The Age of Dignity: Preparing for the Elder Boom in a Changing America.

• Author: Lee, Stephen
• Position: Book review

The Age of Dignity: Preparing for the Elder Boom in a Changing America. By Ai-jen Poo with Ariane Conrad. New York and London: The New Press. 2015. P. 176. $25.95.

INTRODUCTION

Americans are living longer than ever before. The decline in the infant mortality rate, a reduction in heart disease- and cancer-related deaths among adults, and the successes of other public-health initiatives help explain our newfound national longevity. (1) Traditionally, the elderly have been cared for by family members, but the "elder boom"--and the uncertain period of care it invites--is testing the limits of what families can do on their own. While our lives have gotten longer, our pockets have not necessarily gotten deeper. The strict policies on eldercare-related leave that most workplaces continue to maintain exacerbate this reality. (2) The challenges posed by the elder boom go beyond finding enough money to pay for services. Even the wealthy among us--who can afford outside help--have reasons to worry about securing care for their elders: labor studies project a shortage of caregivers in future labor markets. (3) All of this forces an urgent question: Who will take care of us once we are too old to take care of ourselves? Ai-jen Poo, (4) a nationally recognized activist and 2014 MacArthur "genius grant" recipient, takes up this question in The Age of Dignity: Preparing for the Elder Boom in a Changing America. (5)

In tracing the consequences of the coming elder boom, Poo begins with the observation that existing federal programs offer very little support for those in need of home care (pp. 35-36). She notes that Americans overwhelmingly prefer to care for their elders at home with the help of family, but that such an arrangement is simply too costly for most families (pp. 2, 5). Programs like Medicaid provide some coverage for home-care services but only for those at the lower end of the wage scale (pp. 36-37). Such a policy most directly affects middle-class Americans who have no meaningful options when it comes time to care for an elder (pp. 32-36). Meanwhile, the difficult work of home care, domestic work, and nursing is often performed by immigrant women, and especially unauthorized immigrant women, which means that caregivers are often underpaid (6) and lacking in basic workplace protections. (7) Caregiving takes place at home beyond the public's view, which makes detecting labor and employment violations virtually impossible.

The Age of Dignity concludes with a call for a "comprehensive federal policy of caring" that makes eldercare more affordable for those who need it and less exploitative of those who provide it (p. 154). Poo's vision for reform includes a number of different interventions, ranging from expanding the availability of tax breaks (thus alleviating some of the burden borne by middle-class families) (8) to the bolstering of existing labor protections (thus ensuring a safer and more dignified workplace for caregivers). (9) The Age of Dignity also offers support for comprehensive immigration reform that includes a path to citizenship, a reduction in deportations, and a system for managing future flows of care workers (pp. 163-65). It is this last aspect of the book that I focus on in this Review. Poo argues that immigration reform should include "channels for workers to migrate legally to the United States in the future to work as care workers" and that these channels should include anti-exploitation features like "portable status" to prevent wards and their families from exploiting these workers (p. 164). This Review examines Poo's choice to lodge her vision of reform within the labor migration system. Pushing for greater opportunities and stronger protections for labor migrants offers intuitive appeal. After all, Poo advocates on behalf of eldercare workers. But the intuitive choice is not an inevitable one, or even the best one depending on one's larger aspirations.

To start with, caregiving work undermines what I call the "productivity/affinity" binary, which undergirds our immigrant admissions system. The vast majority of immigration rules allow individuals to migrate to the United States either as workers or as family members, which reflects an underlying policy preference for those who are "economically productive" or those with whom current members of the national polity feel an "emotional affinity." But caregiving work possesses elements of both types of migrants without neatly fitting into either category. Although many caregivers operate within the informal economy, their work certainly counts as economically productive work--especially considering how they enable family members to continue earning income (usually in the formal economy). At the same time, the nature of caregiving reflects the kind of emotional and physical support most commonly assumed to be provided by blood-based family members. Caregivers, then, occupy the interstitial space separating the workplace and the home, acts of labor and acts of intimacy, and all too often, the outer worlds of men and the inner spheres of women.

The challenges Poo describes fit within a growing body of immigration scholarship that explicitly or implicitly questions the productivity/affinity binary. (10) And in the most pointed contribution to this conversation, immigration scholars have suggested that the family-based migration system might do better at filling labor gaps in the low-wage and unskilled market than the employment-based system. In this Review, I briefly canvas what our family-based and employment-based migration systems can and cannot do, as well as what neither can do, to help manage future flows of eldercare workers. More generally, I hope to use The Age of Dignity as an opportunity to invite other immigration scholars to consider the membership implications of caregiving, especially of our elders. Confronting instances in which (adult) children care for their (elderly) parents in many ways upends visions of caregiving memorialized in the immigration code, which largely privileges parents caring for their children. (11) As The Age of Dignity compellingly shows, caregiving runs in multiple directions across several generations in immigrant families. Uncles and aunts care for nephews and nieces, and grandparents tend to grandchildren. (12) These issues are crying out for scholarly examination.

This Review proceeds as follows. Part I summarizes The Age of Dignity. Part II explains how this segment of immigrant workers challenges the productivity/affinity binary that dominates immigration law's formal migration rules. Part III shows how this binary sets up dual migration streams, both of which could account for future flows of care workers. As Part III shows, the example of the eldercare industry nicely illustrates how the employment-based and family-based migration systems simply represent two different ways of filling labor needs. I then conclude.

1. THE PEOPLE WHO CARE FOR US AS WE GROW OLDER

   It is well-established that immigrants are overrepresented at the bottom of the labor market. Nearly one-fifth of all construction, food service, and agricultural workers were born elsewhere, but that ratio does not come close to foreign-born representation within private households in which nearly half of all workers are foreign-born. (13) There are simply not enough domestic workers to fill these jobs. People are living longer than ever before, which means that a record number of people will eventually need care as they transition out of the paid workforce into their twilight years. The "baby boomer" generation will be at the front of this elder boom. The numbers are startling. As Poo explains: "We know that 70 percent of individuals who are sixty-five years of age or older need some form of long-term services and support. With the elder boom, the total number of individuals needing long-term care is projected to grow from 12 million to 27 million by 2050" (p. 154).

   Public benefits in the form of Medicaid cover some of the costs of caregiving, but these benefits target low-income Americans. Eligibility is tied to income, which means that those who are fortunate enough to climb out of poverty must do so at the cost of surrendering their eligibility for eldercare assistance (p. 37). Of course, none of this affects the wealthy who can afford the costs of caregiving either at home or at a caregiving facility. (14) But the vast majority of Americans who are neither "impoverished enough" to qualify for public benefits nor wealthy enough to pay their own way struggle mightily. Poo recognizes that most caregiving transpires informally between and among family members (p. 26). But the economic costs of caregiving exact a particularly steep toll on those belonging to the "sandwich generation," which Poo describes as those who are "struggling in isolation to manage the demands for care and attention from two generations--the one that came before and the one that came after theirs--alongside work and everything else life brings" (pp. 26-27). All of this fosters an eldercare system separated into "two tiers of care," neither of which, Poo explains, serves middle-income Americans: "Medicaid for the poor, often in nursing homes, and privately financed residential or home care for the wealthy, with wide disparities in access and quality" (p. 154).

   Poo's lucid and detailed description of the demand side of the eldercare industry complements the poignant and moving analysis of that industry's supply side--that is, of the workers attending to the emotional and physical needs of wards and their families. The universe of caregivers is a heterogeneous one. By Poo's account, registered nurses, geriatricians, certified nursing assistants, home health aides, personal-care assistants, and home attendants--among others--all populate the universe of those paid to care for the elderly (pp. 37, 84-85). This workforce, Poo explains, is the fastest growing...