The ads are everywhere: on the radio as I walk through the grocery store, on the sides of buildings and following me as I browse the internet. They highlight building relationships with clients, helping older people with the tasks of daily living, and aiding people to remain in their homes. The ubiquity of these ads is not without reason—every day 10,000 people turn age 65 and 70% of those older than age 65 will need long-term care at some point in their lives. As a result, we will need approximately 1 million new home care workers across the next decade—more than any other occupation.
The home care workforce is crucial in the lives of Americans across the age spectrum. Home care workers help us to age with dignity and in our homes, but also enable the caregivers in our families—primarily women—to maintain their own jobs. As we often say where I work at the National Domestic Workers Alliance, “domestic work is the work that makes all other work possible.”
Immigrant Workers in Home Care
So how do we meet the growing need for home care workers? We need to think creatively about immigration and wages and labor standards across the industry as key labor market interventions to meet the growing demand for caregiving. Currently, the 2.4 million home care workers who support individuals in private homes are overwhelmingly women, particularly women of color. Immigrants make up a disproportionate share of the workforce, accounting for more than 30% of home care workers. Across the past 60 years, changes in U.S. immigration policy and the structure of the global economy have increased the share of immigrants in home care and domestic work (domestic workers include house cleaners, nannies and home care workers), and in health fields more generally.
Immigrants account for more than 30% of home care workers.
For example, in 1965, Congress abolished the quotas that discriminated against immigrants from Asia and Africa in favor of Northern Europeans and instituted a preference system giving priority to family members of U.S. citizens and permanent residents. Changes in immigration law, combined with economic changes across the global economy, led to a massive demographic shift across the United States.
Pathway to Citizenship Could Meet the Care Gap and Improve the Workplace
Domestic workers, including nannies, house cleaners and home care workers in the gray market (working unregulated and often under the table), should be the first candidates we look to in order to meet the growing need for home care workers. Many domestic workers already do some sort of care work but have been locked out of the formal home care market funded through Medicaid—the largest payer of home care—by a lack of immigration status. We have options for how to provide these prospective home care workers a pathway to citizenship and work authorization. In 2021, Sens. Alex Padilla and Elizabeth Warren and Reps. Joaquin Castro and Ted Lieu introduced the Citizenship for Essential Workers Act to enable domestic workers and other essential workers a pathway to citizenship.
Another possibility is creating a pathway to citizenship specifically for home care workers. Such a program could be structured to allow immigrants the ability to earn permanent residency by working in the home care sector. The program could be structured to allow people to apply for permanent residency after a set number of hours and years working in home care, with current home care workers in the private pay market qualifying to apply based on past work experience. The program would also allow other workers without immigration status the opportunity to gain permanent residency after two or three years of work in home care. This would directly build a new pipeline of workers.
Providing a pathway to citizenship for home care workers would not only enable a new stream of workers to enter the formal home care market, but also empower workers to earn better wages and assert their labor and employment rights. Too often, immigration status and the fear of immigration enforcement, whether or not it’s stated explicitly by employers, keeps workers from exercising their basic workplace rights.
Workers like Diwata (not her real name), a home care worker from the Philippines who loves her work caring for people one-on-one in their homes, would be able to work with dignity and enforce their rights with a pathway to citizenship. Diwata has lived in the United States for more than 30 years but has always been afraid of being deported. She worked as a caregiver for four years for one client. Although the pay was advertised as $15/hour, Diwata was only paid $10/hour—less than the minimum wage in California. Because of her immigration status, she was afraid to speak up.
Most pathways tie the guestworker’s immigration status and ability to work to their employer, making it extremely difficult to speak up about exploitation.
A pathway to citizenship would allow home care workers like Diwata to move into the formal home care market, live with greater dignity, and enforce their rights, which would in turn help improve standards across the sector.
Skepticism of Guestworker Programs
Some have suggested that Congress should create a new temporary guestworker program for home care workers to address the care gap. But we should be skeptical that guestworker programs, without a major structural overhaul, would sustainably meet the need for home care workers or do so in a manner that improves work standards and service delivery for older Americans. In 2019, nearly 2 million temporary migrant workers were employed in the United States. But many of these temporary visa programs suffer from major structural flaws that routinely lead to the exploitation of workers.
Guestworkers often arrive indebted after being charged illegal recruitment fees, and many programs, particularly those for workers at the lower end of the wage spectrum, such as the H-2B program, do not allow workers’ spouses to work, making it all but impossible for workers to bring their families with them. Most pathways tie the guestworker’s immigration status and ability to work to their employer, making it extremely difficult for workers to speak up about exploitative work conditions. Abuses in these programs have been well documented for years. Combined with the isolation of home care workers in individual homes, safeguards would be difficult to adequately enforce, with negative consequences for individual workers and standards across the home care industry.
As our population ages, we desperately need more home care workers. Creating a pathway to citizenship for home care workers and immigrants already in the United States would be a win-win-win strategy to meet caregiving needs. It would allow older Americans to age in their homes and transform caregiving jobs into good jobs with family sustaining pay, protections and dignity, in turn attracting more workers to home care.
Trudy S. Rebert, J.D., M.Sc., is the federal policy counsel with the National Domestic Workers Alliance (NDWA) and is based in New York City. NDWA is the leading voice for the 2.2 million domestic workers who work as nannies, home care workers and house cleaners in private homes, providing essential care and supportive services to children, aging parents and family members with disabilities.