A larger pool of immigrants in the U.S. could both improve nursing homes’ ability to hire for frontline positions and reduce dependency on institutional care in the long-term, speakers at a healthcare and immigration reform panel said Tuesday.
The Brookings Institution sponsored the session, focusing on the intersection of aging baby boomers, the increased demand for care they will bring nationwide, and the ongoing shortage of U.S.-born workers needed to fill more than 400,000 long-term care positions vacated over the last two years.
“Including immigration as part of — if we were to have one — a national strategy about how we’re going to take care of our older adult population going forward, that’s just table stakes,” said Anne Tumlinson, CEO of ATI Advisory. “It’s not even a question of ‘if.’ It’s more, to me, a question of ‘how.’”
Several speakers said finding caregivers for elders will be a global need as life expectancy increases. In the U.S., half of those who hit age 65 will need at least short-term assistance with daily activities at some point, Tumlinson said. Worldwide, there are fewer younger people to provide that caregiving in family or other informal roles.
In the U.S., speakers said, immigration policy hasn’t kept up with labor trends and those in the healthcare realm specifically.
“The presence of a robust immigrant workforce is really an important component of thinking about the decision of Americans to age in place or stay in the community,” said economist Tara Watson. “Immigration inflows have slowed dramatically in the last few years. Of course, that’s partly due to the pandemic and some of that may reverse, but there are also policy changes and backlogs in immigration.”
Watson, professor of economics at Williams College and research associate of the National Bureau of Economic Research, noted that higher immigration in specific areas has tended to accelerate the trend of falling SNF use in those same areas. That finding overlaps with the overrepresentation of immigrants in the home health sector, where some 28% of aides are foreign-born, Watson said.
Immigrant labor and better outcomes linked
But many immigrants also gravitate toward skilled nursing facilities, a trend several speakers could be encouraged with changes or additions to the U.S. visa program.
Delia Furtado, associate economics professor at the University of Connecticut, said there were two broad reasons to expect that “more abundant immigrant labor” would lead to better nursing home care.
“When there are more people in the area available to work, nursing homes can staff, fill the nursing shortages, even without having to increase wages. With better staffing, nursing homes can better take care of their residents,” she said. “Another possibility is that foreign-born nurses are more effective or more productive because they might not be as able to be picky about where they work.”
Furtado co-authored a 2020 paper that linked a five-year increase in local immigration to multiple quality improvements in nearby nursing homes, including a 4% decrease in falls, a 33% reduction in use of restraints and a 20% drop in pressure injuries.
“It seems reasonable to believe that a more open immigration policy is a less costly way to increase staffing compared to other policy tools, like minimum staffing standards and policies aimed to increase nurse wages,” Furtado said, later referring to a $7.25 billion price tag associated with a 2019 staffing rule proposal.
The nation’s two largest provider organizations have been lobbying for immigration reform over the last several months, embracing the idea of helping resettle Afghan refugees and those fleeing war in Ukraine.
Courting political will
Despite some recent overtures by the Biden administration, Brookings speaker Kristie De Pena noted that immigration rates remain suppressed because the U.S. hasn’t changed its overall immigration laws in about 40 years.
“We are starting to see some of the deleterious effects of that,” said De Pena, vice president for policy and director of immigration policy at the Niskanen Center. “We have to start that incremental march toward thinking about the kinds of immigrants that we need, how to balance that out with humanitarian needs of the rest of the world and how we can participate in that.”
She encouraged providers and others who favor immigration reform to start sharing with elected leaders the impact of a too-small labor force and the tangible ways a larger immigrant pool could help. She also said it was critical to make seniors realize that immigrants might be the key to ensuring a robust and sustainable continuum of long-term care services.
“Ultimately, if we want to keep up and we want to fill these needs, the answer is in a refreshed immigration policy that reflects what people are clamoring for, even if they don’t recognize those are immigration needs per se,” De Pena said.
She recommended the federal government make technical changes to the immigration rules in the U.S, including updating for the first time since the early 2000s which jobs qualify as “shortage occupations” for immigration purposes. That designation makes it easier for employers to hire foreign-born workers, but only RNs and therapists qualify currently — not badly needed nurse aides.
Howard Gleckman, an LTC expert and senior fellow at the Urban-Brookings Tax Policy Center, questioned whether an influx of immigrants could drive down wages and benefits in the sector. But even when home care workers are paid $11 an hour, he said many families can’t afford them. He called for more investment in the system, noting that immigrants accepting caregiving jobs would need to earn enough to avoid being a “public charge” and having their visas denied.
The labor challenge is a “a strikingly important issue,” Gleckman said. “If we don’t deal with it, we’re going to have, really, a growing crisis among family members who just can’t manage the care by themselves.”
