When we talk about staffing shortages in long-term care, we often look at caregiver burnout and nurses leaving the industry. We talk about COVID and pay rates and workplace flexibility. 

But staffing shortages in the United States long-term care industry go deeper than the COVID crisis, and the industry will grapple with the causes and repercussions of those shortages for decades to come. Because the real cause is age demographics.

Nursing homes are at the crux of U.S. demographic change. Old people need nursing homes in order to survive, and nursing homes need young people in order to operate. But the U.S. is aging. We are producing old people much faster than young people.

This has heavy consequences, especially for long-term care. First, regardless of whether the U.S. enters a recession in the near term, the power dynamic between nursing homes and the pool of caregivers has shifted for the long term. As those facilities compete to attract increasingly scarce labor, they must alter how they recruit and manage that workforce. “Business as usual” could mean going out of business.

US demographics

The number of Americans aged 65 or over is set to nearly double to 92 million between 2018 and 2060, according to the U.S. Census Bureau. By 2034, the entire Baby Boomer generation will be retirement age or older. Those people will gradually lose their ability to perform the functions of autonomous adults and rely heavily on caregivers. But where will the caregivers come from?

In 2020, the average number of children an American woman would bear in her lifetime (also known as total fertility rate) hit an all-time low of 1.64, according to the National Center for Health Statistics. For a population just to replace itself, it must pass a fertility threshold of 2.1 children per woman. Americans are simply not creating enough children.

In 2021, the US showed a net gain of 224,000 new residents from immigration and natural growth (births over deaths) of 148,000. Both of those numbers are an order of magnitude smaller than what they’ve been in recent years.

The search for solutions

Solutions to problems on a demographic scale can only be achieved through policy, and everyone impacted by the long-term care industry should be aware of the policies that will help alleviate the demographic pressure on nursing homes.

Solutions to these deep demographic problems will require bipartisan cooperation. While many issues in America have been politicized, we need to discuss them without a political agenda. America’s demographic trap is self-evident, and there are only a few possible exits. We have a short list of solutions to choose from.

● Reproduction

● Immigration

● Automation


Across the world, countries are struggling to maintain their birth rates. Most developed nations, be they in the Americas, Europe or Asia, are well below the replacement threshold, with countries like Japan and Korea showing overall population decline. 

France stands out as a country closest to the replacement threshold at 1.87 children per woman. Its robust social services, including universally accessible public services such as child healthcare and nurseries, significantly lower the costs and burden of starting and raising young children.

But the welfare state is not a panacea: countries such as Norway and Sweden are much farther from replacement despite their policies. Societal norms, the affordability of housing and early education, and government regulations are also important. The U.S. and its nursing home industry must start studying now the most effective means of maintaining a working-age population if it is to avoid the worst effects of demographic decline.


Historically, settled nations like the US and Canada have grown their populations through robust immigration and attracted professionals with expert skills, entrepreneurs with risk appetites, and laborers with work ethics that continue to help build our country. It is silly to be “for” or “against” immigration — we should just be for “the right immigration,” which is the immigration that keeps America working. Long-term care is an industry that relies heavily on migrant labor.

A study by the Economy Policy Institute shows that immigrant women make up 12.8% of the total caregiving workforce in American nursing homes, almost double their share in other industries. In Canada, the proportion of immigrants working as nurse aides, orderlies and patient service associates rose from 22% to 36% in the two decades between 1996 and 2016.

Caregiving jobs, some of which require just a few weeks of training to prepare for the hard, menial labor of lifting and moving nursing-home residents, have traditionally been more accessible to immigrants than other occupations. Without a steady flow of immigrants seeking to fill those positions, many facilities simply cannot operate smoothly.


Japan has aged faster than America, and it can serve as an object lesson in how to navigate a rapidly aging society. Because of roadblocks to immigration, the Japanese are placing large bets that automation will help nursing homes continue to serve the elderly. 

In 2017, 26% of all Japanese nursing homes employed robots for tasks as varied as monitoring residents, lifting them, communicating with them and increasing their self-mobility. Japan has a nationwide “Robot Plan” that subsidizes and promotes the use of robots in long-term care, with local governments subsidizing their adoption.  

A Stanford study found that those robots correlated with a decreased burden on the human caregivers, better nursing-home management and an increase in the flexibility of workforce hours. America’s robotics industry is strong, but our inclination to accept robots into our lives is much lower than in Japan. In the coming decades, we may have no choice.

You’ll notice that I didn’t talk about nursing education here. That’s because the challenges we face go much deeper than the cohorts that graduate from our nursing schools. Graduates are not the only bottleneck. America will not be able to supply the applicants to those nursing programs if we do not take action. 

I hope the leaders of the long-term care industry will actively explore solutions to these challenges in order to ensure that our elderly receive the care they need in the decades to come.

David Coppins is the Co-Founder & Chief Executive Officer of IntelyCare. As IntelyCare’s CEO, David is dedicated to empowering the long-term care industry to manage its workforce better through access to technologies such as PRN float pool management tools. Under his leadership, IntelyCare has helped healthcare facilities fill over 10 million nursing shift hours.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.