This article is part of the HHCN+ membership
The Trump administration's immigration crackdown has urged care providers at home-based caregivers, fearing that changing policies for migrant workers could lead to intrinsic staff losses, and providers are beginning to realize these threats.
In early July, the US Department of Homeland Security (DHS) notified Honor CEO Seth Sternberg that some of its employees could be revoked.
“Given the notification from DHS, we will begin to reaffirm the eligibility of current employees who have already been verified and are permitted to work,” Sternberg told Home Health Care News. “If an employee's approval is revoked, it must be removed from the client and replaced with another employee.”
The San Francisco-based honor is a home care technology company that instead owns a home.
Sternberg said in a LinkedIn post that his team “doesn't make sense” while following the law.
“This does not rule out immigrants with criminal records,” he wrote. “This is to cancel work approvals for thousands of documented workers (several professional caregivers) that our seniors need.”
A significant number of home care providers rely on foreign-born labor. According to Leadingage, more than 30% of all home care aides and more than 20% of nursing assistants are born abroad.
John Sneath, CEO of Framingham, Massachusetts-based Tribute Home Care, said his company had received similar notices, already losing nine caregivers and at least six are at risk. This not only presents the issue with employees being fired, but also the company and its clients.
In Massachusetts, one in four healthcare workers are immigrants. The proportion was even higher, with 46% of foreign-born labor even before the recent influx of immigrants to the nation.
Immigration is an important part of long-term care workers in other parts of the United States. As of 2023, more than 820,000 immigrants were providing long-term care in the United States as direct care workers providing long-term care in the United States, according to KFF. In particular, the share of direct care workers providing immigrant LTC services increased from 24% in 2018 to 28% in 2023.
“All of these caregivers were working with clients who had a relationship with them. It was tough for them. Obviously, everyone works in the compliments and sees it happen,” Sneath told HHCN.
The need for change
In a letter to Executive Director Kristi Noem on April 30, Leading CEO Katie Smith Sloan said the DHS decision “generated immediate uncertainty and concerns for employers and workers as well.”
“Unlike other sectors that rely heavily on foreign-born workers, the aging services sector requires continuity, consistency and trust between direct care workers and workers who serve,” writes Sloan. “Long-term relationships with staff directly contribute to the emotional well-being and security of residents. The sudden loss of these individuals makes care routines uncertain and reduces the quality and distress of care for residents who rely on familiar, stable support in their daily lives.”
Sneath understands the argument that the US hopes that more Americans have the opportunity to be placed in these care positions, but the fact is that not many Americans apply.
“Not many Americans apply, especially in Massachusetts,” he explained. “In Maryland, about half of caregivers are born in the United States. Let's look at the industry and think of a system that identifies systems that can use foreign-born workers.”
Beyond filling in positions that Americans don't necessarily apply, Sneath said foreign-born caregivers often bring a different perspective to caregivers, as they come from countries where caring for elders is usually a cultural norm.
“It may sound cliché, but many caregivers came from countries that care for relatives, and referrals to care were caring for (elder relatives),” he shared. “They have sensitivity and experience.”
Sternberg pointed out that the opinion is not political, but it is “to protect the caregiving infrastructure on which millions of families depend.”
“When the workforce is already struggling to keep up with demand, revoking approval of legal work from people caring for our seniors is deeply counterproductive,” he said. “It won't have people they know, trust and trust. It will increase the cost of care.”
Within the law
These regulations come when Congress recently proposed a bill to support Home and Community-Based Services (HCB).
The bill will allocate Medicaid funds to states for two years to stabilize the HCBS service network, recruit and maintain HCBS direct care workers, and to meet the long-term service and support needs of individuals who can accommodate Medicaid home-based and community-based services.
But according to Sternberg, “Mathematics doesn't work,” agreed David Jackson, CEO of Choice Health at home.
A massive deportation of undocumented immigrants could lead to a loss of $1.1 trillion to $1.7 trillion from US gross product in 2022, according to a report by the U.S. Immigration Council. Meanwhile, Medicare spending on home health care is continuing to decline.
“It's hard to ignore juxtaposition,” Jackson said. “We're saving money and reducing Medicare benefits that help older people get aging properly. Meanwhile, we're doubling the deportation policy that could erode the very workforce we rely on, all of which is happening as the deficit increases.”
Headquartered in Tyler, Texas, Choice Health is a multi-state provider of home hygiene, hospice, personal care and rehabilitation services.
Jackson said one of the most difficult parts for him is seeing fear in the faces of legal resident caregivers.
“It's difficult for me and I hope that the rhetoric will change a little,” he said. “I don't think these people should be afraid of being good people who just care for those who need to be cared for. We've done a lot of work to create confidence, but that's the fear of our employees.
Sternberg writes that if the US tries to cancel one program, it is “essential to replace it with another,” and lawmakers need to expand it, rather than shrinking the already shallow, shallow caregivers workforce. This means training qualified Americans who want to be caregivers, but there aren't enough people for the job. He asked lawmakers to establish work approval programs, saying that coming from other countries' qualified personnel to the United States would allow our elderly population to gracefully endow them with age, and “there is no other solution.”
Inside the immigration law
The new law could improve the ranking of home care providers facing staff cuts due to stricter immigration policies. To reform immigration and to make long-term immigrants work, Congressional Maria Elvira Salazar (R-FLA.) and Veronica Escobar (D-Texas) introduced the 2025 Dignity Act on July 15th.
The goal of this law is to ensure borders, implement measures, improve the U.S. asylum system, ensure long-term immigration dignity, support American workers, and strengthen the legal immigration process.
“Immigrants, especially those who have been in the United States for decades, constitute important components of our community and the American workforce and economy,” Escobar said. “The majority of immigrants are hardworking, law-abiding residents, and most Americans recognize that finding bipartisan reform is in our country's greatest interest.”
Part of the law includes the creation of a dignity programme that provides a seven-year temporary legal status to undocumented immigrants who have been in the country for more than five years prior to 2021. As a program's requirement, immigrants must pass a criminal history check and pay $7,000 over seven years. Once these conditions are met, they can stay and work in the country.
The law also creates a new $70 billion fund that trains and trains American workers by providing subsidies for apprenticeships, on-site training and higher education. The fund is funded through payments made by immigrants in the Dignity Program.
In a statement, Leadingage said it supports the law while advocacy groups work towards “a subsequent bipartisan bill that addresses the reforms needed to benefit more directly from members by creating and expanding legal pathways for foreign-born workers to enter the aging services sector.”
“Leadingage continues to advocate for these types of reforms to be added to the Dignity Act or other laws, monitor the progress of the bill, assess the impact on providers and direct care workers, and advocate for administrations for immigration policies that benefit the ageing service workforce before Congress.”
Although such laws are the beginning, providers like Sternberg believe there is still progress in solving the problems between the immigration situation and maintaining caregivers in home care.
“We encourage lawmakers to consider the full impact of these decisions and quickly implement a prompt visa policy for qualified individuals who want to look after seniors in America,” Sternberg said. “If there's no caregiver, there's no warning.”
