The Trump Administration has adopted tough new rules aimed at barring low-wage workers from coming to the US.  Direct care workers such as personal care aides, home health aides, and certified nursing assistants will be among the biggest victims. But so will frail elders and younger people with disabilities, who will find it even more difficult to get the help they need.

The new “public charge” rule, first proposed last year, will take effect in 60 days. It will bar legal immigrants from getting a “green card” that allows them to work if the government decides they are likely to receive public benefits such as Medicaid, housing supports, or food stamps (SNAP).  People seeking to come to the US would be blocked from entry unless they can convince US officials that they are not likely to receive such benefits anytime in the future.

Worsening shortages

Trump is imposing the rule at a time when home care agencies and nursing facilities report a growing shortage of aides, thanks to a combination of low wages, a strong economy, and past curbs on immigration. The market is so tight that some agencies are requiring their workers to sign non-compete agreements to prevent them from moving to competitors or working directly for their clients.

And the shortage will only get worse as the Baby Boomers age.  According to CareerCast, Americans will require a half-million more home health aides and 750,000 more personal care aides by 2025.

Yet the new rules will slash the number of green card and other visa applications by hundreds of thousands, reports the Department of Homeland Security.

According to Robert Espinoza of the Paraprofessional Healthcare Institute (PHI), about one-quarter of the nation’s four million direct care workers are immigrants. Because their wages are so low, about 43 percent of these immigrant workers access some public benefits. Two-thirds receive Medicaid and more than half get food and nutrition assistance. About 4 percent receive cash assistance (aka welfare).

A cruel cycle

The median wage of direct care workers is about $11 an hour. But because many home care aides work only part-time, their median annual income is $15,100. Here is what is especially cruel about this: Those wages largely are set by Medicaid itself, which is a primary payer of long-term care services. Because Medicaid pays them so little, they must rely on the same government program to get their own health care. And, according to this new rule, because they receive public supports such as Medicaid, they are barred from working in the US.

Advocates say the rules will block many immigrants earning less than 250 percent of the federal poverty level ($64,000 for a family of four) from getting green cards. The Administration insists the cut-off will be about $32,000, though even that is twice the median wage of a home care worker.

While the new rules do not apply to current green card holders, they effectively will end the pipeline for new workers in an industry with notoriously high turnover.  Refugees and asylum-seekers, military members, and children and pregnant women will be exempt from the curbs, according to acting director of US Citizenship and Immigration Services Ken Cuccinelli. However, separately, the Trump Administration is working aggressively to bar people from claiming refugee or asylum status.

Orwellian explanation

In an especially Orwellian explanation, Cuccinelli said,

“Through the public charge rule, President Trump’s administration is re-enforcing the ideal of self-sufficiency and personal responsibility, ensuring that immigrants are able to support themselves and become successful in America.”

In fact, the rule is guaranteeing that immigrant direct care workers will not be able to support themselves.  They will likely respond in several ways. Some will work but jeopardize their health by not accessing needed benefits. My Urban Institute colleagues estimate that even in response to the proposed rules, about one-in-five low-income workers did not apply or withdrew from government benefit programs.

Others will work off-the-books. And some will, as the Administration intends, avoid coming to the US.

And that will dramatically shrink the workforce available to assist frail elders and younger people with disabilities. That, in turn, will put their health and well-being in jeopardy.  And, in another paradox, may result in more people getting care in nursing homes. Those facilities may be understaffed , but a short-staffed facility may be a better option than no paid care at all at home.