Demand for nurses and home health aides is growing, but anti-immigrant policies threaten to cut off the supply of labor. For decades, the U.S. has faced a shortage of nurses and home health aides. “ The Conference Board’s Labor Shortage Index rates registered nurses (RNs) in the 94th percentile in terms of risk of labor shortage over the next decade.” Prior to the crackdown on immigrant labor, nursing homes, hospices, and home health agencies recruited nurses from abroad and or tapped the ready pool of immigrants already living here on refugee status.
Families of those who require long-term care often take that a step further. Because of the extraordinary expense of long-term care, families turn to immigrants in the “grey economy,” meaning immigrants here without papers.
Three-and-a-half years into caring for a young father dying of ALS, our family faced a crisis. My son-in-law could no longer walk, dress, or feed himself. I had been his caregiver for ten months, but the 16-hour days had worn me out. I had assumed that my daughter’s gold-plated insurance would kick in the moment I could no longer care for her husband; however, I was wrong.
The Custodial Care Loophole
I soon learned that insurance would only pay for a home health aide for 3 hours a day, but not weekends. Standard health insurance policies do not cover “custodial care,” meaning the Activities of Daily Living (ADL).
Long-term care insurance would have been an option, but only about 8 percent of Americans have coverage, according to the Department of Health and Human Services. A person who can no longer perform Activities of Daily Living won’t qualify for long-term care insurance. Nor do those individuals with Alzheimer’s Disease, dementia, multiple sclerosis, Parkinson’s disease, stroke, or metastatic cancer.
Unfortunately, long-term-care policies do not always provide the safety net the name implies. Premiums rise as the insured person ages. And, long-term-care policies have caps on their coverage. In 1996 the Washington Post reported on actor Christopher Reeve’s struggle as he and his wife faced bumping up against the cap on his insurance. Reeve’s tragic accident and total paralysis left him dependent on a respirator. His caregiver had to be awake and alert around the clock. That’s exhausting and impossible to manage without help.
Similarly, diseases–such as Alzheimer’s–wear out spouses or adult children. The longer the person lives, the more exhausted the caregiver becomes. For elderly patients or those with various forms of dementia, nursing homes provide one way to lessen the burden on caregivers and make care affordable. However, nursing homes are not an option for a young person who requires round-the-clock care.
The Nursing Home Dilemma
Families of adults with neurological diseases such as ALS soon discover that no nursing home will take their loved one, especially if that person has opted to go on a respirator. Although the Americans With Disabilities Act (ADA) technically makes it illegal for nursing homes to discriminate against the severely disabled, nursing home directors argue that a long-term-care facility is not appropriate placement for a young, disabled person. With a staff ratio of 1 Certified Nursing Assistant (CNA) to every 6 to 8 residents, nursing homes do not have enough staff to cover patients with extraordinary needs.
When I made inquiries on behalf of my son-in-law, nursing home directors told me that they would allow him to move in if the family could guarantee the services of a 24-hour, private-duty nurse. According to PayScale.com, the median salary for private-duty nursing is $15 to $39/hour. That’s why our exhausted family decided to keep Joe at home. When we made that decision, a home health aide began coming to our house to bathe and dress him and feed him one meal. But her help barely made a dent in our exhaustion. Joe eventually agreed to let us hire more help.
I assisted him screening caregivers. We looked for qualities such as compassion, a love of family, and reliability. Our first home health aide was a vibrantly upbeat, beautiful, young, Ethiopian immigrant. Among the many candidates who looked good on paper, she stood out for her willingness to laugh at his jokes and do whatever it took to brighten his day.
The young Ethiopian woman was but one of the immigrants who, for the next ten years of his life, filled the care gaps. The others included a British respiratory nurse who had overstayed his visa, a refugee from Haiti, a Filipino, and a Somali refugee. Inquiring about the person’s legal status was not my first priority.
There are many reasons families might want to hire a person who is not in the country legally. They want to hire someone who will be personally compatible with their loved one, not just whomever an agency happens to send over.
Personality and ability to fit into family life are as important as the ability to transfer a person from a wheelchair to a bed or hook up a feeding tube. Caregiving skills can be taught, and generally, when the care needs are high, the family already has those skills and can pass them along.
Running a Small Nursing Home
One of the biggest hurdles for family caregivers is paperwork. The person supervising a disabled person’s care may be a terrific cook and be able to handle laundry and personal hygiene, but that person may not know how to fill out FICA statements, organize weekly payrolls, or pay quarterly taxes.
The reality is that hiring 24-hour care is not just expensive. Essentially, the family member must run a small nursing home. On top of everything else family caregivers need to do, they may feel that the paperwork is overwhelming. That’s one reason families opt to pay workers—whether immigrants or not—under the table.
Informal hiring arrangements put family caregivers at risk of running afoul of the law. And if the person they’ve hired privately becomes ill or gets detained, then the person who needs care won’t have that person showing up. Going through a home health agency means the agency handles all the details, but the family has virtually no say in who shows up at the door.
Stretching the Dollars
Families who need to hire an outside person try to stretch their dollars by offering room and board, by hiring student nurses, or by hiring illegal immigrants who seek work in the underground economy. According to the Pew Research Center, “most Americans (65 %) say immigrants strengthen the country with their hard work and talents.” Immigrants have made great contributions in caring for the disabled and elderly.
The Coming Care Gap
In the near future, the United States will “experience a dramatic shortfall in the number of family members who can supply caregiving services. AARP’s recent Care Gap Report says that when Baby Boomers reach their eighties, they will face a sharp decline in the “caregiver support ratio.” In 2010 the ratio was 1 eighty-year-old to 7 potential caregivers. By 2030 the ratio will be 1 to 3.
There are several reasons for this. Family size is smaller than in the past. Women have rejoined the work force. Children live far from their parents, not just down the block. Advanced medical care means patients with health challenges live longer. And, civic and religious groups that once provided an informal social safety net for families facing a health care crisis don’t exist in many parts of the country. Often, caregiving burdens fall on one person, with occasional respite help from others.
“As the caregiver shortage intensifies, and more and more families struggle to find paid professionals to support their loved ones, immigrants will be a critical solution to filling that gap in available caregivers,” said Robert Espinoza, vice president of policy at PHI (Paraprofessional Healthcare Institute).
That’s particularly true for home health care where immigrants make up a large percentage of the labor force. Many came as refugees, and, until recently, these refugees had legal status.
Temporary Protective Status Is Being Taken Away
Immigrant groups fleeing war or natural disaster had been able to get temporary work permits under a humanitarian program called Temporary Protective Status (TPS). The program allows them to work in the U.S. without fear of deportation. The Trump administration is revoking protection for many of these population groups.
On May 9, the U.S. Citizenship and Immigration Services (USCIS) announced it would terminate Temporary Protective Status for Haitians on July 29, 2019. There are 320,000 Haitians living and working in the U.S., and 59,000 of them are employed in health care. The second largest group is Salvadorans (200,000), many of whom have lived here since 2001. They will see their privileges revoked on September 9, 2019. But changes in immigration policy do not just affect refugees.
Other Visa Problems Faced by Health Care Professionals
In addition to TPS, the Trump administration is revoking work permits for health care workers using a TN visa. These are Mexican and Canadian professionals working under the North American Free Trade Act, or NAFTA. The Canadian Broadcasting Corporation reported that “An estimated 30,000 to 40,000 Canadians work in the U.S. under the non-immigrant NAFTA professional (TN) visa.” These nurses have been told to apply for H1-B visas.
According to a report by the Conference Board, H1-B visas aren’t appropriate for nurses. To obtain a nursing license, nurses don’t need a four-year bachelor’s degree; however, a bachelor’s degree is the minimum requirement for an H1-B.
It is unlikely that immigration policy regarding health care workers will be relaxed anytime soon. A report by the Migration Policy Institute found that the U.S. immigration system does not place a priority on foreign-born health care workers. Their analysis of Department of Homeland Security (DHS) data found that 62 percent of H1-B visas went to “workers in computer-related occupations.”
The Need for Home Health Aides
And, yet, it’s immigrants who, prior to the recent changes, were filling the gap between supply and demand. “Immigrants from the Philippines accounted for nearly 30 percent of the 486,000 immigrants working as registered nurses, followed by those from India (6 percent) and Nigeria (5 percent),” the Migration Policy Institute found. In the less skilled segment of the health care industry, “Mexicans, Haitians, and Jamaicans together accounted for 31 percent of the 489,000 foreign-born nursing, psychiatric, and home health aides.”
Home care workers fall in three categories: personal care assistants, home health aides, and nursing assistants, according to the Policy Health Institute (PHI). These are the very people most needed when it comes to bathing, dressing, and caring for disabled children or adults. The shortage of home care workers will only grow more acute.
Hospitals, nursing homes, home health care agencies, and families have benefitted from immigrant labor. With changes in Temporary Protected Status work permits, many of those who have found employment in home health care may be returning to their countries of origin. Along the northern and southern borders, hospitals won’t be allowed to hire nurses from our NAFTA partner countries. With limited insurance coverage, family caregivers face tough choices about how to cover the costs of long-term care. Changes in immigration policy will put added pressure on an economy already struggling to find workers to fill jobs in health care.