“If you want to be happy in a million ways, for the holidays, you can’t beat home, sweet home.” The late Perry Como’s observations reflect a bittersweet truth about an unattainable goal — not just during the holiday season, but each day of the year — for the 1.4 million Americans age 65 and over who reside in long-term care facilities. Older Americans who might prefer to age in place at home often have no financial option but to move to such facilities due to extremely limited options for in-home care.

The ongoing COVID-19 pandemic presents an opportune time to ask why Medicaid continues to channel senior citizens with moderate needs into institutional settings when they — in the vast majority of cases — would prefer to age in place at home. While most Americans have come to appreciate the virtues of physical distancing during the past 21 months, public health policy regarding long-term care produces precisely the opposite outcome: high-density residential settings in which illness spreads rapidly across vulnerable populations.

New approaches are necessary to give America’s seniors options beyond Medicaid-funded nursing home placement when they deplete their assets and are no longer able to live on their own. A new model of service delivery based loosely on the “sharing economy” holds great promise for helping seniors age in place in the familiarity and comfort of home, assisted by a new type of guest worker.

The U.S. Department of Health and Human Services (HHS), Congress, and organizations that represent America’s seniors should work collaboratively to develop a “Health Care Guest Worker” (HCGW) initiative that would allow elderly Americans to receive assisted-living services and basic nursing services from foreign-born guest workers in the comfort of the senior citizen’s home.

Such an initiative would be particularly appealing to seniors who have adequate space in their homes to accommodate one or more live-in HCGWs as their mobility and overall health decline.

Just as Airbnb has allowed Americans to monetize extra space in their homes on a short-term basis, a HCGW initiative would allow lower-income and middle-income seniors — many of whom are “house rich and cash poor” — to derive a significant, tangible benefit — in-home health care — at a cost they (and taxpayers) could afford.

To make such an initiative possible, Congress should redefine and dramatically expand the H-1C visa category (which expired in 2009) to include not only nurses but also lower-skilled caregivers who would assist America’s seniors. The U.S. State Department could identify countries where significant numbers of qualified, English-proficient citizens reside; manage recruitment; evaluate prospective workers’ health status; and, in concert with the Department of Homeland Security, conduct thorough background checks on all potential HCGWs.

Prospective HCGWs who live in poverty in underdeveloped countries — yet who have learned English and have a strong work ethic — would welcome the opportunity to work in the United States as caregivers to America’s seniors. To keep costs low and to allow broad participation among elderly Americans, wages could be set by federal law at (or even well below) the standard federal minimum wage of $7.25.

Critics on the left no doubt will be quick to characterize sub-minimum wage levels as exploitative and unfair. By the standards of the developed world, such wages would indeed be undesirable and insufficient to sustain a middle-class standard of living. However, wages that seem a pittance to those in the developed world would be a small fortune to those in the developing world who eke out an existence not at a wage of $7.25 per hour, but rather $7.25 per day—or per week.

The opportunity to work in the United States — even at sub-federal minimum wage levels — would be highly attractive to English-speaking individuals who live in dire poverty in some of the world’s most underdeveloped countries. Once their terms of employment in the U.S. conclude, HCGWs would return to their home countries having earned more money in a few years than many of their neighbors could hope to earn after decades of work.

Providing in-home care would deliver a cost savings compared to long-term nursing home care, which costs Medicaid around $125 per patient per day. To ensure that HCGWs deliver an adequate standard of care, registered nurses from local hospitals or counties’ departments of public health could visit senior citizens’ houses to monitor the patients’ conditions on a regular basis (with appropriate reimbursement by HHS).

A HCGW initiative would by no means end the need for nursing home care in the United States. Rather, it would relieve some of the cost burden on the federal Medicaid program by ensuring that only those who truly need nursing home care would be placed in such a setting after lower-cost, in-home care becomes infeasible.

Congress could choose from any number of funding models, including the use of a sliding scale that takes into account a senior’s ability to pay for HCGW-related services, as measured by net worth. Medicaid-eligible (i.e., poor) seniors would pay nothing during their lifetimes; an updated, federal-level Medicaid Estate Recovery Program (coordinated by HHS) could be implemented to recover some of the expenses incurred by HHS in conjunction with an indigent, elderly individual’s in-home care.

Consistent with the sliding-scale approach, moderate-asset seniors would pay a significant portion of the actual cost of care, and high-net-worth seniors would pay the actual cost of the services provided.

Increased access to in-home care would be tremendously popular with seniors. According to a 2018 AARP study, 76% of Americans age 50 and older “prefer to remain in their current residence as they age.”

Seniors across the country who want to age in place should have a realistic means of staying in a location that is familiar, safe, and comfortable. Health care guest workers could be an integral part of the solution.

Brian Bartoz is a political scientist.

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