President Trump’s decision to revoke what’s known as Temporary Protective Status for immigrants from a dozen countries will severely damage health and long-term care in the US. More than 1 million people are at risk of being deported as a result of the move, including 350,000 from Haiti, many of whom work in health and long-term care.

Trump cancelled TPS at the end of July, after the Supreme Court refused to block efforts to stop the move.  And the Administration has begun deportations.

But even those still in the US have lost their work permits—and their jobs. While they remain in immigration limbo, they cannot work to support their families and many have been fired from jobs they’ve had for years. That, in turn, has worsened an already severe shortage of health and long-term care workers, including nurses, aides, and technicians.

The Impact On One Facility

To better understand the impact, I spoke to the CEO of a multi-site skilled nursing, assisted living, and memory care organization in New Jersey. The non-profit has 300 patients and residents and 500 employees, more than half foreign-born. As a result of Trump’s ending TPS, it had to fire 19 Haitian staffers in the past few weeks. About one-third of those terminated were certified aides, while the others included food service and maintenance workers.

All were working legally, including staff that had been at the facility for decades. Some had been trying to establish permanent residency but were caught up in bureaucratic delays. Some are married to US citizens and have children born in the US.

The CEO did not want me to identify her or her facility because she fears it would be targeted by immigration authorities. But she said of those losing TPS status, “These are all people doing jobs that have a direct impact on the people living here.”

Haitians And Long-Term Care

Nationally, about one-third of the 350,000 Haitians living under TPS are health care workers, according to some estimates. And about one-third of them, perhaps 30,000 or more, are working in home care, home health, as aides in care facilities, or as personal care assistants. Very likely even more work independently in the “gray market” and are not included in public data.

The biggest impact is in Florida, where about half of all TPS Haitians live. There, an estimated 4,000 care workers are losing their jobs. The CEO of a continuing care community there told me she is losing more than 10% of her staff. But the end of TPS for Haitians, and soon for those from other countries including Ukraine, affects people giving and receiving care all over the US.

Many Curbs

Ending TPS is just one step the Trump Administration is taking to bar immigration or force immigrants out of the US.

It now requires people to apply for immigration status from outside the US, which means people who are living and working here would have to leave the country (and their jobs) to apply for citizenship or residency status.

The Treasury has proposed rules that would bar many immigrants from receiving the refundable portion of income tax credits even though they have been living here legally and file tax returns. These subsidies especially hurt families with children.

The prohibition would apply to people living in the US under TPS and Deferred Action for Childhood Arrivals. An estimated 34,000 DACA recipients work in health and long-term care.

In addition, beginning in September, it will give immigration officers the authority to deny entry to those they believe would use public programs such as Medicaid, food stamps, or housing assistance. This new rule would effectively bar access to many care workers , who often make so little income they are eligible for public assistance.

Trump even has moved to limit issuance of all visas, regardless of category.

Remember, everyone in the US under TPS was here legally. They have work papers that allow them to be employed. Many in long-term care, such as certified nursing assistants and home care and home health aides must be licensed by their state, which requires proof of legal work status.

They pay income, payroll, and sales taxes. Many have children who were born in the US, are US citizens, and have no ties to their parents’ home countries.

The Impact On Staff And Finances

At the New Jersey organization, one fired staffer was well on the way to getting a green card. He is married to a US citizen and expecting a child. But his hearing kept being delayed. No reason was given, but it may have been because the Trump Administration fired so many immigration judges, adding to slowdowns.

Still, the facility had no choice but to fire her.

It also fired a woman whose immigration attorney says she’ll almost certainty qualify for asylum. But that process will take at least another eight months. And, until then, she cannot legally work.

This not only hurts those losing their jobs, it also is painful for management and for residents. The CEO says she is struggling to figure out what to tell her fragile residents, whose caregivers often have been with them for years.

The non-profit is scrambling to hire substitutes. But finding qualified staff at a time of severe shortages is not easy. For now, aides are being replaced with temporary agency workers. But they cost more than $30 an hour, compared to the average $21 staff got.

The CEO told me her facility is already losing $4 million-a-year on its Medicaid residents. Given ongoing cuts in Medicaid due to last year’s big congressional budget bill, it is improbable at best that New Jersey will increase payments to nursing or assisted living facilities to cover added costs. The state requires this organization to reserve 45% of its nursing home beds and 10% of its assisted living for Medicaid residents.

Last year’s budget bill, which cuts Medicaid by nearly $1 trillion over the next decade, is likely to result in especially deep reductions in home and community-based care since that benefit is optional for states.

But slashing HCBS will drive more older adults and younger people with disabilities into nursing homes. And that is happening just at the time when the Administration is aggressively making it more difficult for operators to find staff.

Restrictive immigration policy is likely to force some facilities to reduce beds. Which leads to the question: Where will frail older adults and younger people with disabilities live?