What if we live a long life and are abandoned or without funds despite our best efforts?” For Wendy Jane Carrel, a senior care specialist with over two decades of experience who operates the consulting service Wellness Shepherd, this question is a looming reality. In the parched deserts of Coachella Valley in the early 2000s, she saw the first ripples of a “silver tsunami” — an aging America colliding with a shrinking pool of caregivers and the soaring costs of care.
Back then, she recalls, “The average American couldn’t even afford the cost.” Today, the situation has only gotten worse for both those needing care and those who offer it. And despite how expensive care is, much of that money isn’t trickling down to caregivers themselves. Caregivers who Carrel has worked alongside often earn poverty-level wages.
“We are all living longer. There are just more of us to take care of and not enough of us to do the caring.”
Demographers have long warned of a “demographic time bomb” threatening wealthy nations. Experts estimate that by 2060, 155 million Europeans (roughly 30 percent of the population) will be 65 or older. About 45 million are expected to have at least one disability that disrupts daily living, effectively doubling current elder caregiving needs. In Japan, the Ministry of Health is forecasting a need for 2.72 million nursing care workers by 2040. A third of the population is already 65 or over. One in six Americans is aged 65 or older — an estimate expected to rise to 47 percent by 2050, according to the U.S. Census Bureau.
“We are all living longer,” says Joanna Hofman, a senior research leader at Rand Europe. “There are just more of us to take care of and not enough of us to do the caring.”
We haven’t reached the peak of the problem yet. The Bureau of Labor Statistics projects that demand for personal care and home health aides will soar by 21 percent between 2021 and 2031 — one of the fastest increases for any occupation. Yet, the workforce is already stretched thin, and Boston Consulting Group warns that by 2030, the resulting shortage could lead to a $290 billion loss per year to the nation’s GDP.
This silver tsunami we are facing is already shifting who receives care, who gives care, and where.
Traditionally, caregivers have worked within local environments, providing unpaid or low-paid support in their own communities. However, as populations age and domestic care work becomes less accessible or less attractive due to low wages, many caregivers find themselves unable to meet the rising needs at home. Many are moving across borders to seek more stable incomes, leaving gaps in local care systems. In the U.S., the rising costs continue to deepen the barriers for families and seniors alike, with an increasing number of people looking to leave the country to live out their final years. Carrel reflects on some seniors living stateside she has worked with, who, while living in the U.S., were forced to make the impossible choice of “choosing between air conditioning and eating in the summer.”
“It’s not just about money,” Carrel says. “It’s about dignity.”
The cost of care
For most of American history, caring for aging parents or frail relatives was a private, often invisible act, carried out in kitchens and bedrooms away from the public eye or conversation, rarely recognized as work. It was simply part of life, of being a part of a family. The notion of caregiving as a paid profession is a relatively recent phenomenon, born out of seismic demographic shifts and the changing structure of families.
The numbers are staggering. In her book, “The Age of Dignity: Preparing for the Elder Boom in a Changing America,” social activist Ai-jen Poo estimates that 48 million Americans provide unpaid care for loved ones — a contribution valued at $600 billion, a figure that dwarfs the annual revenues of the nation’s largest corporations. Even today, the vast majority of care is still performed by relatives, with women shouldering most of the burden.
Over time, caregiving that was once seen as a natural extension of family duties and community responsibility was transformed by individualism, urbanization and economic demands — becoming an institutionalized and commercial industry. In the United States, the professionalization of caregiving accelerated in the late 20th century, as home health agencies proliferated and states began to regulate training and certification. The 1987 Nursing Home Reform Act set minimum standards for care in nursing facilities.
But despite this industry shift, commercialized care proved to be inaccessible for many families without causing substantial financial strain. According to a 2024 report from the Kaiser Family Foundation, the median annual cost of a private room in a nursing home is $116,800, while full-time home health aide services top $288,000 — sums that far exceed the median income of $36,000 for Medicare beneficiaries. Nearly 41 million Americans now provide unpaid care to adults, according to the National Alliance for Caregiving, and as the pool of trained professionals shrinks, families are forced to shoulder even more of the burden at the expense of their own livelihoods.
In many states, turnover rates for direct care workers reaches 60 percent annually. With fewer hands available, the quality and accessibility of elder care are at risk of unraveling.
Economic necessity became the overstory of accessing any kind of care, with the demand for in-home, informal care leading to global migration. In Europe, informal caregivers and undeclared migrant workers now provide about 80 percent of elder care. In the U.S., immigrants make up about 25 percent of the home care workforce, according to PHI, a nonprofit research group. Many are women from the Philippines, Nigeria, Jamaica and Haiti, drawn by the promise of steady work, even if the pay is low and the hours are long.
“Many care workers are still ‘tago ng tago’ or ‘hidden and hiding,’” says Ashlee Monton, who has conducted research about Filipina caregivers in the U.S., making up 1 in 7 immigrant health workers. Compared to back home, wages are high, so many continue to work and live undeclared. And they are willing to work for wages that are far below the costs of institutionalized care.
But there is little upward mobility in the work, and protections are limited, says Hofman. Home health aides, who provide the bulk of hands-on care, earn a median wage of just $16 an hour. In many states, turnover rates for direct care workers reaches 60 percent annually. Additionally, recent changes to visa programs and the tightening of the southern border have made it harder for Latin American and Caribbean workers to fill caregiving jobs. Some are now leaving, seeking better opportunities elsewhere or returning home, raising fears of an even deeper shortage.
“If we lose that workforce, more Americans will be forced to look elsewhere for care, or find a way to come up with new community solutions,” says Carrel, the senior care consultant.
With fewer hands available, the quality and accessibility of elder care are at risk of unraveling, leaving vulnerable seniors without the support they need. Carrel gives one example of a family seeking out her help, where the children lived far away from their mother and realized that “her funds wouldn’t last as long as her possible lifespan” if she planned on living out the rest of her life in the United States with her family.
Americans seeking long-term or end-of-life care find that living abroad can offer a more affordable and comfortable alternative.
Carrel helps those who cannot afford domestic caregiving services, but have enough to relocate to countries with lower costs, primarily in Latin America. European countries are also considered “often based on heritage or past experience.” While costs are rising worldwide, the price for similar levels of care remains generally lower outside the U.S.
She recently supported four siblings relocating their mother, who lived in Washington, to a semi-independent living facility in Lake Chapala, Mexico. The siblings take turns visiting their elderly mother, who is “having trouble remembering things,” and Carrel occasionally has a care specialist who works in family care check in on her. In the U.S. today, “you need one million dollars over the life of memory care,” notes Carrel.
In a recent New York Times Ethicist column, the phenomenon of Westerners retiring abroad was described as “migration with permission.” Northern Thailand, for instance, hosts retirement communities that promise comfort and savings compared to American standards. Increasingly, families are exploring these options for their aging loved ones.
Caregiving across borders
The movement of caregivers is not just a one-way journey to the United States. There are some Americans who are moving to countries like Germany to work as caregivers. In Italy, Peruvian women have become the backbone of elder care in cities like Florence, filling a void left by Italians who can no longer afford to care for their parents at home. Croatians cross the Adriatic to work in Italian households, while some Italian retirees, squeezed by the cost of care, move in the opposite direction — to Croatia, where help is cheaper.
Governments are responding by forging new partnerships and formalizing cross-border arrangements to bring in foreign care workers. These agreements set rules for recruiting, training and integrating international caregivers into national health systems. Japan, for instance, has signed agreements with countries like Indonesia and the Philippines to recruit and support trained caregivers, offering language support and pathways to long-term residency for those who pass rigorous exams.
Similar strategies are unfolding across Europe and North America. Canada and the U.K. have streamlined immigration policies to facilitate the influx of care workers, acknowledging that their aging populations depend heavily on foreign labor. Even in the U.S., where immigration debates remain contentious, thousands of international caregivers continue to quietly fill vital roles in homes, hospitals and nursing facilities.
The “silver tsunami” is shifting who receives care, who gives care, and where.
These agreements do more than address workforce shortages. They highlight a global recognition that elder care is a shared challenge. It transcends borders. As populations age and resources tighten, the movement of caregivers — and the choices about where to receive care — is becoming integral to modern life.
In the years ahead, how nations negotiate and manage the tsunami will shape the well-being of their oldest citizens and the social cohesion of their communities. For Carrel, this includes reexamining and integrating traditional values of compassion, respect and intergenerational support into new caregiving frameworks to ensure aging populations are cared for with dignity and communal solidarity.
“Shouldn’t your departure be just as holy and sacred as when you were welcomed into this world?” she asks.
“Even here,” she adds softly, “dying is a challenge.”
This story appears in the July/August 2025 issue of DeseretMagazine. Learn more about how to subscribe.