In countries far along in the demographic transition, rapidly aging populations are colliding with a severe shortage of health care and elder care workers. Japan may be the most pertinent case study of this and other impacts of demographic disruption. The country’s fertility rate is decreasing faster than projected, and as of 2025, 30% of its population was aged 65 or older. These trends have contributed to a persistent gap between surging demand for elder care and a shrinking care workforce.

To cope with this crisis, the Japanese government has implemented several programs to promote the use of robots in nursing home care. These care robots (or “kaigo robots”) assist care workers and support residents with daily needs. But how does their adoption affect workflows, staff retention, and overall staffing of long-term care facilities? Few studies have empirically examined these questions.

Shedding light on the debate surrounding new automation technologies and their impact on workers, a recent study, published on August 6 in the inaugural issue of the journal Health Affairs Review, finds that care robots help address challenges posed by population aging and care-labor shortages without necessarily displacing workers or lowering care quality.

The study, titled Robots and Labor in the Service Sector: Evidence from Nursing Homes, is part of a collaborative effort driven by the Asia Health Policy Program (AHPP) at the Walter H. Shorenstein Asia-Pacific Research Center. The study’s co-authors are Stanford health economist Karen Eggleston, the director of AHPP; Toshiaki Iizuka of the University of Tokyo’s Graduate School of Economics, a former AHPP visiting scholar; Yong Suk Lee of the University of Notre Dame’s Keough School of Global Affairs, formerly the SK Center Fellow at Stanford’s Freeman Spogli Institute for International Studies; and Ellie Xi, a rising junior at Stanford studying biomedical computation on the pre-med track and a former research assistant to Dr. Eggleston.

“One of the aspects of the paper that I found most interesting is its attempt to move beyond simply documenting where robots are being adopted and instead ask what their adoption may actually do to the long-term care workforce, especially given the sector’s high turnover rates and physically demanding working conditions,” says Xi.

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Lessons from Early Diffusion of Robotics in the Long-Term Care Sector

The researchers grouped the robots prevalent in Japanese nursing homes into three main categories:

• Transfer aids: Wearable and non-wearable devices that assist staff with lifting frail residents from beds to wheelchairs, significantly reducing back strain, a leading cause of caregiver burnout.
• Mobility robots: Assistive systems that help residents move, use the restroom, or bathe more independently.
• Monitoring and communication systems: Sensors that alert staff when a resident has slipped out of bed or fallen, as well as social robots designed to offer companionship and cognitive stimulation.

To examine early diffusion of these robots, the researchers used 2017 survey data on long-term care work across approximately 860 Japanese nursing homes. A second source of data is their compilation of prefecture-level care robot subsidy availability, using regional variation in robot subsidies as an instrumental variable. Think of this as a natural experiment driven by a “geographic nudge.” Starting in 2015, Japan’s central government began providing prefectural governments with funds to subsidize the cost of adopting care robots. Because different prefectures introduced these subsidies at different times and with varying levels of generosity, nursing homes in some regions had a much easier path to acquiring and deploying robots than those in neighboring areas.

By comparing staffing trends between nursing homes that received this external, subsidy-driven "nudge" to adopt robots and those that did not, the researchers could confidently isolate the technology’s causal effects on the caregiving workforce.

The results indicate that nursing homes that adopted robots saw a significant decrease in staffing retention problems. Robot adoption was also associated with a 28% increase in care workers and a 39% increase in nurses, resulting in approximately 26% higher total employment at the facility level. Importantly, this employment growth occurred entirely among non-regular employees – that is, staff members on flexible, often part-time, contracts. The findings also suggest that robot adoption may improve continuity and quality of care while mitigating careworker shortages.

“Using nationally representative data from Japan and an instrumental-variable strategy, the study provides evidence suggesting that robots can complement rather than simply replace care workers, including by alleviating retention difficulties in a sector facing persistent labor shortages and potentially supporting quality of care,” explains Xi. “The paper’s central finding is that robot adoption is associated with reduced retention difficulties and increased employment of care workers and nurses under flexible contracts.”

A Human-Robot Collaborative Future for Elder Care

Caregiving is a physically demanding and high-stress occupation. The study’s findings indicate that, by introducing robots to ease staff burdens and monitor residents, nursing homes were able to promote more flexible work, either by increasing the tasks performed by non-regular employees or potentially encouraging part-time work. This type of work structure is encouraged by the Japan Nursing Association as a means for reducing stress, preventing burnout, and promoting a healthier work-life balance.

“Given recent debates about AI use in healthcare and the future of work, I found it especially interesting that this research highlights the potential for technology to augment caregivers, particularly by supporting physically demanding or indirect tasks, while preserving the human aspects of care that are more difficult to reproduce,” says Xi.

The study's findings are relevant for policymakers seeking evidence on the social value of collaborative robots and their impacts on staffing and care delivery, particularly as aging societies facing demographic pressures similar to Japan consider how to meet growing demand for long-term care.

A Mentorship Story

The study is part of Eggleston’s Innovation for Healthy Aging research track, which investigates how East Asian economies adopt and adapt to emerging technologies, design incentives, and adjust their workforces to support older adults. It builds on an earlier research project focused on the impact of robots on nursing home care in Japan.

For Xi, co-authoring the paper represents an academic milestone. "As someone deeply interested in geriatrics, I first began working with Dr. Karen Eggleston as a research assistant during the summer after my freshman year," Xi recalls. "Last spring, we decided to continue working together through a directed reading."

During that directed reading, Xi was invited to help revise and update a project that had previously circulated as an Asia Health Policy Program working paper. She worked to update the research, framing the original findings within the rapidly shifting landscape of care robotics and artificial intelligence in long-term care.

"I worked on situating the original findings within more recent research and developments in care robotics and considering what Japan’s experience can tell us about the role of these technologies in aging societies today," Xi says. "It was an incredible opportunity to work closely with Dr. Eggleston, Professor Toshiaki Iizuka, and Professor Yong Suk Lee. I was especially grateful to see firsthand how a collaborative project evolves and to contribute to that process as the paper moved from a working paper toward publication.”

"That advantage is entirely theoretical," Doshi conceded. "Unlocking its potential, though, is the central task of American statecraft in this century." In practice, that might mean Japan and South Korea investing in American shipbuilding; Taiwan building semiconductor plants in the U.S.; allies co-producing advanced weapons systems; and all parties maintaining a shared tariff or regulatory wall against China's excess industrial capacity. On the economic side, Doshi called for common investment screening, coordinated industrial policy, and an "economic Article 5" ensuring that when China uses economic coercion against one ally, all respond together.

Addressing the Skeptics
Doshi acknowledged "the new pessimism," the view that Trump-era damage to U.S. alliances has made allied scale impossible. The strain is real, he said, but not terminal, for three reasons:

1. The alternatives are worse. Spheres of influence, unrestrained multipolarity, and a China-led order all leave the U.S. and its partners poorer and less secure. 
2. Alliances have absorbed serious shocks before and survived. For example, France's withdrawal from NATO's unified command, Nixon's opening to China, the Plaza Accord. 
3. The underlying logic of interdependence persists. Allied economies are growing more dependent on U.S. markets as China buys less from them, allies are purchasing record numbers of American weapons, and even the Trump administration has not escaped the pull of allied scale, with Vice President Vance publicly calling for a trading bloc among allies to break China's chokehold on critical minerals.

Eight Principles to Achieve Allied Scale
Doshi closed with a practical blueprint — eight principles for building allied scale.

1. Turn the page on the Trump era. Persuade allies that the most damaging recent policies were products of individual leadership rather than durable features of the American political system.

2. Begin with humility. Start with small, achievable projects: a joint shipbuilding effort, a critical minerals offtake agreement, a co-production line. Build from there.

3. Build mutually beneficial bargains. Allies invest in America; America invests in allies. All extend each other more preferential terms than they do to non-market economies like China.

4. Pay attention to domestic politics. “The danger of the ‘Trump Approach’ is alienation and polarization of allied politics that makes diplomacy impossible.” Any allied scale strategy must be first grounded in domestic politics.

5. Build ad hoc coalitions. Allied scale does not mean doing everything with everyone. It means assembling the right groupings for specific challenges and opportunities.

6. Bolster credibility through congressional legislation. Executive orders are too easily reversed. Durable commitments to allies require legislative backing that is harder to undo with a change in administration.

7. Build on existing platforms. Frameworks like the Quad, AUKUS, the U.S.-Japan-South Korea trilateral, and the G7 already exist. Allied scale should strengthen what works, not start from scratch.

8. Articulate an affirmative vision. "Allied scale can't just be about balancing China," Doshi said. "It has to be about building the kind of world that we want to see and live in."

“That work is hard,” Doshi concluded, but “it's not impossible. And the alternatives are far more concerning than the future that I’m outlining.” Doshi ended his address on a note of optimism: a call to action for the U.S. to reforge our alliances and rebalance the world order to create a better world for not just the U.S., but for nations across the globe.

A full recording of Dr. Rush Doshi’s talk is available on YouTube and below.

This article was supported by research using Claude. All outputs were reviewed by humans and the final expression was produced by the author.