Jonas Atta-Kyereme helps 85-year-old David Reese dress in the morning and prepare for bed at night. He makes sure the retired pediatrician takes his medicine, and calms him when he gets anxious looking for his wife, Jane, who died last year.
It’s a typical shift for Atta-Kyereme, a caregiver who began working in Reese’s home after the older man sustained a traumatic brain injury during a fall last year.
“He needed 24-7 care,” said Reese’s brother-in-law George Sullivan. “He didn’t even recognize his own home that he’d lived in for 50 years.”
Home health workers and caregivers like Atta-Kyereme, who immigrated from Ghana two years ago, fill a critical role in the health care ecosystem as America ages and demand for caregivers soars. But government funding cuts, a caregiver shortage and immigration limits are layering new strains on an industry already hard-pressed to meet demand: Home health and personal care openings are projected to jump 17 percent from 2024 to 2034, according to data from the U.S. Bureau of Labor Statistics, and home health spending is expected to nearly double, to $317 billion, in 2033.
Costs are fast increasing: Spending on at-home elder care shot up 7 percent from August to September, the largest monthly increase on record, according to government data. Nursing home costs rose 4 percent from September 2024 to September 2025, while home health care surged 12 percent, far exceeding the 3 percent overall rise in inflation during that time.
The U.S. elder care industry is caught between competing forces as demand swells: Many families say they would prefer in-home care but can’t afford it. Yet the industry struggles to attract people willing to take on the intimate, labor-intensive work of caregiving, largely because of the low pay. For a home health or personal care aide, the median salary was $34,900 annually or $16.78 an hour. Nurses and other medically trained staff who also attend to seniors at home earn more.
Even retail and restaurant jobs can offer better compensation, said Jake Krilovich, chief executive of the Home Care Alliance of Massachusetts. When his state passed a $15 minimum wage, “we saw a lot of the workforce migrate as a result of that.”
The tension is rapidly coming to the fore as changes in immigration policy threaten to squeeze the workforce. While foreign-born workers make up 19 percent of the U.S. labor force, they accounted for about 1 in 3 home care workers in 2023, according to a KFF analysis.
After the U.S. ramped up immigration enforcement under its Secure Communities policy, the home care workforce shrank 7.5 percent between 2008 and 2013, according to a 2025 study by professors at the University of Pittsburgh and the University of Pennsylvania. The data also showed that older adults in need of assistance were 5 percent less likely to get home care.
The Trump administration has significantly lowered the cap on refugee admissions this year and has moved to end temporary legal protection, called TPS, and work authorization for immigrants from Venezuela, Haiti and other countries destabilized by armed conflict, natural disasters or other forces.
“We think our findings reflect ‘chilling effects,’” whereby immigrants are deterred from participating in public life, said Amanda Kreider, a co-author of the 2025 study and a health policy and management professor at the University of Pittsburgh. “I’d suspect that TPS revocations or sharp reductions in refugee admissions could have similar effects,” she said.
Federal funding cuts are also taking a toll on the industry.
Medicaid, which provides health insurance for low-income and other Americans, uses state and federal dollars to help pay for nursing homes and in-home caregiving. States are not required to offer home care, but often do. Health policy experts fear that Medicaid changes included in the domestic policy bill that Trump signed into law this summer will spur states to cut back — as was the case between 2010 and 2012, when every state cut home care spending in response to a federal funding reduction, said Rachel Werner, executive director of the University of Pennsylvania’s Leonard Davis Institute of Health Economics.
Meanwhile, late last month the government cut Medicare funding for home health agencies by 1.3 percent, or $220 million, for 2026. It is the fourth consecutive year of cuts for such programs under Medicare, the public insurance program for people 65 and older.
“It’s kind of like watching a slow-moving car crash,” said Diane Slezak, chief executive at AgeOptions, a Chicago-area agency that coordinates aging services.
A spokesperson for the Centers for Medicare and Medicaid Services said the administration “recognizes the concerns regarding access to home health care, particularly in rural and underserved areas,” and the potential for rate cuts to affect providers’ stability and patients’ outcomes. But the agency said the cuts “were implemented in a way that fulfills statutory obligations without jeopardizing beneficiary access.”
White House spokesman Kush Desai called the Medicaid changes commonsense reforms, and said it is “intentionally misleading” to suggest they will jeopardize access to home- and community-based services. The Republicans’ domestic policy bill includes about $150 million for such care, though experts say that amount is dwarfed by the expected reductions.
Desai also said there are plenty of Americans available to bolster the health care workforce and that the president is “committed to ensuring all industries have the legal workers needed to succeed.”
“Over one-in-ten young adults in America are neither employed, in higher education, or receiving vocational training,” he said.
Home health closures mount
In-home caregivers assist with nonmedical tasks. They might help a client dress, prepare meals or provide companionship. Some state Medicaid programs cover the cost, but there are often waiting lists. Many Americans pay out of pocket, experts said.
By contrast, Medicare will pay for those with more sophisticated medical needs to get home health care as they recover, for example from an injury or an illness. The person might get some help around the house, but only if they’re also visited by home health providers giving injections, changing wound dressings or providing other medical services.
This generally doesn’t include the network of unpaid family and friends or aides found through word of mouth who may be unlicensed or lack legal status.
Lack of caregiving options can shunt more of the responsibility onto families, or leave some unable to find qualified help, experts say. The number of family caregivers jumped 45 percent in the last decade, to 63 million, according to a July report from AARP and the National Alliance for Caregiving. (About 4 million of those caretakers were looking after a child with an illness or disability.)
In other cases, it can prompt people to move into a more expensive assisted-living facility.
Wyatt Kash’s mother was 95 and still picking up her own groceries when she suffered a spell of dehydration-induced dizziness and briefly ended up in a rehabilitation center in 2022. When she returned home, she recognized she needed occasional help with cooking and other tasks, Kash said.
He started researching online and calling home care agencies, but couldn’t find a workable option. “My mom lived in Long Island. She lived on a little peninsula town in Glen Cove, and most of the people were coming from Queens, which is 45 minutes away,” he said.
In the end, Kash’s mother agreed to move into an assisted-living facility — selling her four-bedroom home of 40 years to do so, he said. She ran through her long-term care insurance after 26 months and now pays about $12,000 a month.
Despite the demand, home health companies say they’ve been struggling. Half of U.S. counties lost at least one home health agency between 2020 and 2024, a period that overlaps with the covid-19 pandemic, according to the National Alliance for Care at Home. About a third of patients referred for home health don’t receive it, according to reports based on 2015 and 2016 data.
Midland Care Connection, a Midwest nonprofit that offers home health and hospice services, last year acquired a Visiting Nurse Association agency offering the same services in hopes of bolstering the agency’s struggling finances. It explored the option of selling the agency’s home health division or joining forces with other nonprofits, said chief executive Shawn Sullivan, but was unsuccessful.
The acquired home health agency closed this fall, a decision Sullivan called “excruciating.”
He blamed Medicare cuts as well as the growing number of older adults signing up for Medicare Advantage, which allows enrollees to secure a Medicare-approved plan from a private insurer. Sullivan said some of those plans pay less for home health than it costs to provide the service.
Combined with the proposed Medicare cuts, “we’re left here thinking, ‘How can we make this work?’” Sullivan said.
Chronic worker shortages
Facility closures often affect rural areas. In 2023, nearly 90 percent of home health agencies were majority-urban — 86 percent compared with 83 percent in 2017.
Enhabit Home Health and Hospice, which has nearly 250 home health facilities across more than 30 states, has closed eight home health locations this year and downsized its coverage areas, chief executive Barb Jacobsmeyer said. She cited financial pressures coupled with the competitive labor market for skilled nurses, who — unlike aides — must typically be clinicians with experience in the field.
“We cannot hire a new grad. We are putting people in a home alone caring for a patient,” Jacobsmeyer said.
Smaller service areas allow nurses — who spend much of their time driving from one patient’s house to another, especially in sparsely populated areas — to visit more people during a shift. That saves money that can then be used to recruit and retain workers, Jacobsmeyer said.
The company would prefer to cover the entire area for which they’re licensed, she said. The “terrible” part is that closures affect rural markets, she added. “But we are just at the point where we’re having to make these really tough decisions.”
Some providers have been shaken by recent changes to immigration policy.
Goodwin Living, a nonprofit that operates senior living communities — including the one where Reese received rehabilitation — had to let go of four employees from Haiti in July, chief executive Rob Liebreich said. Nine in 10 of their nursing-home caregivers are immigrants, with 80 countries represented among the roughly 1,500-person staff, Liebreich said.
The departing employees were hard to replace, he said.
“These are people that came in legal ways, that had been vetted,” he said.
Unexpected departures affect both providers and families, who sometimes form close attachments with their caretakers. Tribute Home Care had to let go of eight caretakers from Haiti over the summer, and expects to lose 10 more in the next three months, chief executive John Sneath said. One had recently won the company’s quarterly “Caregiver Excellence Award.”
“The whole service rises and falls on that caregiver,” Sneath said. “Clients form very tight attachments to caregivers. When that’s disrupted, it’s a problem.”
The low-paid work of caregiving may dissuade American-born applicants. But industry officials say other cultures may also place a greater premium on caregiving as a profession and on older adults in general.
Tribute pays its workers $22.50 an hour in Massachusetts and offers a flexible schedule and benefits that include health care, paid time off and a 401(k), Sneath said. Still, he said he doesn’t think they’d be able to operate without immigrants, especially in Massachusetts, where they make up 90 percent of his company’s in-state workforce. Immigrants make up about 60 percent of Tribute’s employees at their Maryland and Chicago locations.
“The basic problem is that we haven’t considered these professional jobs,” said Katie Smith Sloan, president of LeadingAge, an association of nonprofit aging service providers. “We’ve considered them low-wage workers” and haven’t appreciated the skill and training required, she added.
“There are people who come from other countries where older people are revered, where elders hold a special place of respect,” she said.
George Sullivan had moved into Goodwin Living’s independent living apartments when his sister Jane, Reese’s wife, died last year. He helped Reese move into a wing for residents needing more care and encouraged Goodwin Living to bring Atta-Kyereme aboard.
Atta-Kyereme said it’s common to have multiple generations living in a household in Ghana, where he spent 17 years as a teacher before joining his wife in the U.S. in 2023. She immigrated through a diversity visa lottery program, then sponsored him for a green card, he said.
“We have old men and women in our homes and we’ve been taking care of them. So it’s not something new,” he said.
Given how much time they spend together, Atta-Kyereme has come to know Reese’s likes and dislikes, and how to gently change the subject when he frets about his late wife: He just brings up Princeton University, the older man’s alma mater. “That’s something that I’ve been doing and it works a lot,” Atta-Kyereme said.
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