By Robyn I. Stone and Natasha Bryant
Immigration policy has become a political “hot potato” since Donald Trump was elected. Although this issue has been subject to debate for decades, President Trump has implemented strict immigration policies that increase deportations and limit immigrants coming into the United States. Changes in immigration policy have potentially dire consequences for America’s aging population, particularly with respect to the availability of direct care workers—certified nursing assistants, homecare aides, and personal care workers who provide the lion’s share of formal long-term services and supports (LTSS) to older adults.
Several demographic changes will create workforce challenges in the LTSS sector over the next twenty years (Gonyea, 2009; Stone, 2015). These include the projected growth of the older adult population, especially people ages 85 and older, who are most likely to need these services; reduced availability of family caregivers due to increased incidence of childlessness and divorces among middle-age and older women; and expanding career options for working-age women, who have traditionally provided paid and unpaid care. Collectively, these trends point to an increased demand for formal services and a decrease in the availability of informal and formal caregivers to meet that demand.
Foreign-born individuals currently represent a large segment of the direct care workforce across LTSS settings. Mass deportation and limits on immigration are negatively affecting employed immigrant workers, and will likely reduce the pipeline of workers, as the United States begins to experience a significant demand for LTSS and a workforce shortage.
This article summarizes the prevalence and characteristics of the immigrant direct care workforce, describes how these workers come to the United States, highlights the importance of the immigrant workforce to LTSS service delivery, reviews the implications of today’s immigration policy for the current and future immigrant direct care workforce, and provides an alternative vision for immigration reform that supports direct care workforce development.
The Immigrant Direct Care Workforce
Roughly one-fourth of all direct care workers are immigrants who provide hands-on care to older adults. In 2015, this group totaled approximately 860,000 individuals; if workers hired independently by consumers are considered, there may be more than 1 million immigrants in the LTSS field (Espinoza, 2017). Proportions vary by location; in New York, California, New Jersey, Hawaii, and Florida, for example, immigrants comprise more than 40 percent of direct care workers (Espinoza, 2017). An estimated 10 percent to 20 percent of direct care workers are unauthorized immigrants, although this may be an underestimate because there is a large gray market in which much of the work provided by unauthorized workers goes undocumented (Espinoza, 2017).
Immigrant workers are more prevalent in homecare (28 percent) than in nursing home settings (20 percent) (Espinoza, 2017), which may be related to less stringent regulation and oversight in homecare. In addition, the organizational structure of nursing homes may require better language skills than in the homecare setting (Rodrigues, Huber, and Lamura, 2012). Immigrant workers are more prevalent in the private sector than in the nonprofit sector.
Immigrant workers primarily come from the Caribbean (25 percent), Central America (19 percent), and Southeast Asia (13 percent), with Mexico (15 percent), the Philippines (10 percent), and Jamaica (7 percent) representing the top three countries. Spanish is the most common language spoken at home among immigrant workers (Espinoza, 2017). Immigrant direct care workers tend to have a higher education and more advanced qualifications than are normally required for the work they perform, likely because credentials and qualifications earned in workers’ countries of origin frequently are not recognized in the United States (Rodrigues, Huber, and Lamura, 2012).
These workers are predominately low-paid (median annual income is $19,000), middle-age women (median age is 48). Fifty-six percent are U.S. citizens by naturalization; this population of workers tends to be older and have a higher percentage of males, non-whites, and people of Hispanic origin than their native-born peers. As a group, they experience high poverty rates—44 percent live at or below 200 percent of the Federal Poverty Level—and two out of five immigrant workers rely on public benefits. (Espinoza, 2017). Recent studies have found that immigrant aides are more likely than native-born caregivers to work full time and experience less favorable work conditions, such as working longer hours and being assigned to the night shift (van Hooren, 2012; Shutes and Chiatti, 2012; Khatutsky, Wiener, and Anderson, 2010).
Pathways to Employment in the U.S. Workforce
The three main paths of admission into the U.S. workforce are legal permanent admissions (with a visa supporting work), temporary legal admission (with a visa supporting work), and unauthorized work (with either authorized or unauthorized entry). Legal permanent immigrants, also known as Green Card holders, are persons who are entitled to live and work permanently in the United States and can apply to become U.S. citizens if they meet certain eligibility requirements. Individuals may enter for family unification, humanitarian interests (refugees who were resettled from overseas and those who sought asylum), and employment.
Legal temporary workers are those who enter the country for a limited time period through a visa process and are not considered permanent or indefinite. The United States has few dedicated avenues of legal admission for direct care workers (Martin et al., 2009). The permanent and temporary classes of admission admit substantial numbers of professional healthcare providers, but there are effectively no visas for direct care workers. Most direct care workers enter the United States via family unification or refugee programs.
The Value of Immigrant Direct Care Workers
Having a supply of foreign-born direct care workers is important to the development of the direct care workforce. They comprise a large proportion of today’s workforce, and are likely to be essential to meet current and future demand for LTSS. Aging services providers often have difficulty attracting and retaining native-born workers and cannot rely on traditional sources of labor, particularly in robust economies when higher-paid job options are available in healthcare or other sectors. Immigrants fill care gaps within geographic areas experiencing a serious labor shortage, and mitigate shortages in both the formal care sector and the gray labor market, where caregivers are employed directly by families.
Foreign-born caregivers are more likely than native-born LTSS workers to hold positive attitudes about their supervisors, to demonstrate a willingness to learn new skills, to be satisfied with workplace morale and their jobs, and to be very confident in their ability to do their jobs (Khatutsky, Wiener, and Anderson, 2010; Bryant, Sutton, and Stone, 2015). There is some evidence that foreign-born workers demonstrate more loyalty and experience less turnover than native-born workers (Spencer et al., 2010). Low turnover among immigrant workers may be attributed to the strong employer-based networks that form among caregivers coming from the same nation or region.
There is no literature about the effects of employing foreign-born rather than native-born workers upon quality of care. Some evidence suggests that actively diversifying the LTSS workforce by hiring immigrant workers may improve outcomes for certain ethnic and linguistic minority client populations. Sullivan and Mittman’s research (2010) concluded that clients or senior facility residents who are matched with immigrant workers from the same racial, ethnic, or linguistic backgrounds report greater satisfaction, are likely to better understand medication instructions, and to demonstrate greater overall medication compliance.
Employing immigrant workers helps to build a culturally competent system of care to meet the needs of an increasingly diverse consumer population. The number of immigrants ages 65 and older more than doubled from 2.7 million in 1990 to almost 5 million in 2010—encompassing 12 percent of the older adult population in the United States. One quarter was between the ages of 80 to 89 (Batalova, 2012). Immigrant workers can provide linguistically and culturally appropriate support to these older adults, and can offer employers the opportunity to match older clients or senior facility residents with workers who share their culture (Priester and Reinardy, 2003).
Implications of Current Immigration Policy for Direct Care Workers
The executive and legislative branches of the federal government have been exploring immigration reform for several decades. In 2012, President Obama began the Deferred Action for Childhood Arrivals (DACA) program that “offers renewable, two-year deportation deferrals and work permits to undocumented immigrants who had arrived in the U.S. as children and had no criminal record.” By March 2018, more than 800,000 people had taken advantage of DACA (Felter and Renwick, 2018).
President Trump came into office with significant immigration reform as a major part of his political and policy agenda. In less than two years he has signed several executive orders focused on border security and interior enforcement and on reversing policies enacted by the Obama Administration that make it more difficult for immigrants to come to or remain in the United States. These orders expanded application of expedited removal to anyone who cannot prove they have been in the United States for two years, and expanded the categories of immigrants who can be considered for deportation, including DACA recipients.
The Trump Administration has more than halved the annual cap of refugees admitted to the United States to 50,000, making it more difficult for individuals to seek asylum, and also has ended the Temporary Protected Status (TPS) program for immigrants from El Salvador, Haiti, Sudan, and Nicaragua. TPS permitted this special class of beneficiaries to live and work legally in the United States; they now have up to six months to more than a year, depending on the country, to voluntarily leave the United States or face deportation (Felter and Renwick, 2018; Bailey, 2018).
President Trump announced plans to phase out DACA, but said current beneficiaries would be allowed to renew their status up to March 2018. A judge in San Francisco has ruled that DACA must remain open as long as legal challenges continue and as lawmakers in Congress continue to debate a potential deal to extend legal protections for those covered by DACA.
Congress has debated numerous pieces of immigration reform over the past two decades, but as of June 2018 had not yet passed legislation. The RAISE (Reforming American Immigration for Strong Employment) Act, for example, would reduce legal immigration from 1 million people annually to around 500,000—largely through cuts to family-based immigration—steeply restricting the number of spouses, children, parents, and siblings that citizens and legal permanent residents could sponsor for immigration. It also would end the diversity visa program and limit acceptance of refugees, which would be capped at 50,000 annually (Campbell, 2018).
While there are no hard data to document the short-term effects of the recent zero tolerance policy and other Trump Administration attacks on immigrants, anecdotes suggest that these efforts are negatively affecting the perceptions and the behavior of incumbent immigrant direct care workers and contributing to the LTSS labor shortage nationwide. Because the family-based path to legal status often is the only option available to immigrant direct care workers, significantly reducing or eliminating this avenue in favor of a “merit-based” policy—under exploration by President Trump—would diminish the pool of direct care workers entering the United States and worsen an already severe shortage of aides who care for frail older adults and younger people with disabilities.
Mass deportation and large numbers of immigrants unable to work or who are fearful of attracting unwanted attention create a tremendous strain on the LTSS workforce and undermine its stability. Unknown numbers of workers are DACA recipients who might eventually be forced to leave the country. Although the size of the immigrant direct care workforce with TPS status is unknown, employers and families who have hired caregivers from Haiti, El Salvador, Nicaragua, and Honduras risk losing this workforce if these workers are deported. Legal immigrant workers may consider moving when relatives are deported and when their neighborhoods and communities feel targeted (Bailey, 2018).
At any time, unauthorized immigrants could be subject to deportation or other uncertainties in their status. If 20 percent of direct care workers are undocumented and deported under the Trump Administration’s policies, the older adult caregiving population would lose about 200,000 persons (SeniorsMatter.com, 2017). One study analyzing the impact of immigration reform on the long-term-care insurance industry (Ulery, 2018) focused on the impact of a scenario where the number of unauthorized immigrants declines at an escalated pace and more LTSS jobs are filled by U.S. citizens and authorized immigrants, both of whom on average earn higher wages. The study concluded that an increase in the average cost of services provided by U.S. citizens, coupled with a decrease in the population of unauthorized immigrants and an increase in demand for direct care workers with U.S. citizenship, would lead to higher costs of LTSS and more expensive insurance claims.
Assuming an optimistic scenario of only a 2 percent increase in future claims, this would add at least another $3.6 billion to total industry claims, where there is no supply-and-demand influence on additional wage inflation. In a worse scenario assuming 30 percent higher future claims, these actions could add $22.8 billion or more.
The fear of deportation may cause some to find employment as caregivers in private homes, depleting the pool of individuals available to nursing homes, assisted living facilities, and homecare agencies. Given current anti-immigrant rhetoric, many immigrants may be hesitant to apply for direct care jobs, as one human resource director for an LTSS provider told The New York Times. She reported seeing a reduction in the number of immigrant applicants, and believes the Trump Administration’s immigration policies have discouraged potential workers (Span, 2018).
Ultimately, these reforms may cause LTSS providers to stop admissions or shut down because they are unable to hire enough staff. Older adults receiving homecare may not be able to find workers. This will leave many elders without care and create an added strain on families (Bailey, 2018).
The emotional toll of deportations and anti-immigrant rhetoric can be significant for immigrant direct care workers who choose to remain in their jobs. Distress, fear, and a sense of insecurity among workers may translate into poorer performance and undermine relationships with other staff and care recipients (Campbell, 2018). The psychological impact on older clients or senior facility residents also may be significant—especially for those with cognitive impairment; for them, consistency is an important factor in their quality of life.
An Alternative Vision of Immigration Reform
Any changes to the structure of immigration policy have the potential to profoundly shape the circumstances of foreign-born direct care workers and the potential pool of individuals available to provide LTSS to America’s aging society. Over the past year, a proliferation of articles in social media and the mainstream press have documented the potentially negative implications of the Trump Administration’s and Congress’s initiatives to increase deportation and reduce immigration through family unification. A growing number of consumer, provider, and direct care worker groups, including Caring Across Generations, the Eldercare Workforce Alliance, PHI, and provider organizations such as LeadingAge, are fighting the Trump Administration’s actions and legislative proposals and advocating for immigration reforms that recognize the essential role immigrants play in delivering LTSS, today and in the future.
Predictions of strong job growth in the LTSS sector, particularly in the direct care workforce, suggest the need for changes in the structure of immigration policy that differ dramatically from those implemented or proposed by the Trump Administration and Congress. Policies that make it easier for people to legally work in the United States, such as expanding the visa system to recognize these jobs as merit occupations rather than relying on immigrants who entered through family unification; this strategy would increase the number of direct care workers, put immigrant workers on an even playing field with native-born workers, and create fairer competition for jobs. Also, it would be important for ensuring quality of care, as it allows for improved training and makes it easier to ensure that all direct care workers are doing their jobs effectively.
In response to increasing demand for LTSS workers, several countries have created permanent migration channels for direct care workers, and special visas for LTSS workers. Canada’s Live-in Caregiver Program admits migrant direct care workers if they fulfill certain criteria before admission. Live-in caregivers can apply to become permanent Canadian residents if they complete two years of caregiving work within three years of arrival. Israel has private agencies that recruit foreign-born workers to fill LTSS vacancies left by native-born workers. These agencies also train workers while they are still living in their countries of origin. Foreign-born aides who work in the caregiving sector are registered and permitted to work in Israel for a period of up to five years, at which time they are required to leave the country. Israel has bilateral agreements with Nepal and Sri Lanka, governing the hiring and oversight of live-in caregivers (The Global Ageing Network and LeadingAge LTSS Center @UMass Boston, 2018).
In addition, several Organisation for Economic Co-operation and Development countries that rely on foreign-born, undocumented LTSS workers issue work permits and implement regularization programs that give migrants who are in a country without authorization the opportunity to legalize their status. Regularization programs guarantee that foreign-born LTSS workers are paid a minimum wage, and have access to good working conditions and formal training, which can help ensure high standards of care (The Global Ageing Network and LeadingAge LTSS Center @UMass Boston, 2018).
Another option to increase pathways to legal status and increase the availability of temporary workers is to create a “provisional visa” for workers at all skill levels, including direct care workers. This option would allow the immigration system to readily respond to current and emerging demands for workers by making adjustments according to labor standards. The federal government and states could share authority for selecting immigrants to the United States, creating an alternative “hybrid model” path for admission. The federal government could determine the number of visas permitted, based on specific criteria. States could use a point system to assess and address labor shortages (Bryant, Sutton, and Stone, 2015).
The politics of immigration is an important component of the politics of aging. Stakeholders concerned about “who will care for grandma” need to recognize the implications of current immigration reform proposals and advocate for an alternative strategy that helps to build a pipeline of quality direct care workers today, and going forward.
Robyn I. Stone, Dr.P.H., is senior vice president for Research at LeadingAge in Washington, D.C. She can be contacted at email@example.com. Natasha Bryant, M.A., is managing director and senior research associate at the LeadingAge LTSS Center @UMass Boston in Washington, D.C. She can be contacted at firstname.lastname@example.org.
This article is taken from the Winter 2019 Issue of Generations, which examines politics and aging. ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store.
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