WASHINGTON — President-elect Donald Trump’s vowed crackdown on immigration could strain an already struggling elder care workforce that relies on foreign-born workers in nursing homes and home health settings.

Industry players and experts argue that increasing the long-term care workforce requires more immigration, and Trump’s plans could further undermine efforts to shore up the workforce as need for services increases with an aging population.

“Restricting entry of immigrants into the U.S. could really have a detrimental impact on long-term care for older adults,” said David C. Grabowski, a professor of health care policy at Harvard Medical School. “They [immigrants] play a critical role in the delivery of long-term care broadly, but especially in nursing homes.”

Home health aides, personal care aides and certified nursing assistants are considered the backbone of the long-term care workforce, helping people age in their homes and often making up the majority of staff in nursing homes and residential care facilities.

There’s already a shortage of workers performing long-term care, and that shortage will worsen in the coming decades. People 65 and older are expected to make up more than 20% of the population by 2030; an estimated 75% will need some type of long-term care.

In all, demand for direct care workers including nursing assistants, personal care aides and home health aides will grow by 35% to 41% between 2022 and 2037, according to projections from the National Center for Health Workforce Analysis published in November.

But employment of home health and personal care aides is only projected to grow by 22% over the next decade.

Analysts argue that immigration is part of the solution.

“We’re really going to struggle to find sufficient numbers of workers to deliver high-quality care if there’s anything that threatens the influx of these workers,” Grabowski said.

Direct care demographics

Currently, about 27% of direct care workers are immigrants, but many more likely operate in a “gray market” where they are paid directly by families to care for people in their homes using private funds, according to the Paraprofessional Healthcare Institute, a nonprofit that advocates for direct care workers and improved quality of care.

By comparison, 17% of the total workforce is immigrant, they found, which includes naturalized citizens, people with temporary work authorizations and undocumented people.

Trump and his supporters have called for reducing immigration into the U.S. while prioritizing visa slots for “highly skilled” workers.

Direct-care workers are not typically classified as highly skilled by the current immigration system — many arrived to the U.S. through “chain migration,” a family-preference immigration system that Trump has called to end.

Trump’s policies could also impact the immigrant workforce that is already in the U.S.

Immigrants in the direct care workforce have a variety of immigration statuses. Among foreign-born direct care workers, 56% are naturalized citizens. About 44% are not U.S. citizens, and that includes people who are undocumented and people with work authorizations or visas, though there is no specific breakdown.

Temporary protected status

Trump has also called for making it more difficult for people to seek asylum and humanitarian parole, including by ending temporary protected status for people from unstable countries.

Meanwhile, Vice President-elect JD Vance has said temporary protected status would only be allowed on a case-by-case basis and not for entire countries.

Temporary protected status for a specific country can last six, 12 or 18 months at a time and is often renewed. For example, TPS has been in place for El Salvador since 2001. Trump ended it in his first term but was blocked by the courts.

He’ll face decisions about renewals for more than a dozen countries including Honduras, Venezuela and Haiti next year.

That could impact states like Florida and California, where 30 to 40% of the long-term workforce are immigrants with varying statuses, including naturalized citizens and people under TPS. Many immigrants live in mixed-status households, and the deportation of a family member could destabilize an entire family.

“Mass deportations or targeting immigrants would have devastating impacts on the care economy, in addition to the trauma and separation of families,” said Arnulfo De La Cruz, president of SEIU 2015 in California, the largest union representing long-term care workers, half of whom are immigrants. “I think the ultimate cost and impact would be to American citizens who already struggle to find a caregiver.”

Trump has also floated ending birthright citizenship and conducting “mass deportations” of people in the country illegally, saying he would first focus on people who have committed crimes.

And Trump has waffled on the future of the Obama-era Deferred Action for Childhood Arrivals program, which protects immigrants who arrived in the U.S. illegally as children from being deported and allows them to work. He sought to unwind it during his first administration, but now says he wants to work with Democrats on a solution.

‘Backbone of our sector’

The nursing home industry has urged the Trump administration to make its plans more clear while working with employers to understand “what are our needs related to immigration.”

“They really are the backbone of our sector,” said Nicole Howell, director of workforce policy at LeadingAge, an association of nonprofit aging services providers. “Given that we have such a growing number of older adults requiring care and support and services, and many of them indicating their desire to maintain residence in their homes, we need to grow our sector.

“And so we would ask President Trump’s administration to work with health care and aging services to expand immigration pathways.”

LeadingAge been on Capitol Hill with representatives from other industries including agriculture to urge members to work with the Trump administration on immigration reform and “to impart how important immigration and the foreign born workforce is to our sectors.”

Clif Porter, the president and CEO of the American Health Care Association, which represents nursing homes, said it will work with the Trump administration and Congress on addressing the “growing caregiver shortage.”

“Streamlining legal pathways for passionate people to come to our country and serve our seniors is an important part of how our sector will answer the growing demand for long-term care,” Porter said.

Porter argued nursing homes rely on immigrants to save money on labor costs and that an increased supply of labor reduces wages.

But supporters of reducing immigration have argued for making those jobs more attractive for people born in the United States.

“It is funny in a way we’re hiring someone to take care of a loved one but don’t expect them to spend much money on it,” said Steven Camarota, director of research for the Center for Immigration Studies, which contributed to Project 2025, a blueprint for a second Trump administration. While Trump distanced himself from the blueprint during his campaign, he has selected several people who contributed to it to serve in his administration.

“If the vast majority [of long-term care workers] are not illegal, that does suggest we can get Americans to do the work, but you have to pay them more,” Camarota said.

Still, caring for older people is considered a difficult, emotionally and physically taxing job that faces stigma and a lack of respect.

For example, the number of certified nursing assistants born in the U.S. has declined rapidly since the mid-2010s, while the number of foreign-born CNAs has remained constant, according to an analysis published in HealthAffairs in January 2024.

The paper, coauthored by Grabowski, found staffing shortages during the COVID-19 pandemic would have been worse if not for foreign-born CNAs remaining in the workforce.

It also found nursing homes in regions with a higher share of immigrant CNAs were associated with more staffing for residents and better nursing home quality performance.

A 2023 paper also co-authored by Grabowski found increased immigration “significantly raises the staffing levels of nursing homes,” which has a positive effect on patient outcomes.

Grabowski and coauthors found that an influx of immigrants to an area did not decrease wages, suggesting excess demand for those workers.

“Nursing homes are looking for additional workers,” Grabowski said. “They aren’t bidding down wages for native-born workers, they’re working alongside native born workers.”

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