How Immigration Policy Changes Worsen Ongoing Long-Term Care Workforce Challenges

Posted on December 4, 2025 by Gabriela Lazalde Leave a comment

This entry is part 63 of 63 in the series Wide World of Public Health Systems

Changes in immigration policy climate in the US stem from both actual changes to federal laws and practices, such as reduced pathways to legal residency and increased deportations, and from perceived threats of such actions. Findings from the recent KFF/New York Times 2025 Survey highlight how these changes have begun to affect some aspects of population health, increasing stress levels and negatively influencing mental health, diabetes, and hypertension-related outcomes among immigrants polled. On top of effects immigrants experience, these changes have the potential to ripple outward to affect other populations.

For example, pressures on immigrants reducing their ability and willingness to work will intensify longstanding issues around worker recruitment and retention within the long-term care workforce. This poses a serious threat to the health of older Americans.

An estimated 6 million older Americans rely on paid long-term services and supports (LTSS) in community-based settings (ie, outside of nursing homes or other facilities). Direct caregivers help them with tasks like medical care delivery, care coordination, and transportation. Demand for LTSS is growing, with an increasing proportion of older adults experiencing chronic conditions affecting their physical and cognitive abilities. LTSS help older adults to age in place (ie, within their own homes and community), and aging in place has been shown to enhance mental and physical health. Despite the valuable services the LTSS workforce provides, most direct caregiving jobs have low wages, high turnover, and limited growth opportunities compared to other industries.

As a result, immigrant workers– those born outside of the US, who often have fewer work opportunities compared to those born in the US– are overrepresented in this workforce. An estimated 28% of the current US direct care workforce was born outside of the US. The LTSS workforce was already facing predicted shortages upwards of 150,000 workers by 2030 and over 350,000 by 2024 prior to COVID because of growth of the aging population outpacing that of the growth of the workforce. Given continued increases in healthcare shortages across healthcare sectors since the beginning of the COVID-19 pandemic, it is unlikely that the estimated 9.3 million direct care job openings emerging between 2021 and 2031 will be easily filled. Indeed, immigrant labor will continue to be essential to maintaining a functional LTSS workforce.

Ongoing political changes relevant to immigration are disproportionately affecting current and future participants in this workforce, adding uncertainty to its future. Specifically, perceived threats of loss of worker protections, along with mass detention, deportation, and the prospect of potentially violent arrests in public, have likely intensified and will continue to affect ongoing labor shortages in the direct care workforce and ultimately detract from the quality-of-care older adults receive. This adds urgency to questions like: how will the LTSS workforce change in the immediate future? Who will fulfill the increased demand for LTSS services? What public health and health care policies and practices can be implemented to protect immigrant LTSS workers and the older adults dependent on their services?

Addressing these questions and improving outcomes for immigrant LTSS workers and the older adults they serve will require cooperation across sectors. Interest-holders in seeking solutions include: LTSS workers and the organizations they serve, public health and aging services advocates, policymakers and advocates, and public health workforce researchers. Among workforce researchers, key steps will include continuing to monitor trends in the LTSS workforce and ideally, the effects of perceived and actual immigration policy. Better enumeration and understanding of the needs of the “gray market” for direct care workers and family caregivers may be areas of growing concern. Immigrants who are leaving formal job markets at alarming rates may be relegated to working in these less formal roles with even fewer worker protections. Data generated from work in these areas could be helpful for informing advocacy strategies and approaches to improving worker recruitment and retention in this critical field.

About the Author

Gabriela Lazalde: Gabriela Lazalde is a researcher for the Center for Public Health Systems. As a social scientist trained in theory-driven quantitative analysis, her work focuses on how policy affects health. She holds an MPH from the University of Minnesota School of Public Health and a PhD from UCLA.

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