurses over from the Philippines, and also from Puerto Rico. But both countries have their own unique bureaucratic hurdles.  

“It’s a political problem that depends on the state,” Lewis says. “There is no long-term solution to increase the [reimbursement] rates around the country when the administration is talking about cutting the [federal] budget.” 

LTC Workers Love Bonding with the Residents 

One thing that Lewis is skeptical about as a source of the staffing crisis is the negative headlines about elder abuse in nursing homes. Many workers did leave during the COVID-19 pandemic because of “compliance and regulatory headaches”, but he feels that the staffing crisis has more to do with the societal fear of aging, especially in an institutional setting.  

Fischer concludes by bringing the spotlight back to the Leppert sisters. They are young, but they love the work and the residents they’ve grown close to. “One is 109 years old and tells them stories about going to Coney Island as a teenager and dancing with her friends,” Fischer writes. “Another is originally from Jamaica and spent years in the military jumping out of planes, while another had been at Woodstock and tells stories about the music, dancing and debauchery.” 

Ultimately, this is why the Leppert sisters—and doubtless so many other LTC workers—do what they do: for the love of the people they work with.  

“That’s why we want to do these interviews,” Katie Leppert says, “to show people it’s not a scary place for workers, or residents.” 

Rajiv Nagaich – Your Retirement Planning Coach and Guide 

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(originally reported at www.nextavenue.org)