The Nursing Home Industry at the Crossroads of Immigration

Direct care workers are the mainstay of nursing homes (NHs), assisted living facilities (ALFs), and home health care agencies, providing services to millions of older and disabled Americans. These predominantly lower wage jobs are both physically and emotionally grueling and are often stigmatized by other sectors of the health care industry as well as society in general. As a consequence, certified nursing assistants are increasingly difficult to recruit and retain. The Migration Policy Institute reported that 17% of the 12.4 million people employed in the United States in health care occupations in 2015 were immigrants and that immigrants constitute the highest educated (28%) and the lowest educated (24%) segments of the health care industry. Immigrant women are more likely to be in that 24% category while performing direct care services.

The New York Times reported on February 2, 2018, that 1 in 4 of the direct care staff employed in NHs and ALFs are foreign born. When examining what is known as the “gray market”—older adults paying under the table for personal care services—the impact of the increased demand for workers requires a concerted effort to address the gap between supply of direct care staff with the rising demand for these services.

As the demand for elder care workers increases as baby boomers age, increasing competition to secure enough staff for long-term care facilities will lead to significant shortages of staff. The fact that the overwhelming number of front-line staff are women who have long been economically disadvantaged and limited in their ability to access health insurance complicates the industry’s need to develop a long-term solution to the supply of nursing assistants, including support for their health, education, and social needs.

In their report to the US Department of Health and Human Services titled “Who Will Care for Us? Addressing the Long-Term Care Workforce Crisis” nearly 20 years ago, Robin Stone and Joshua Weiner argued that multiple policy initiatives were needed to address the impending wave of Americans requiring some degree of support, including reimbursement, regulatory, labor, welfare, and immigration policy. They noted that several European countries with rapidly aging populations have initiated policies to encourage immigration from countries with large supplies of direct care workers. Stone and Weiner warn that focusing on highly skilled immigrants as a priority for both temporary and permanent residency will be of little benefit to an industry that relies on lower-skilled immigrants to provide basic care. As unpopular as this notion may be, the authors suggest that some form of public assistance will likely be necessary to support these immigrants as well as American citizens who may need to rely on food stamps and other government programs despite working fulltime in the long-term care industry.

No matter what political views you may personally hold, the issue of immigration does significantly impact the long-term care industry. Long-term care providers need to consider how immigration reform will impact the industry and what steps need to be taken to ensure sufficient numbers of professionally trained staff will be available to provide care today and in the future.

Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, has been practicing nursing for 33 years, specializing in the care of geriatric patients. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.

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