The US desperately needs more direct care workers to provide personal assistance to frail older adults and younger people with disabilities. Many native-born Americans were unwilling to do this work even before the Covid-19 pandemic. Now, shortages are far worse. Yet, the US continues to bar entry to those who are willing and able to care for frail older adults and people with disabilities—immigrants.

This week, I participated in a fascinating Brookings Institution panel discussion on immigrants and caregiving. Some panelists were immigration experts, two of us came from the long-term care world. Yet our conclusion was unanimous: Without a substantial increase in immigrant care workers, the shortage of people available to provide personal assistance will not abate anytime soon.

Yet, even as President Biden slowly unwinds some of the Trump Administration’s highly restrictive immigration rules, many curbs remain in place. Democrats are battling among themselves over how, and whether, to lesson some of these curbs. And Republicans are nearly unanimous in opposing more immigration.

Who will pay?

While largely unnoticed, the price of this political gridlock is being paid by older adults and their families. It drives up the cost of care, leaves many with no paid support at all, forces more adult children to quit their jobs or reduce their own hours of paid work, and puts even more pressure on already-struggling long-term care facilities.

The shortage of care workers in the US is simply unsustainable. It is forcing nursing homes and assisted living to turn away residents because they don’t have staff to care for them. It is driving some out of business.

Roughly 400,000 care workers left their jobs during the pandemic. And a 2021 study by the Advocacy Group PHI and the University of California San Francisco found that, as of a year ago, almost none had returned to the direct care workforce. Workers occupations were beginning to rejoin the labor force, but care workers were not returning to their old jobs.

Instead, they may have taken jobs in retail sales, customer service, warehouses, hospitality, and even cleaning services. While these also are low-wage jobs, they pay better than direct care work, are less dangerous, and at least some have better opportunities for advancement.

Better quality, lower costs

The reality seems clear: Many native-born workers and even immigrants already in the US do not want to do direct care work. Before the pandemic, many were women in their 40s and 50s, who now seem unlikely to return.  In today’s labor market, when employers are begging for new workers, much of this new direct care workforce will have to come from other countries.

One panelist at our Brookings session, University of Connecticut economist Delia Furtado, found that, in nursing homes, more immigrant workers can not only reduce labor costs but, at least in competitive markets, improve the quality of care for residents.

Another, Julia Schmieder of the Berlin School of Economics, studied what happened when Austria made it easier for immigrants to get jobs as care workers. She and her coauthors found that adult children of  parents who had suffered strokes were much less likely to give up their jobs to serve as family caregivers than before the law changed. Not only were more aides available but the increase in workers also lowered their caregiving costs.

Of course, the US is not Austria. For one thing, Austria has a public long-term care insurance program that helps pay for long-term care. The US only supports long-term care for the very poor through Medicaid.


But it doesn’t take a PhD economist to understand that more home care aides will reduce the caregiving burden on at least some adult children. Today, in the US, a new source of aides would ease the burden on caregiving children and allow them to stay in their jobs.

The decline in labor costs driven by immigration raises other important issues: It may keep costs manageable for families that struggle to pay for care. But what would it mean for the wages for already-low-paid aides?

It is a real issue. But in an environment like the one in the US today, with massive shortages of both home care and facility-based workers, wage effects might be muted.

What could be done about all this? One possible solution: The US could create a special visa for health and long-term care workers.

I understand that immigration is a hot button issue. And that many in the US will reflexively oppose opening doors to those from other countries  (except, perhaps, for some Afghans and Ukrainians). But the reality is stark: Without an influx of foreign-born workers, there simply will not be enough people to care for our parents. And we all will suffer.