Tough new rules proposed by the Trump Administration would make it effectively impossible for immigrants to come to the US to work as home health aides or as staff at nursing homes or assisted living facilities.
Because at least one million aides (one of every four) is an immigrant, the complex rules Trump proposed over the weekend would dry up a major source of personal care for older adults or younger people with disabilities. At a time when the pool of available family caregivers is shrinking dramatically, the long-term result could be a caregiving catastrophe.
The Trump proposal exposes the existential paradox of our caregiving system. We pay the people who care for our aging parents and other disabled relatives so little that they must rely on public supports such as Food Stamps and Medicaid to survive. Yet the cost of long-term care is so high that most Americans already can’t afford it.
Slamming the door
In that environment, Trump would slam the door to an important source of direct care workers. The inevitable result: An even-more severe worker shortage than we already face perhaps higher wages. But where will the money come from to pay those workers?
The proposed new rules effect something called “public charge.” Trump wants to bar residency (green card) status and limit access for other types of visas for people who receive– or are likely to receive– most forms of public assistance. You can read the proposed rules here. For a good plain English explanation, here is a nice piece by Vox reporter Dara Lind.
This is the problem: Wages for home care workers and most staff at nursing homes and assisted living facilities are so low that many must rely on government support such as Food Stamps (SNAP), low-income housing assistance, or Medicaid.
According to Robert Espinoza of the Paraprofessional Healthcare Institute (PHI), 42 percent of immigrant direct care workers access public benefits. Two-thirds are Medicaid beneficiaries and more than half receive food and nutrition assistance. About 4 percent receive cash assistance (aka welfare).
Living on $11-an-hour
Their median wage is about $11 an hour. But because many home care aides work only part-time, their median annual income is $15,100. Keep in mind that these wages apply only to on-the-books aides. There are hundreds of thousands in the gray market about whom we know very little.
Wages are somewhat higher for nursing assistants in nursing homes: They make $21,200-a-year on average.
But even that wage is far below the income test included in the proposed rules. According to one interpretation, those making less than $62,750 in 2018 could be barred from residency in the US. And those making less than $31,375 would be penalized, according to the proposed new formula for determining residency.
Keep in mind that Medicaid itself, which effectively sets those very low wages, is a major reason why aides are paid so poorly. Given the state of the labor market, the far more sensible policy would be to raise the Medicaid wage, not cut the supply of workers.
Replenishing the worker pool
The proposed rules do not appear to apply to current green card holders, but would affect those immigrants who currently are in the US awaiting permanent resident status or those who come to the US in the future. In addition, because turnover among aides is so high, and because many aides are reaching an age when they can no longer do this physically demanding work, the pool of such workers must constantly be replenished.
Without new immigrants, there will be far too few workers to provide personal care. This at a time when the US population is rapidly aging and the demand for aides is rising. According to CareerCast, Americans will require a half-million more home health aides and 750,000 more personal care aides by 2025.
The new proposal is just the latest salvo in Trump’s long-standing war on immigration and on immigrant direct care workers. Not only has he moved aggressively to bar undocumented immigrants, he also has moved to limit legal immigration and deport hundreds of thousands of “dreamers,” those young people who are children of parents who came to the US illegally. He’s also vowed to deport residents from countries such as Haiti, El Salvador, and Honduras, who are legally in the US under a program called Temporary Protected Status (TPS). PHI estimates they include about 35,000 direct care workers.
But these new rules are especially draconian. The Department of Homeland Security itself estimates that each year 382,600 green card applications and 517,500 applications for other types of visas could be subject to the new public charge test.
Many of these applicants would be much-needed direct care workers, either in homes or in facilities. The question is: What are the frail elderly going to do without them?