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Care for America’s elderly and disabled people relies on immigrant labor

June 5, 2019

Topics: Quote of the Day

By Leah Zallman, Karen E. Finnegan, David U. Himmelstein, Sharon Touw, and Steffie Woolhandler
Health Affairs, June 2019


As the US wrestles with immigration policy and caring for an aging population, data on immigrants’ role as health care and long-term care workers can inform both debates. Previous studies have examined immigrants’ role as health care and direct care workers (nursing, home health, and personal care aides) but not that of immigrants hired by private households or nonmedical facilities such as senior housing to assist elderly and disabled people or unauthorized immigrants’ role in providing these services. Using nationally representative data, we found that in 2017 immigrants accounted for 18.2 percent of health care workers and 23.5 percent of formal and nonformal long-term care sector workers. More than one-quarter (27.5 percent) of direct care workers and 30.3 percent of nursing home housekeeping and maintenance workers were immigrants. Although legal noncitizen immigrants accounted for 5.2 percent of the US population, they made up 9.0 percent of direct care workers. Naturalized citizens, 6.8 percent of the US population, accounted for 13.9 percent of direct care workers. In light of the current and projected shortage of health care and direct care workers, our finding that immigrants fill a disproportionate share of such jobs suggests that policies curtailing immigration will likely compromise the availability of care for elderly and disabled Americans.

From the Introduction

As the US elderly population grows, health care workforce shortages (which already limit care) are expected to increase in the coming decades. The Institute of Medicine projects that 3.5 million additional health care workers will be needed by 2030. Currently, immigrants fill health care workforce shortages, providing disproportionate amounts of care overall and particularly for key shortage roles such as rural physicians. Immigrant health care workers are, on average, more educated than US-born workers, and they often work at lower professional levels in the US because of lack of certification or licensure. They work nontraditional shifts that are hard to fill (such as nights and weekends), and they bring linguistic and cultural diversity to address the needs of patients of varied ethnic backgrounds.

The size of the elderly population is expected to double by 2050, raising concern that long-term care workers will be in particularly short supply. Direct care workers—nursing, psychiatric, home health, and personal care aides—are the primary providers of paid hands-on care for more than thirteen million elderly and disabled Americans. These workers help elderly and disabled people live at home (the preferred setting for most people) by providing assistance with daily tasks such as bathing, dressing, and eating. They also help elderly and disabled people in nursing or psychiatric facilities when living at home is not possible and during transitions home after hospitalization.

Workers prepared to fill these roles are already in short supply, and the Health Resources and Services Administration projects a 34 percent rise in the demand for direct care workers over the next decade, equivalent to a need for 650,000 additional workers. Projected shortages are compounded by high turnover and retention challenges, which create ongoing obstacles to maintaining a sufficient labor supply for long-term care.

Recent years have seen a steep decline in the number of unauthorized immigrants entering the country. The administration of President Donald Trump has taken steps to further reduce the flow of immigrants and has proposed legislation to reduce the number of legal immigrants with a focus on “skilled immigrants,” which could sharply reduce the number of low-wage immigrant workers.


The US health care system as a whole is dependent on the work of over three million immigrants, who account for 18.2 percent of all health care workers. More than one in four direct care workers are immigrants, including nearly one in three direct care workers in home health agencies. Immigrants also account for a disproportionate share of housekeeping and maintenance personnel in nursing homes.

Our study adds to the literature on immigrants’ role in the nonformal direct care sector by including workers who are privately hired to support elderly and disabled people. We found that workers in the nonformal sector provide care to hundreds of thousands of people living at home or in other nonmedical settings such as senior housing. Such care likely reduces the need for (and expense of) institutional care.

Our findings have important implications for the care of elderly and disabled people. In light of current shortages, high turnover rates, low retention rates, growing demand for direct care workers, and immigrants’ already disproportionate role in filling such jobs, policies that curtail immigration are likely to compromise the availability of care. Moreover, the anti-immigrant rhetoric and policies that restrict immigration threaten the health and well-being of immigrants who are entrusted with the care of the nation’s elderly and disabled people.

Our study also adds to a growing literature that highlights immigrants’ support for the health care of the US born. We have previously documented that immigrants pay tens of billions of dollars more annually in taxes to Medicare and in premiums to private insurers than Medicare or private insurers pay out on their behalf, effectively subsidizing the care of US-born people. Immigrants also make major contributions to the health professions: One in four US physicians has been trained in a foreign medical school, including 38.6 percent of all US internists, 43.6 percent of cardiologists, and 50.7 percent of geriatricians. Our study highlights immigrants’ contribution to the everyday care of elderly and disabled people.

Addressing the direct care worker shortage will require a multifaceted approach, including better wages, benefits, and education and training programs to draw people into the labor force while reducing turnover. However, curtailing immigration will almost certainly move us in the wrong direction, worsening the shortage and the availability of high-quality care for elderly and disabled Americans.



By Don McCanne, M.D.

Health policy frequently interacts with other public policies, in this case with immigration policy. This study shows the very important role that immigrants have played in providing health care and long-term care, especially for elderly and disabled people.

Further, there has been a shortage in direct care workers and that is likely to worsen with the anticipated increase in the numbers of disabled elderly, and with the immigration policies that our current administration is putting into place. For our health, we need to support these workers through better wages and benefits, which we can do through a Single Payer Medicare for All program. but it will also be imperative that we get immigration policies right.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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