Washington, D.C. — Nursing homes and long-term care facilities across the country are quietly absorbing a staffing hit that has nothing to do with wages or burnout. It’s driven by immigration policy — and industry leaders warn the damage is accelerating.
Immigrants make up roughly 28% of the direct care workforce in long-term care, totaling more than 820,000 workers, according to a KFF analysis of federal survey data. That includes about 21% of nursing facility workers, nearly a third of home care aides and more than 30% of housekeeping and maintenance staff in nursing homes.
Recent federal policy changes have hit that labor pool hard.
Protections Gone, Workers Gone
The termination of Temporary Protected Status and humanitarian parole programs — which had allowed workers from Cuba, Haiti, Nicaragua and Venezuela to live and work legally in the United States — stripped work authorization from thousands of direct care employees, sometimes with little warning.
Amanda Mead, director of workforce policy at LeadingAge, put it plainly: “Every setting, every service line and nearly every job category is feeling the squeeze. The result is reduced capacity, higher costs and growing concerns about access to services for older adults.”
The effects are playing out in real time. Rob Liebreich, president and CEO of Goodwin Living, described losing four dining services employees last July — all with Haitian humanitarian parole. “When they left, it took us a long time. Cooks in particular are extraordinarily hard to find,” he said.
The disruption runs deeper than lost documentation. Some workers stopped showing up before their paperwork even expired, fearful of enforcement actions. Even legal employees are rattled. “I have team members who are really fearful and are so brave to come to work,” Liebreich said. “They’re legal. They shouldn’t have any concern. One of my team members who became a U.S. citizen is saying, ‘My kids, they’re scared.’”
Nurses Caught in a Different Squeeze
While direct care workers face immediate displacement, the pipeline for international nurses is being choked from a different direction.
The administration imposed a $100,000 fee on new H-1B petitions and replaced the random H-1B lottery with a wage-weighted selection system effective February 27. For nursing homes — which can’t match hospital salaries — that tilts the odds against them. Internationally trained nurses now have stronger financial incentives to take hospital positions, and some are weighing whether to work in Canada or Germany instead.
“There are lines upon lines upon lines,” said Mark Sanchez, chief operating officer of United Hebrew in New Rochelle, New York. “And now they’re saying, ‘I’m going to go to Canada’ and ‘I’m going to go to Germany,’ and they’re welcoming me with open arms.”
What Facilities Are Doing
Some operators aren’t waiting for policy to catch up. Goodwin Living has helped nearly 230 employees pursue citizenship and raised its base pay from $11.75 per hour in 2019 to $20 — a 70% increase aimed at competing in a tightening market. At Ingleside, a Maryland and Virginia operator, residents volunteer to tutor staff studying for citizenship exams.
Industry groups are pushing for structural fixes. AHCA/NCAL supports the Healthcare Workforce Resilience Act, which would recapture unused visas from prior years for doctors and nurses. That push comes as CMS has more than doubled its nursing home staffing grant campaign to over $200 million — but funding alone won’t replace the human pipeline being cut off at the source.
A Collision Already Happening
The longer-term math is stark. PHI projects the country will need 9.3 million direct care workers by 2030 — not just to meet growing demand, but to replace those already leaving the field. By 2034, adults 65 and older will outnumber children under 18 in the United States for the first time.
“The aging population is a straight line up,” said Doug Myers, CEO of the Westminster Ingleside Foundation. “The workforce to care for them? Flat. We have all this growing need — and no growing workforce to meet it.”
Research from Harvard Medical School found that when the share of immigrant workers rose in an area, nursing home residents became less depressed, less anxious and less likely to need antidepressants — with effects strongest in already understaffed facilities.
The question facing the industry isn’t whether immigrants matter to long-term care. That’s settled. The question is whether the people who care for America’s aging population will still be there when the need peaks.
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