The Case for Immigration: Incentivizing U.S. Workers Won’t ‘Come Anywhere Close’ to Solving SNF Labor Crisis

The intersection of nursing home staffing and immigration has long been a conversation among operators before and during the pandemic, becoming even more pressing as industry leaders clamor to provide solutions to a historic workforce shortage.

Incentivizing U.S. workers to take long-term care jobs won’t “come anywhere close” to filling the need the industry is already seeing and expects to see going forward, according to Kristie De Peña, vice president for policy and director of immigration policy at the Niskanen Center, a nonpartisan think tank based in Washington, D.C.

De Peña served as a panelist during a webinar on Tuesday, hosted by The Brookings Institution, a nonprofit public policy organization based in D.C. Researchers and industry leaders explored the connection between long-term care and immigration.


“Questions that follow here are whether we can accommodate those growing needs, given our current immigration infrastructure, and if not, what do we really need to do to get there,” De Peña said. “At this point, I can resoundingly say that the pathways that exist now for migrant labor to come to the U.S. are woefully inadequate.”

American Health Care Association (AHCA) President and CEO Mark Parkinson has indicated the aging services organization would start “pounding away” and “planting the seeds” for more comprehensive immigration reform to bring nursing home workers overseas.

AHCA pushed for lawmakers to amend the country’s current immigration visa prioritization to consider prioritizing the entry of foreign-trained nurses and health care workers into the U.S. prior to the end of 2021.


Parkinson admitted immediate reforms are unlikely, however, given the current partisan divide in Congress.

Nursing-specific visas

Visas are almost entirely exclusive to physicians and surgeons, De Peña said. A program prompted by nursing shortages created the H1C visa to have registered nurses (RNs) temporarily come to the U.S., but that pathway expired in 2009, she added.

“There isn’t a lot of political will behind increasing opportunities for migrants and a lot of these lower skilled health care sectors, even though there’s this incredible demand,” added De Peña. “There’s really no unique employment-based visa categories accessible to home health aides, personal care aides, [CNAs].”

Still, about 28% of long-term care aides are immigrants, according to panelist Howard Gleckman, senior fellow at the Urban-Brookings Tax Policy.

For Anne Tumlinson, CEO of ATI Advisory, a more open immigration policy is just “table stakes” for the nursing home staffing shortage.

“It’s not even really a question of if, it’s more to me a question of how,” said Tumlinson, referring to immigrants helping stem the labor shortage. “I’m really struck by the fact that we’re going to be competing for this labor force … [other countries are] ahead of us in terms of their immigration policy, but they’re also ahead of us in terms of their care delivery systems and financing for these services and supports.”

More traditional employment visas like the H1B visa are still incredibly difficult for most of these workers to get, De Peña said; the U.S. has about 1 million employment-based green card applicants in its backlog, and gives out only 140,000 each year.

Immigrant doctors, surgeons and clinicians with advanced degrees have to overcome hurdles that range from opaque licensing requirements to rigid visa mandates to practice in the U.S., De Peña said during the webinar.

The United Kingdom, Canada and Australia are doing an “exponentially better” job of recruiting and retaining foreign talent, putting the U.S. at a more distinct disadvantage as the industry continues with a worsening labor crisis, De Peña said.

Immigration and quality of care

Delia Furtado, an associate professor in the department of economics at the University of Connecticut, provided a notable data point from her research on immigrants in the nursing home labor force – SNFs saw a 4% decrease in resident falls as the number of immigrants within local labor markets increased between 2000 and 2010.

Furtado also saw a 33% decrease in the number of restrained residents, and a 20% drop in pressure ulcers connected to that influx of immigrants in local labor markets.

“All of this suggests that a more open immigration policy might lead to improvements in the quality of care provided in nursing homes,” Furtado said. “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 maintaining minimum staffing standards and policies aimed to increase nurse wages.”

Furtado’s research paper, currently under revision in the Journal of Human Resources and initially published by the IZA Institute of Labor Economics in July 2020, explores the possibility of immigration improving quality of care in nursing homes.

An open policy toward immigration is even more important as baby boomers start approaching the age at which they will need more acute, institutional care, and nursing homes increasingly become the setting for that care, she said.

About $172 billion was spent on nursing home care in 2019, and Furtado expects that number to increase even further.

Meanwhile, quality of care was impacted as clinicians struggled to treat Covid among an elderly, frail population, Furtado added. Nursing home residents account for less than 1% of the U.S. population, but made up 19% of all Covid deaths, she added.

Furtado brought up the National Academy of Sciences, Engineering and Medicine (NASEM) report on nursing home care, notably its description of the industry as “ineffective, inefficient, inequitable, fragmented and unsustainable.”

“The report specifically brings up inadequate staffing as one of the main issues to address in our paper,” said Furtado. “We consider whether increasing the availability of immigrant workers might lead to improvements in the quality of nursing home care, even without the use of policy tools, like increased minimum staffing standards.”

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