combination of private, paid caregivers and family caregivers. The healthcare industry consolidation trend examined in this article is unlikely to substantially affect the availability, affordability, or quality of private, independent, self-employed LTSS caregivers whom consumers seek to hire with their own funds, 93 although certainly there will be other challenges to the retention and expansion of an adequate number of unaffiliated direct-care workers. 94 Similarly, consolidation should have little impact on paid or informal family caregiving for consumers who need LTSS at home, neither lightening nor worsening the availability of family caregivers to LTSS consumers. 95 Confronting the LTSS system’s extremely extensive dependence on informal caregiving is a matter of grave and immediate public policy concern. 96
It is estimated that informal caregivers voluntarily provide three quarters of all long-term care to elderly friends and family members. In 2009, the unpaid care that was provided by 42 million family caregivers was valued at approximately $450 billion dollars. However, the configuration of the modern family has made caregiving an ever more challenging activity. In addition, family caregivers are no longer solely assisting in instrumental activities of daily living (preparing meals and paying bills) and activities of daily living (helping to bathe and feed); rather, many are providing complex medical care to their older loved ones. 97
The adverse effects of family (and even more pointedly, female) 98 caregiver burden (physical, mental, and financial) must be addressed on an
CAREGIVING IN THE U.S. (2015); Sketchley and McMillan, supra note 86. 93. “According to the Bureau of Labor Statistics (“BLS”) estimates, nearly a quarter of personal and home care aides in 2008 were self-employed. This figure is undoubtedly an underestimate because national databases do not adequately capture this segment of the market.” Robyn I. Stone & Natasha S. Bryant, Educating Direct Care Workers on Transitions of Care, 31 ANN. REV. GERONTOLOGY & GERIA TRICS 167, 169 (2011). 94. See generally Lori Simon-Rusinowitz et al., Expanding the Consumer-Directed Workforce by Attracting and Retaining Unaffiliated Workers, 11 CARE MGMT. J. 74 (2010); see also Candace Howes, Love, Money, or Flexibility: What Motivates People to Work in Consumer-Directed Home Care?, 48 GERON TOLOGIST 46 (2008). 95. See generally A. E. Benjamin et al., Retention of Paid Related Caregivers: Who Stays and Who Leaves Home Care Careers?, 48 GERONTOLOGIST 104 (2008) (reporting on a study of the caregiving careers of “related workers” (families and friends of the LTSS consumer)). 96. See Allison K. Hoffman, The Reverberating Risk of Long-Term Care, 15 YALE J. HEALTH POL’Y, L. & ETHICS 57, 62 (2015); see generally Michael Poku, Letter, Be Mindful of the Caregiver, 63 J. AM. GERIATRICS SOC’Y 1723 (2015); see also Bridget Haeg, The Future of Caring for Elders in Their Homes: An Alternative to Nursing Homes, 9 NAELA J. 237, 240- 41 (2013). 97. Thomas & Applebaum, supra note 61, at 57. 98. See Mercedes Martinez-Marcos & Carmen De la Cuesta-Benjumea, How Women Caregivers Deal with Their Own Long-Term Illness: A Qualitative Study, 70 J. ADVANCED NURSING 1825, 1826 (2014).