Saving "Countless Lives"?

Emily K. Abel

“It’s a landmark law that we’re doing today,” Trump remarked before signing the Laken-Riley Act to make it easier to deport immigrants accused of crimes. “It’s going to save countless lives,” he added. In fact, the law threatens to do just the opposite because it also facilitates the deportation of immigrants who have not been accused of a crime. Immigrants represent more than one fourth of all direct care workers, variously known as personal care aides, home health aides, and nursing assistants. Constituting the lowest rung of the health care industry, they provide personal services to elderly people and people with disabilities in nursing homes and private households. Deporting sizeable numbers of immigrants in those jobs will exacerbate an already severe labor shortage and undermine the quality of care delivered to vulnerable populations.

Regardless of the setting in which they work, direct care workers who are immigrants share certain characteristics: The overwhelming majority (86 percent) are women. Forty-seven percent have some education beyond high school. Many leave family members (both children and elderly people) in the care of other relatives. Although they can stay in contact through technologies such as email and FaceTime, those who are undocumented face formidable obstacles when they try to travel to their country of origin for visits or bring family members to the United States.

Attempting to explain why home health agencies need to hire immigrants, David Voepel, head of the Arizona Health Care Association, stated, “We want people to come in here and to help because they’re the ones that have the knowhow to do it because they are very family oriented.” A better explanation is that Americans don’t want the jobs. Because the United States tries to provide long-term care services on the cheap, the remuneration is paltry. The median hourly wage in 2023 was $13.50; the median annual income was $25,275. The many workers who can find only part-time employment must piece together several jobs, often working far more than 40 hours a week. Benefits are either inadequate or nonexistent.

Although often required to perform medical tasks, the workers receive very little training. The work is extremely hazardous, involving heavy lifting, needle punctures, and assaults. Nursing home assistants report more injuries than workers in any other occupation, including construction and truck driving. During the Covid-19 pandemic, many workers lacked personal protective equipment and information about the disease. A survey released by the Service Employees International Union (SEIU), the largest union of nursing home staff, reported that nearly 80 percent believed that they put their lives in danger when they went to work. Direct care workers also worried about transmitting the virus to their clients, many of whom had chronic conditions that placed them at heightened risk of infection and mortality, and to their communities, which already had borne the brunt of the pandemic.

Unsurprisingly, most workers leave as soon as possible for better jobs. The annual turnover rate is nearly 100 percent for nursing assistants in nursing homes and nearly 80 percent for homecare aides. Such high turnover aggravates the labor shortage which is projected to deepen as the population continues to age rapidly. According to one estimate, the United States will have a shortage of 151,000 direct care workers by 2030 and 355,000 by 2040, despite the fact that the number of people 65 and over totaled 60 million in 2022 and is expected to exceed 80 million in 2050. Mortality rates rise when nursing homes cannot hire sufficient staff and elderly and disabled people cannot find anyone to assist them at home.

Immigrants are especially prominent in the homecare sector, which is growing rapidly as long-term care services increasingly move out of institutions and into homes and the community. Immigrants represent 21 percent of workers in nursing homes but 38 percent of those in the homecare sector. In states with large numbers of immigrants, they represent even higher proportions of home health aides—two thirds in New York and half in California and Maryland.

Immigrants may constitute an even larger percentage of the homecare labor force than those statistics suggest because they exclude the large number of workers hired in the “gray market.” Most individuals and households find homecare workers not through agencies but rather through ad hoc, informal arrangements, asking friends and acquaintances for recommendations. Immigrants are especially likely to obtain employment through such channels.

Homecare workers face special challenges. Like other domestic workers, such as cleaners and nannies, they are isolated and invisible. Without coworkers, they have no one who shares their complaints about their jobs and can help them assert their rights. They also lack basic job protections. The Occupational Safety and Health Act of 1970 explicitly excludes workers in private households. Three other major pieces of legislation—the Civil Rights Act of 1964, the Americans with Disabilities Act of 1967, and the Age Discrimination in Employment Act of 1971—do not cover those in jobs with single employees, thereby excluding virtually all direct care workers hired in the gray market.

In the wake of the Covid-19 pandemic, several prominent U.S. philanthropic organizations announced the formation of the Care for All with Respect and Equity (CARE) Fund, investing $50 million in projects that seek to improve the conditions of both paid and unpaid carers. Were the United States willing to prioritize care rather than efficiency, the conditions of direct care workers might be improved enough to make their jobs attractive to Americans. Until then, we will need to rely heavily on immigrants. As one homecare worker remarked, “If it wasn’t for us Latinos, they [gringos] wouldn’t have people to employ to do the work they don’t want to do.” That work, not the law Trump gleefully signed, is what “saves countless lives.”

Sources:

Rebecca Davis O’Brien and Miriam Jordan, “A Chill Sets In for Undocumented Workers, and Those Who Hire Them, New York Times (March 9, 2025).

Eileen Boris and Jennifer Klein, Caring for America: Home Health Workers in the Shadow of the Welfare State (New York: Oxford University Press, 2012).

Emily K. Abel, Elder Care in Crisis: How the Social Safety Net Fails Families (New York: New York University Press, 2022).

Kathy Ritchie, “Can Home Health Companies Continue without Hiring More Migrant Workers? Many Say No,”

https://www.npr.org

Robert Espinoza, “Bridging the Gap: Enhancing Support for Immigrants Direct Care Workers and Meeting Long-Term Care Needs,”

https://www.phinational.org

Richard Schweid, The Caring Class (Ithaca: Cornell University Press, 2021).

Zolan Kanno-Youngs and Erica L. Green, “Trump Signs Bill Easing Deportation of Immigrants Accused of Crimes,” New York Times, January 29, 2025.

Emily K. Abel is professor emerita at the UCLA-Fielding School of Public Health. Her most recent book is Gluten Free for Life: Celiac Disease, Medical Recognition, and the Food Industry (New York University Press, 2025).