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PHOENIX, Ariz. — Marlene Carrasco takes care of aging adults in their homes, a job she has done for nearly 30 years.

The challenging and low-paid work often falls to immigrants like Carrasco, who play an outsize role in caring for older Arizonans, an analysis by The Arizona Republic and the Migration Policy Institute shows.

But unlike workers employed in other immigrant-heavy industries such as construction and hospitality, immigrant workers who care for aging Arizonans remain largely invisible.

The workers who care for aging adults are already in short supply. The need for workers like Carrasco will become more critical as Arizona’s already large population of older adults soars in the coming years, the analysis found. But with Arizona’s immigrant population as a share of the total population shrinking, there may not be enough immigrants to help fill the gap without action by local, state and federal officials, experts say.

“The U.S. population is aging. People live longer. And the population in need of these services is growing. Hence, the projections show that the workforce needed” to care for the aging population “will be growing much faster,” said Jeanne Batalova, a senior policy analyst at the Migration Policy Institute who assisted with the data.

That is especially true in Arizona, where the share of people over 65 is growing faster than in the U.S., Batalova said.

Without enough immigrants to help care for the growing aging population, family members may have to shoulder more of the responsibility.

Meanwhile, federal immigration solutions that could help Arizona and the U.S. meet the growing demand for workers to care for the aging population are not even on lawmakers’ radar amid the political chaos in Washington.

“It’s not in our national policy conversation because immigration reform is just nowhere on the table,” said Julia Gelatt, associate director of the U.S. Immigration Policy Program at the Migration Policy Institute.

The lack of interest by lawmakers in addressing immigration solutions means that many of the immigrants who care for the elderly will remain undocumented, which could make aging people vulnerable to liability issues or elder abuse, caregiver advocates say.

‘A great relief’: What do caregivers offer?

Immigrants play a huge role in caring for the elderly

Recruiting enough workers to care for Arizona’s soaring aging population will be a challenge without the help of immigrants to bridge the gap.

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The Republic

On a recent Wednesday, Carrasco, 52, spent the afternoon with one of her clients, Carmen Garcia, an 85-year-old with short, graying hair. Garcia lives with her 60-year-old son Gabe Martinez in a two-bedroom apartment in northeast Phoenix near the affluent suburb of Paradise Valley.

Carrasco arrived promptly at 1 p.m., wheeling a black bag filled with supplies. She stayed until 6 p.m., when Martinez returned home to pick up his mother and drive her to his job so she wouldn’t be left alone that evening.

Martinez is the liturgical music director at Our Lady of Joy Roman Catholic Church in Carefree. Wednesdays are his busiest days planning for Sunday Mass, meeting with couples getting married, and rehearsing four choirs.

On those days, Martinez pays Carrasco $20 an hour to care for his mother while he’s at work. He then rushes home at dinner and brings his mother back to the church, where she sits through his choir rehearsals. Without Carrasco’s help, his aging mother would be home alone all day.

“It’s a great relief because I don’t have to worry about my mom, about whether she’s had something to eat” or is being taken care of, Martinez said.

Caring for older adults is not easy. The job can be physically and mentally demanding, as the afternoon Carrasco spent with Garcia demonstrated.

“It takes a lot of patience and a lot of empathy,” Carrasco said.

Those who care for older adults often work in their homes unsupervised for long periods. “It also takes a lot of trust,” Carrasco said.

Carrasco was greeted at Garcia’s apartment by two little barking dogs, Karina, a black and white Chihuahua and Chanco, a white French poodle.

After settling in, Carrasco helped Garcia bathe. Then Carrasco cleaned her bathroom. She also helped Garcia get dressed.

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Once Garcia was bathed and dressed, Carrasco prepared and served her lunch — on this day, a tostada with tuna and a bowl of red salsa on the side. Later, Carrasco made coffee, which she served with a sweet roll on a plate.

“May I have some sugar in my coffee?” Garcia asked after taking a sip.

“There is enough sugar in your sweet roll,” Carrasco told her, conscious of Garcia’s diet.

After that, Carrasco sat down at the kitchen table with Garcia and pulled out several games to exercise Garcia’s mind. They played dominoes, lotería, and a money-counting game. Carrasco then led Garcia through a series of light exercises, starting with leg lifts while leaning on the kitchen counter for support and finishing with walks back and forth down the hallway.

In between, Carrasco did several loads of laundry.

Carrasco logged notes in a binder to keep track of the food Garcia ate and the activities she did. Carrasco also texted updates to Garcia’s son throughout the afternoon.

“The goal is for them to maintain as much independence as possible” so clients can continue to live at home, Carrasco said.

How many caregivers will Arizona need?

There is already a shortage of workers such as Carrasco who care for aging adults in the U.S. The shortage is expected to worsen in the coming years, especially in Arizona, where the population is growing fast, and the population of older adults is growing even faster.

The population of people over 65 in Arizona soared 56% from 2010 to 2022, much faster than the overall population, which grew 15%, according to the Migration Policy Institute’s tabulation of 2022 U.S. Census Bureau data.

People over 65 made up 19% of Arizona’s population in 2022, up from 14% in 2010, the data shows. In the U.S., the population of people over 65 makes up 17% of the population, up from 13%.

With nearly 1.4 million people over 65, Arizona has the 12th largest population of older people, according to a University of Arizona Center for Rural Health report.

More than 51,000 new direct care workers will be needed in Arizona by 2030 to care for older people, according to PHI, formerly the Paraprofessional Healthcare Institute, a national research and workforce solutions organization. In 2021, there were just under 85,000 direct care workers in Arizona, according to the group.

Direct care workers include home health aides, personal care aides and nursing assistants. They are the workers who care for aging adults and people with disabilities in their homes or other residential settings such as assisted living facilities.

The need for direct care workers is projected to grow from 2021 to 2031 at a pace that is more than twice as high as total employment growth, 40% versus 17.2%, according to estimates by Batalova of the Migration Policy Institute.

The direct care worker industry depends heavily on immigrants such as Carrasco. Immigrants make up about one in four direct care workers in Arizona, according to Batalova’s estimates based on U.S. Census Bureau and Arizona Commerce Authority data. In comparison, immigrants make up about 16% of the overall workforce — about one in six workers, Batalova said.

The share of direct care workers who are immigrants, however, is most likely an underestimate, Batolova said. A significant number of immigrants who care for the elderly are undocumented or are paid in cash and, therefore, might not have been counted in official data, Batalova said. Others are recently arrived refugees and asylum seekers with permits that allow them to work legally temporarily.

Arizona’s immigrant population, however, is shrinking as a share of the overall population.

Immigrants made up 13.1% of the overall population in 2022, a dip from 13.4% in 2010, according to U.S. Census Bureau data. They made up 17% of the working-age population, down from 17.7% in 2010, the data shows.

The decrease in the immigrant share of the overall population raises questions about whether there will be enough paid workers to care for Arizona’s growing aging population, she said.

There are several reasons why immigrants are overrepresented in the workforce that cares for aging adults, Batalova said. Similar to taking care of children, taking care of older adults provides an opportunity for immigrants to enter the workforce because the job does not require a college degree, highly specialized skills, or even the ability to speak English well, she said. Poor working conditions, the lack of health insurance, low pay and other factors often associated with the caregiver industry are often a deterrent to Americans with better job options, creating opportunities for immigrants, she said.

The job is also attractive to undocumented immigrants who may not be able to get jobs in the formal economy where documents are checked, she said.

Immigrants will be needed to meet impending caregiver challenge

Recruiting and retaining enough workers to care for Arizona’s fast-growing aging population will be challenging without the help of immigrants to help bridge the gap, experts say.

“The reality is that a lot of people are aging; a lot of people are needing long-term care supports. People are often supporting not just their aging parents, but their own children,” said Robert Espinoza, executive vice president of policy at PHI, describing the sandwich generation of middle-aged people who have to care for both younger and older family members.

Between 2021 and 2031, nearly 9.3 million job openings in direct care nationwide will need to be filled, including new jobs and job vacancies created when workers leave the field or labor force, Espinoza said. At the same time the need for more direct care workers is growing, the industry is losing workers due to poor working conditions, the lack of advancement and low pay, Espinoza said.

How will Arizona and the nation fill the need for more direct care workers “unless we completely transform the quality of these jobs and we think about new labor pools like immigrants?” Espinoza said.

His organization has proposed several immigration solutions to help meet the demand for direct care workers. Among them:

• Expanding caregiver visas to allow temporary workers from other countries to come to the U.S. and take care of aging Americans.
• Enacting the Citizenship for Essential Workers Act. The proposed legislation would provide a pathway to citizenship for undocumented immigrants who worked through the pandemic as essential workers, including direct care workers.
• Improve working conditions by providing legal services to immigrants working in sectors with chronic shortages of workers, including the direct care workforce. “How do we create better workplaces and help people understand their labor rights?” Espinoza said.
• Partner with resettlement agencies to recruit refugees and asylum seekers to become caregivers.
• Devote resources to learn more about the direct care workforce. “For many people, it’s an invisible issue. The more we study it and the more we draw public attention to it, the more people understand what a big part of the sector immigrants are,” Espinoza said.

Federal immigration reforms would benefit immigrants and aging Americans who depend on them for care, said Zach Shaw, secretary, and Seth Layman, president, of the Arizona In-Home Care Association. The nonprofit organization works to improve standards for the private home care industry. They also run an agency that provides home care to older adults, Affordable Home Care.

“Immigrants are vital” to the caregiver industry, Shaw said.

However, undocumented immigrants willing to work for lower pay drive down wages, which contributes to the shortage of caregivers, they said. Undocumented immigrants who work as caregivers often lack workers’ compensation and professional liability insurance, which puts people who receive care at risk of being held liable in the case of an injury, they said.

“So if they’re providing one-on-one care to somebody without any of these insurances and they injure themselves at that elderly person’s home, who do you think is going to be liable for their medical bills?” Layman said.

Shaw and Layman pointed out that caregivers who receive payment through Medicaid must be licensed by the state.

But the private in-home care industry in Arizona is not regulated. The lack of oversight makes older people who need care vulnerable to unscrupulous caregivers, they said.

Caregivers and clients: ‘We become very attached’

Carrasco is originally from Monterrey, the capital of the state of Nuevo Leon in northeast Mexico. She and her husband, Raul Carrasco, 55, came to Arizona in 1994 as visitors to attend a wedding and then stayed as undocumented immigrants. They are now legal permanent residents authorized to work legally in the U.S.

During an interview at their Phoenix home, Carrasco said she and her husband began taking care of aging adults little by little, almost by accident.

After first arriving in Phoenix, they cleaned houses for a living and rented a casita from an aging couple who lived in the larger house in front. After the husband was hospitalized, Carrasco and her husband offered to run errands for them and help around the house. Eventually, they became the couple’s full-time caregivers.

After the couple passed away, Carrasco and her husband began caring for other aging adults. They found their clients mostly through word-of-mouth referrals, Carrasco said.

“We’ve taken care of four best friends and their wives,” Carrasco said as an example of how word spreads.

They registered their business, Caring Companion Assistance, with the Arizona Corporation Commission in 2016 and have workers’ compensation and professional liability insurance, Carrasco said.

The services the business provides include light cleaning, transportation to medical appointments, laundry, errands, personal care and medication reminders. Carrasco and her husband have received training in CPR, first aid and home safety, she said.

Carrasco placed a scrapbook on the dining room table filled with photos of some of the 50 or so clients they have taken care of over the years. Although Carrasco and Raul are immigrants, most of their clients are not immigrants, Carrasco said.

“The vast majority have been Americans, Anglo-Americans,” Carrasco said in Spanish.

Carrasco said she and her husband often form strong bonds with their clients. A lawyer with cancer Raul Carrasco had been taking care of for five or six months died in May, just before he turned 70. They had also taken care of his parents for four years.

“It’s very beautiful work,” Carrasco said. “At the same time, it’s sad” because when clients pass away, “it hurts. It hurts because we become very attached.”

Caregiver agencies have difficulty competing with other employers

Arizona’s shortage of caregivers, including workers who care for aging adults, has already reached a crisis.

“When counting new jobs and job openings created as workers leave the field, employers in the state will need to fill nearly 130,000 paid caregiver jobs openings from 2016 to 2026,” a 2021 PHI report found.

Because of the state’s growing population of older adults, paid caregiving services are in extremely high demand, the report said.

“Without intervention, the paid caregiver crisis will worsen in Arizona,” the report said.

Although there is growing demand for caregivers, they have been underpaid historically. The median hourly wage for paid caregivers was just $12 in 2019, a decline from nearly $13 in 2009 after adjusting for inflation, the report said.

Nearly 50% of the workforce lives in or near poverty, and over half rely on some form of public assistance to make ends meet, the report said.

The rising minimum wage in Arizona has also made it hard for caregiver agencies to compete with other industries for workers, such as fast food and retail, the report said.

“These compounding challenges lead to high turnover and widespread vacancies in the field,” the report said.

Caregiver business rebounding after decline caused by COVID-19

There are more than a hundred home health agencies in Arizona licensed to accept Medicaid clients, according to the Arizona Health Care Cost Containment System website.

But adults who don’t qualify for Medicaid, which is based on income, must turn to private caregivers such as Carrasco.

Carrasco said they plan to become licensed to accept Medicaid clients eventually. In the meantime, they only accept clients who can pay by cash or check.

With the money they have earned caring for older adults, they have raised three children, now college students in their 20s. Their daughter, Nathalie, 26, is studying clothing design. She sometimes sews buttons and mends clothing for some of her parents’ clients.

The family also owns a 13-year-old cat, Rosie. They inherited her after one of their clients died.

Carrasco said their business lost clients during the pandemic, when clients and their families became concerned about outsiders bringing the COVID-19 virus into their homes. But it’s now rebounding.

Making sure people have what they need

Back at the apartment, Carrasco prepared to wrap up for the afternoon. While Garcia watched a cooking show on TV, Carrasco pulled laundry out of the dryer.

She then folded the laundry, neatly hung the clothing in the closet, and sorted it inside dresser drawers labeled in Spanish in large letters: blouses, pants, socks.

Before she left, Carrasco served Garcia a last cup of decaf coffee and a sweet roll. Carrasco then gathered her belongings, waved goodbye to the dogs and wheeled her black bag out the door.

“See you,” Carrasco told Garcia as she departed.

“Thank you,” Garcia replied.

Daniel Gonzalez can be reached at daniel.gonzalez@arizonarepublic.com.