What Role Do Immigrants Play in The Direct Long-Term Care Workforce?

Introduction

President Trump has made a slew of immigration policy changes focused on restricting entry at the border and increasing interior enforcement efforts to support mass deportation. While these actions are focused on undocumented immigrants, they likely will have ripple effects across immigrants of all statuses and millions more people living in immigrant families.

Mass deportations could negatively impact the U.S. economy and workforce, given the role immigrants play, particularly in certain industries. Deportation of immigrants may exacerbate health care workforce shortages as immigrants and their adult children play outsized roles in the health care workforce. To increase understanding of how shifting immigration policies may affect the direct care workforce providing long-term care services, this data note uses the 2023 American Community Survey (ACS) to provide an overview of the role that immigrants play in the direct care workforce for long-term care (LTC) services (see Methods). Key takeaways include:

• Immigrants make up 28% of the overall direct care workforce for LTC services. As of 2023, there were over 820,000 immigrants working as direct care workers providing long-term care in the U.S. (including over 500,000 naturalized citizens and over 300,000 noncitizen immigrants).
• Immigrants play a particularly large role in the home care workforce, making up one in three workers (32%) in home care settings. They also make up 21% of workers in nursing facilities and 24% of workers in residential care settings.
• Immigrants have made up an increasing share of the direct care LTC workforce over time. The share of direct care workers providing LTC services who are immigrants increased from 24% in 2018 to 28% in 2023.

Together the data show that immigrants comprise a large and growing role of the direct care workforce providing LTC services, particularly in home care settings. Restrictions on immigration and mass deportations could lead to reductions in immigrants available to fill these roles, which would exacerbate workforce shortages, making it harder for people to find caregivers for themselves and their loved ones.

Background

Direct care workers play a pivotal role in providing long-term care services in both home care and institutional care settings. Direct care workers provide a broad range of paid and unpaid medical and personal care services that assist with activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medication, and housekeeping). More than 6 million people use paid LTC delivered in home care settings and more than 2 million people use LTC delivered in institutional settings, according to CBO estimates. This workforce performs demanding, high-stress work for low wages and often no benefits.

Prior research shows that immigrants help fill workforce shortages in the direct care LTC workforce and contribute to improvements in care. There is historic demand for long-term care services, with particularly high demand for workers who can help people age at home. One study found that communities that have increased immigration have a greater share of adults that are able to age in place. Other research finds that the home care workforce is declining relative to the number of adults needing these services. Analysis of the Secure Communities immigration enforcement program found that the program reduced direct care staff hours, suggesting that stringent immigrant enforcement exacerbates health care worker and direct care worker shortages in the U.S. Research also finds that immigration increases the local supply of workers in nursing fields, with the largest effect on the number of nurse aides. Similarly, increased immigration significantly raises the staffing levels of nursing homes in the U.S., particularly in full time positions.

Immigrants also provide culturally competent care to an increasingly diverse population of older adults. In particular, some older adults may feel more comfortable with direct care workers who share or understand their language, race, ethnicity, or other cultural characteristics. A KFF focus group of family caregivers noted that a challenge to finding paid care was a language barrier. One caregiver described the difficulty of finding culturally competent care because her father only spoke Spanish.

Key Findings

Using 2023 ACS data, this analysis identifies immigrants as a share of the direct care workforce providing LTC, how this share varies by setting, and how this share changes over time. The direct care workforce includes aides (home health aides, personal care aides, and nursing assistants) and nurses (licensed practical nurses and registered nurses). We define the direct care workforce as all individuals 18 and older who earned at least $1,000 during the year and indicated that their job was in both the long-term care industry and their occupation fell under the category of either aide or nurse (see Methods for more details). The ACS does not include unpaid LTC caregivers, such as relatives and friends, who provide the majority of home-based long-term care in the U.S.

Immigrants make up 28% of the overall direct care workforce providing LTC services, higher than the share of all adult workers in the U.S. who are immigrants (17%) (Figure 1). This includes 17% who are naturalized citizens and 11% who are noncitizen immigrants. Immigrants make up a higher share of aides (30%) than nurses (20%). The large majority of immigrants in nursing roles are naturalized citizens. Most immigrants working as aides also are naturalized citizens, although there is a more mixed distribution of naturalized citizens and noncitizen immigrants. Aides provide hands-on assistance to older adults and people with disabilities and include home health aides, personal care aides, and nursing assistants.

Immigrants play a particularly large role in the home care workforce, making up one in three workers (32%) in home care settings (Figure 2). Immigrants make up 21% of workers in nursing facilities and 24% of workers in residential care settings. The share of workers that are immigrants is highest in home care settings when compared to other settings because aides (who are more likely to be immigrants when compared to other direct care workers) make up the majority of workers in home care settings. Reflecting this pattern, noncitizen immigrants make up a larger share of immigrants working in home care settings compared to nursing facilities and residential care settings.

Immigrants make up a growing share of the direct care workforce, increasing from 24% of direct care workers in 2018 to 28% in 2023 (Figure 3). This growth reflects increases in the share of workers who are naturalized citizens; the share who are noncitizen immigrants remained relatively stable during this time period. Immigrants’ role in the direct care workforce grew in both home care and residential care facilities. The share of the total direct care workforce who are immigrants increased from 28% to 32% in home care and from 19% to 24% in residential care facilities between 2018 and 2023 (data not shown). The share of the direct care workforce who are immigrants has remained relatively stable over time in nursing facilities (data not shown).