Nelly Prieto, an 18-year home care veteran in Washington state, faces heart-wrenching questions from her elderly and disabled clients: "Who will care for us if we lose you? What replaces your help?" Her answer devastates them: "No one, and nothing."
The direct care industry, already struggling to hire and retain workers for home and community-based services, relies heavily on documented and undocumented immigrants. Now, President Trump's deportation policies and anti-immigrant stance are shrinking this critical workforce precisely as America's population rapidly ages.
Aging America Meets Shrinking Workforce
The demand surge is undeniable: AARP projects 10,000 people turning 65 daily for the next five years. Federal data shows the 80-85 age group (most likely to need care) will swell to 14 million by 2040 – a 111% increase since 2022. Yet, Trump's deportation policies threaten to leave millions without adequate care.
The consequences are dire, as Prieto knows firsthand. When one client lost her services due to insurance changes, no replacement could be found. "She was left alone for days, found wrapped in her own feces," Prieto recounted, her voice breaking. Rushed to the hospital, the woman declared she didn't want to live and died shortly after. "A lot of clients really are going to lose their lives," Prieto warns.
Ripple Effects of Deportation Policies
Advocates predict widespread suffering:
* **Vulnerable Patients Left Alone:** Those needing care will struggle to maintain basic quality of life; some risk losing homes and joining the fastest-growing homeless demographic: Americans 50+.
* **Children Losing Vital Support:** Pediatric nurse Alison Chandra describes how her care enables a child to attend school with peers instead of an institution. Without caregivers like her, children lose community, connection, and normalcy.
* **Families Overwhelmed:** More Americans will join the "sandwich generation," forced to quit jobs to care for relatives without proper training, leading to emotional and financial devastation. Prieto stresses the specialized knowledge required: "Every client has different medical issues... if you're not trained, you won't know how."
Immigrants: The Backbone of Care Under Attack
Immigrants are essential to direct care:
* Documented immigrants comprise 28% of the overall direct care workforce and 32% of home care workers specifically (PHI data).
* Undocumented workers, though harder to quantify (estimates range from 4.4% to 7%, likely higher), are most vulnerable to deportation.
* **Chilling Effect:** Even documented workers face fear. Many live in mixed-status households and may flee formal jobs for the unregulated "gray market," stripping workers and patients of protections. "Widespread fear... will cause a contraction of the workforce," says Kezia Scales of PHI.
An Industry on the Brink
The direct care sector, despite adding 1.6 million jobs in the last decade (reaching 5 million in 2023), faces catastrophic turnover (up to 80-100% annually). Low wages (median $16.78/hour), demanding work, and limited advancement drive workers away. The industry expects to add another 860,000 jobs by 2032 – the most of any sector – but positions stay unfilled for months.
Elder law attorney Harry Margolis warns: "You don’t need a huge change to create a huge problem. A 10% cut in caregiver availability... will create huge problems." These low-wage, high-skill jobs rely on immigrants with little economic power. Making it harder for them to work "will make it harder and harder to find care when you need it."
Policy Escalation: Raids, Cuts, and Fear
Trump's policies exacerbate the crisis:
1. **Raids in "Sensitive Areas":** Revoked guidelines now allow ICE operations in hospitals, schools, and churches, terrorizing patients and staff.
2. **I-9 "Silent Raids":** Expected to surge (reaching record highs under the last Trump admin), these workplace checks often lead to on-the-spot arrests, even without warrants.
3. **Medicaid Cuts:** The recent GOP spending bill slashes nearly $1 trillion from Medicaid – the primary payer for much home care – while allocating $170 billion to immigration enforcement (tripling ICE's budget, adding $45 billion for detention centers). "Republicans consider Medicaid recipients... expendable," states SEIU's Leslie Frane.
A Healthcare System in Terror
The fear permeates healthcare:
* Patients forgo prenatal care and vital medications due to ICE fears.
* Essential staff – CNAs, custodians – fear coming to work.
* Clinicians and medical students report being stopped and questioned.
* Revoking protections like Temporary Protected Status (e.g., for Haitians) causes havoc in hospitals and communities.
"This is medicine as a whole that’s being threatened," warns Chandra. Dr. Brett Lewis of Boston Medical Center sums up the atmosphere: "Everyone is terrified." The convergence of an aging population, a reliance on immigrant caregivers, and aggressive deportation/cut policies threatens to collapse the home care system, leaving the nation's most vulnerable – the elderly, disabled, and children – without the essential support they need to survive and thrive.