The Rotation to the National Nursing Home is running out of foreign born workers

The biggest secular driver has been deprived of its rocket fuel

• Rotation to the National Nursing home, recapped and implications laid bare

• the most common job in america is (and will be)

• Uncle Sam’s Immigrant Nursing Brigade, sans immigrants, NYC edition

• above-trend hiring exists, if you know where to look

• foreign born labor force, going in reverse

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Rotation to the National Nursing Home is running out of foreign born workers

Random Walk has been highlighting the outsized role of “healthcare” in the economy for some time.

I’ve variously called it a lot of things, but the Rotation to the Nursing Home is one of my faves.

The implications are:

• economic growth generally, and labor market growth specifically, are deceptively weak. Healthcare isn’t really growth (even if it counts for GDP), and, in any event, we’re paying for it with credit that we can’t really afford (and that too, is not really growth);

• at the margins, it’s been a substantial driver of cultural and socio-political change, as well, inasmuch as healthcare hiring has been a massive pull for women and “foreign born” into the workforce, and a boon for lower-income service workers¹ (and has helped offset the decline in manufacturing jobs, and an otherwise slowing-then-contracting labor force generally);

• put another way, Healthcare Makes All the Jobs, Job Growth is a Foreign Born Story, The Open Border Saved the Economy, The Great Replacement is Real, and Uncle Sam’s Immigrant Nursing Brigade are five(!) sides of the same coin: net-new demand for workers is driven increasingly by healthcare/senior care, and net-new supply is almost entirely “foreign born;”

• the trend will likely continue as it’s a function of getting older (and failing to reproduce), combined with a deeply entrenched preference for socializing those costs, i.e. the bill is on auto-pay;

• the flipside is that employment is relatively stable (and higher rates create less downward pressure) because Uncle Sam is a price-insensitive buyer who will keep paying for healthcare (and hoovering up the available credit), whether or not it’s a loss-making venture—other businesses evaporate when the economics don’t work, but Uncle Sam just keeps going;

• although, query where the new workers will come from, given the current admin’s policy on immigration, and what inflationary pressures that will create, given demand for e.g. home health aids, will plod ahead of supply.

Basically, we can’t live with it (because it’s making us bankrupt and balkanizing the polity), but we also can’t live without it (because (a) the disbursement is on auto-pilot; and (b) take that spend out of the economy and look out below).²

Cheery picture, I know, but now you see why Doing More with Less is the only trade that matters, and why so much is riding on the Deus ex Machina ending.³

Anyways, throat-clearing (and thematic table-setting) aside, just some charts to illustrate the points above.

“The most common job in America”

What is the most common job in the country?

Well, it’s home health and personal care aids:

Bloomberg

Home-health aids top the leaderboard at 4M (followed by the retailers who feed and clothe them), and registered nurses aren’t far behind.

Why is Bloomberg calling attention to this matter?

To warn us that Trump’s immigration policy is threatening to put this “fastest growing” industry out of business:

President Donald Trump’s immigration crackdown threatens to shrink the workforce for one of America’s fastest growing jobs: Home health and personal care aides.

Demand for such care is expected to swell as the US population ages, and the industry has increasingly relied on immigrants to fill home health positions. Foreign-born people comprise roughly one in five US workers, yet they account for more than 40% of home health aides and nearly 30% of personal care employment . . .

Trump’s push to . . . curb immigration has providers and industry experts worried about their ability to hire and retain workers. . . .

And this vital source of economic dynamism is only growing, while the supply of labor falls ever-short:

The Bureau of Labor Statistics projects home health and personal care aides, which is already the most common occupation in the country, will also be one of the fastest growing professions over the next decade – soaring 21% by 2033.

That depends on workers wanting the job. Hospitals, nursing homes and other providers are still scrambling to fill nearly 1.5 million open positions . . .

The jobs are physically demanding and low paid. In 2024, home health and personal care aides made $34,990 annually — roughly half the average pay across all US occupations.

Got it. The fastest growing profession is a low-paying, caretaker for seniors, which depends on immigrants to fill its ranks, but even so there are not nearly enough bodies.

I mean, they’re not wrong, it’s just that pointing out that foreign-born healthcare workers were the prime mover in the ‘firing on all cylinders’ pandemic-recovery was a borderline conspiracy theory circa 2023-24.

Like with the brits, now it’s apparently a highly salient observation to make.

Where is this challenge most acute?