Immigration Policies Hit Home-Based Care Industry As Providers Lose Workers 

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The Trump administration’s immigration crackdown has prompted home-based care providers to fear that changes in immigrant worker policies could lead to a loss of essential staff – and providers have begun to see these threats materialize.

In early July, the U.S. Department of Homeland Security (DHS) notified Honor CEO Seth Sternberg that work permits for some of the company’s employees could be revoked.

“Given the notice from DHS, we will begin re-verifying the eligibility of current employees who have already been verified and authorized to work,” Sternberg told Home Health Care News. “Should any employee’s authorization be revoked, we will need to remove them from their clients and replace them with another employee.”

San Francisco-based Honor is a home care tech company that owns Home Instead.

Sternberg said in a LinkedIn post that while his team will follow the law, it “just makes no sense.”

“This isn’t removing immigrants with criminal backgrounds,” he wrote. “This is cancelling work authorizations for thousands of documented workers – some number of them professional caregivers – who our older adults need.”

A significant number of home-based care providers depend on a foreign-born workforce. Over 30% of all home care aides and more than 20% of all nursing assistants are foreign-born, according to LeadingAge.

John Sneath, CEO of Tribute Home Care, headquartered in Framingham, Massachusetts, said his company has received similar notice and has already lost nine caregivers, with at least six more in jeopardy. This has not only presented problems for the employees being terminated, but also for the company and its clients.

In Massachusetts, one in four health care workers is an immigrant. The percentage is even higher for home health aides, which had a 46% foreign-born workforce even before the recent influx of migrants to the state, according to the American Immigration Council.

Immigrants are a significant part of the long-term care workforce for the rest of the U.S. as well. As of 2023, over 820,000 immigrants were working as direct care workers providing long-term care in the U.S., including over 500,000 naturalized citizens and over 300,000 noncitizen immigrants, according to KFF. Notably, the share of direct-care workers providing LTC services who are immigrants increased from 24% in 2018 to 28% in 2023.

“All of these caregivers were working with clients who had built relationships. [Losing them] was tough for clients and, obviously, tough on everyone [who] works at Tribute to see that happen,” Sneath told HHCN.

Need for change

In an April 30 letter to Secretary Kristi Noem, LeadingAge CEO Katie Smith Sloan said that DHS’ decisions “have created immediate uncertainty and concern for employers and workers alike.”

“Unlike other sectors that depend heavily on foreign-born workers, the aging services field requires continuity, consistency and trust between direct care workers and those they serve,” Sloan wrote. “Longstanding relationships with staff contribute directly to residents’ emotional well-being and sense of security…the sudden loss of these individuals risks unsettling care routines, diminishing quality of care and distress among residents who depend on familiar, stable support in their daily lives.”

Sneath said that while he understands the argument that the U.S. wants more Americans to have the opportunity to be placed in these caregiving positions, the fact is that there aren’t many Americans who apply.

“We don’t see too many Americans apply, particularly in Massachusetts,” he explained. “In Maryland, about half of our caregivers are American-born. Let’s come up with a system that looks at industries and identifies those where we could use foreign-born workers.”

Beyond filling positions that Americans aren’t necessarily applying for, Sneath said foreign-born caregivers often bring a different perspective to caregiving, as they are usually from countries where caring for their elders is a cultural norm.

“It may sound cliché, but a lot of caregivers are from countries where they care for their relatives, and their introduction to caregiving was taking care of an [older relative],” he shared. “They have a sensitivity and experience.”

Sternberg noted that opinions were not political, but were about “protecting the caregiving infrastructure millions of families rely on.”

“To revoke legal work authorizations from those caring for our aging population, when the workforce is already struggling to keep up with the demand, is deeply counterproductive,” he said. “It will leave older adults without people they know, trust and rely on. It will drive up the cost of care.”

Inside the legislation

These regulations come at a time when Congress recently proposed a bill to support home- and community-based services (HCBS).

The bill allocates Medicaid funds to states for two years to stabilize their HCBS service networks, recruit and keep HCBS direct care workers and address the long-term service and support needs of individuals eligible for Medicaid home- and community-based services.

However, according to Sternberg, “the math doesn’t work.” Choice Health at Home CEO David Jackson agreed.

The mass deportation of undocumented immigrants could lead to a loss of $1.1 trillion to $1.7 trillion in 2022 dollars from the U.S. gross domestic product, according to a report from the American Immigration Council. Meanwhile, Medicare spending on home health has been continually reduced.

“The juxtaposition is hard to ignore,” Jackson said. “We are cutting a Medicare benefit that saves money and helps seniors age in place, while doubling down on deportation policies that could erode the very workforce we rely on. All of this is occurring as our deficit increases.”

Choice Health at Home, headquartered in Tyler, Texas, is a multi-state provider of home health, hospice, personal care and rehabilitation services.

Jackson said one of the most difficult parts for him is seeing the fear in the faces of his legal resident caregivers.

“That’s hard for me, and where I wish the rhetoric would change a bit,” he said. “I don’t think that these people who are just good people taking care of people that need to be taken care of should be afraid. We’ve done a lot of work to create confidence, but it’s the fear of an employee – that’s something they should not feel.”

Sternberg wrote that if the U.S. is going to cancel one program, it is “imperative that it be replaced with another” and that rather than shrinking an already untenably shallow caregiver workforce, lawmakers need to expand it. This would mean training qualified Americans who want to become caregivers, but there are not enough people for the job. He called on lawmakers to put a work authorization program in place, allowing qualified people from other countries to come to the U.S. to enable our older adult population to age gracefully, saying, “There is truly no other solution.”

Inside immigration legislation

New legislation could improve the standings for home-based care providers facing reductions in staff due to more stringent immigration policies. To reform immigration and keep long-term immigrants working, Congresswomen Maria Elvira Salazar (R-Fla.) and Veronica Escobar (D-Texas) introduced the Dignity Act of 2025 on July 15.

The goal of the act is to secure the border, enforce measures, improve the U.S. asylum system, ensure dignity for long-term immigrants, support American workers and strengthen the legal immigration process.

“Immigrants – especially those who have been in the U.S. for decades – make up a critical component of our communities and also of the American workforce and economy,” said Escobar. “The vast majority of immigrants are hard-working, law-abiding residents, and most Americans recognize that it is in our country’s best interest to find bipartisan reforms.”

Part of the legislation involves creating the Dignity Program, which provides a seven-year temporary legal status for undocumented immigrants who have been in the country for five years or more, prior to 2021. As a requirement of the program, immigrants must pass a criminal background check, pay $7,000 in restitution over seven years, not claim any federal benefits or entitlements and have no path to citizenship. Once these conditions are met, they may stay and work in the country.

The act also creates a new $70 billion fund for training and upskilling American workers by providing grants for apprenticeships, on-the-job training and higher education. This fund will be funded through the payments made by immigrants in the Dignity Program.

In a statement, LeadingAge said it supports the act while advocacy groups work toward “subsequent bipartisan bills addressing needed reforms to benefit our members more directly by creating and expanding legal pathways for foreign-born workers to enter the aging services sector.”

“LeadingAge will continue to advocate that these kinds of reforms be added to the Dignity Act or other pieces of legislation, monitor the bill’s progress, assess its impact on providers and the direct care workforce and advocate before Congress and the administration for immigration policy that benefits the aging services workforce.”

While legislation like this is a start, providers like Sternberg believe there is still progress to be made in resolving issues between immigration status and retaining caregivers in home care.

“We urge lawmakers to consider the full impact of these decisions and to quickly put in place an expedited visa policy for qualified individuals who wish to care for America’s elderly,” Sternberg said. “Without caregivers, there is no care.”