Millions of immigrants worked alongside fellow Americans during the COVID-19 pandemic as essential workers, ensuring hospitals and health care facilities were staffed, grocery shelves were stocked, and farms were tended.1 Even before the pandemic began in early 2020, the U.S. health care system relied heavily on immigrant workers to address long-standing labor supply challenges in the industry, largely because it can take a long time to train enough domestic health care workers.2
One study found that in 2017, more than 1 in 4 direct care workers in nursing, home health, and personal care were foreign born, and so too were nearly 1 in 3 support staff in health care facilities.3 Then and now, immigrant women in particular are concentrated in the health care and social assistance industry, filling a range of occupations from health care practitioners to hospital support staff.4 Pandemic-related attrition, an aging U.S. workforce and population, and low-quality jobs that are often low pay are exacerbating the severity of workforce supply issues in many occupations in the health care industry.
The lack of good jobs and difficulties in hiring and retaining nurses and direct care workers today is causing the number of available beds to shrink and the number of care units to decline, with these challenges leading to the shuttering of entire care facilities, affecting people of all ages.5 This is happening as the United States faces a dramatic increase in the population of adults ages 65 and older over the next decade.6 As a result, not only will many of those workers be retiring from the care workforce in which they are overrepresented, but more of them will need care themselves as they grow older.7 (see Chapter 4)
In 2008, the Institute of Medicine projected that by 2030, the United States will need to add 3.5 million health care workers, including 868,000 registered nurses and 709,000 nursing aides, just to maintain the then-current health care worker-to-population ratio.8 Yet according to estimates from the Center for American Progress, the number of registered nurses per 1,000 Americans ages 65 years and older has declined from 69 in 2003 to 62 in 2021, showcasing the workforce challenge.9
This chapter of the “Playbook for the Advancement of Women in the Economy” details the issues immigrant women10 face in U.S. health care occupations such as nursing and direct care work and how immigrant women can help address hiring and retention challenges, underscoring the importance of increasing the quality of jobs in the health care industry. (see text box) The chapter then closes with specific policy recommendations at the federal level, among them:
- Expand access for new immigrants, bringing their talents to the United States.
- Establish accountability of immigrant-worker recruitment and staffing agencies.
- Provide a pathway to citizenship for undocumented immigrants.
- Create tailored support for immigrant workers in the direct care workforce.
These solutions should supplement other robust strategies to increase the domestic supply of health care workers, including those that center around improving the quality of jobs for all workers in the industry.11 While the focus of this chapter is on selected occupations, immigrant women also play an outsize role in other occupations in the care industry beyond health care, such as housekeepers and child care workers.12 Given the gender divide in these care professions, it is important that immigrant women are included in the much-needed conversations around easing workforce challenges experienced by these critical industries.
Glossary
Foreign-educated nurses are those who received their nursing education and training in another country.13 For this chapter, foreign-educated nurse excludes U.S. nationals who received their training abroad.
Direct care workers are individuals who provide care in nursing homes and in-home settings as nursing assistants or nursing aides, personal care aides, and home health aides.14
Registered nurses are individuals who obtained their degree from a state-approved school, passed the NCLEX-RN examination, and have received a license from a state board of nursing to practice.15
The problem
To work as a health care professional in the United States, foreign nationals generally must navigate complicated and lengthy immigration pathways, have their credentials verified by U.S. organizations approved by U.S. Citizenship and Immigration Services (USCIS), get licensed by the state in which they want to practice, and make substantial investments in time and funds. On top of this, foreign nationals and their families have to learn to adapt to the new norms and culture of a new country and community.
The U.S. immigration system does not have a separate visa category dedicated to health care professionals except for J-1 exchange visitor visas, which are granted annually to a limited number of international medical graduates to work as physicians in designated underserved areas.16 Under the Immigration and Nationality Act, immigration pathways for immigrant workers, regardless of occupation, are numerically limited, and even those existing pathways are backlogged as a result of restrictions such as annual caps as well as a lack of appropriate resources to process applications.17
The barriers facing immigrant women do not help existing worker shortages in the health care industry, and they also highlight the sector’s deep reliance on immigrant women already working in the U.S. health care industry.
Immigrant women already play an outsize role in the U.S. health care workforce
Women play a crucial role in the health care workforce, making up more than 75 percent of the health care workforce among both U.S.-born and immigrant workers.18 Immigrant women are taking on jobs that range from ones that require higher qualifications, such as registered nurses, to others that are critical but offer low wages, such as home health and personal care aides.19 Of the 2.1 million immigrant women who are health care workers, 21.8 percent are registered nurses, 11.7 percent are nursing assistants, 9.6 percent are home health aides, 16.8 percent are personal care aides, and 14.6 percent are health care technologists and technicians.20
Among 2.1 million immigrant women who are health care workers:
21.8%
are registered nurses.
11.7%
are nursing assistants.
9.6%
are home health aides.
16.8%
are personal care aids.
Filipinos make up an overwhelming 27 percent of all immigrant registered nurses, with more than 150,000 migrating to the United States since 1960.21 The next-largest group from which registered nurses hail is India at 7 percent, and like U.S.-born nurses, they are disproportionately women. The direct care workforce is slightly more diverse, with 14 percent of all immigrant direct care workers immigrating from Mexico; 9 percent from the Philippines; and 7 percent each from the Dominican Republic, Jamaica, and Haiti.22
The role of undocumented workers in U.S. health care settings
Most immigrant health care workers in the United States have some type of lawful immigration status, but research by CAP in 2021 found that there were nearly 350,000 undocumented health care workers, with tens of thousands working as personal care aides, nursing assistants, and home health aides.23 Other research estimates that, among undocumented health care workers, nearly 74 percent were women in 2017.24
Separately, CAP estimates that approximately 29,000 Deferred Action for Childhood Arrivals (DACA) recipients were health care workers during the COVID-19 pandemic, with 3,400 working as registered nurses and 8,500 as direct care workers.25 In addition to these “Dreamers,” many immigrants with temporary protected status (TPS) worked in essential services during the pandemic and continue to work in the direct care fields.26 Both DACA recipients and TPS holders, however, do not have a path to citizenship or permanent residency, despite their contributions in these essential heath care fields.
The hurdles facing desperately needed immigrant nurses are high and often exploitative
Without existing connections, foreign-educated nurses often find navigating the migration process and health care industry intimidating.27 They can use only a few immigration pathways to work in the United States. Those who want to permanently live and work in the United States can apply for a green card under one of the employment-based preferences (nurses generally apply under the EB-3 category) if they have a permanent job offer along with the right combination of skills and certification, with certain provisions for registered nurses.28 Some can also apply for an H1-B temporary work visa depending on the nature of the position, which allows them to work for an employer on a temporary basis.29
But both pathways come with their unique challenges and are subject to numerical caps. The EB-3 category has lengthy backlogs depending on an applicant’s nationality, and H1-B visa applicants are subject to a lottery, which makes it an unreliable pathway to add much-needed workers. Historically, Congress has passed laws to create programs such as the H-1C, which expired in 2009, and prior to that the H1-A, which specifically aimed to increase the number of registered nurses in labor-shortage areas of the health care sector.30
On top of immigration-related barriers, foreign-educated nurses also must get their credentials verified by the Commission on Graduates of Foreign Nursing Schools (CFGNS) and satisfy state licensing requirements.31 A recent survey of foreign-educated nurses conducted by CFGNS reported that more than half of them migrated through an international recruitment and staffing agency, and among nurses who arrived in the last three years, the share jumped to 79 percent.32 The nurses who choose to hire a recruiter sign a contract with them and become their employees. These contracts are often exploitative, coercing nurses into work in subpar conditions with lower-than-average wages and high workloads.33
There are many documented cases of recruitment agencies suing immigrant nurses for thousands of dollars if they decide to leave before the end of their contract period, which could be for more than three years.34 For example, NBC News reported that a recruitment agency sued more than 12 immigrant nurses for more than $100,000 each for leaving their jobs before the end of their three-year contract.35 In 2021, a New York judge found that a nursing agency and a recruiter violated the Trafficking Victims Protection Act because they did not pay the plaintiffs—Filipino nurses—the promised wages and threatened them with “serious harm” if they left.36 The agency was ordered to pay $1.56 million in damages with interest to the plaintiffs.
There have been several court rulings that have brought these egregious violations to the forefront. These recruitment agencies are not clearly regulated. Actions to regulate these practices, hold the agencies accountable, raise wages, reform visa programs to ensure wages offered to immigrant workers are not below market levels,37 and create good working conditions will go a long way to improve job quality, as well as health care services in general.
Immigrant direct care workers provide critical care but are often exploited
Direct care workers—including home health aides, personal care aides, and nursing assistants—provide critical long-term care for older and disabled Americans that helps them remain in their communities and live independently. These workers generally do not have the extensive training, education, or competency requirements required of other health care workers, and they are ineligible to apply for most types of permanent or temporary visas.38
Workers who would like to permanently move to the United States as home health workers could be eligible for the 10,000 visas separated for unskilled workers under the employment-based third (EB-3) category, providing that their credentials can be verified by the USCIS-approved credentialing organization, but this latter requirement would exclude most occupations in this category.39
Still, immigrants play an outsize role in these occupations. One study estimated that immigrants occupy more than 27 percent of direct care jobs despite comprising 17 percent of the workforce overall, and of those immigrant direct care workers, 86 percent are women.40 Another estimated 3.6 percent of health care workers in the formal and informal long-term care sector were undocumented.41
Direct care workers face demanding and poor-quality jobs with high rates of injury, low wages, minimal benefits, and often while lacking legal immigration status and respect for their services.42 Reports show that immigrants in residential long-term care settings face longer working hours, nighttime shifts, and are more likely to work overtime.43 For immigrant women who provide in-home care, lack of legal status makes them especially vulnerable to exploitation.44
Unsurprisingly, employers see high turnover rates and have difficulties in attracting and retaining new workers. Addressing the workforce challenges and shortages in direct care is of utmost urgency given the skyrocketing demand for these workers. Solutions should include strategies to pay fair wages, improve working conditions, provide training and education opportunities, and provide pathways for legal status for undocumented workers.45
The economic benefits
As more Americans live longer lives, a robust health care workforce that supports well-being strengthens our communities and the overall U.S. economy. As the nation’s population over the age of 65 continues to grow, Americans have consistently expressed a preference to remain in their homes and communities as they age, maintaining social and family connections.46
Immigrant health care workers can make this preference a reality for older adults.47 Studies show that a localized 10 percentage point increase in immigrants with less than a bachelor’s degree as a share of the labor force results in a 1.5 to 3.8 percentage point reduction in institutionalization for people ages 65 and older and 80 and older, respectively.48
An often-cited economic reason for not hiring immigrant workers are negative wage effects for U.S.-born workers, but the evidence to that effect is mixed and can be ameliorated by robust worker protections for U.S. born and immigrant workers alike.49 Similarly claims that immigrants take employment opportunities away from the U.S.-born population have been debunked.50
Furthermore, attracting and retaining more health care workers, including immigrants, in the direct care and nursing fields experiencing increasing labor demand issues would likely lower the costs of care that are due to avoidable health outcomes. The American Association of Colleges of Nursing overviews numerous studies that find addressing staffing shortages can improve outcomes for patients, including improved hospital readmission rates, lower rates of infection, and fewer deaths.51
There will be nearly 200,000 openings for registered nurses alone each year from 2022 to 2032, according to the U.S. Bureau of Labor Statistics.52 As two former secretaries of the U.S. Department of Health and Human Services (one appointed by president Obama and the other by president Trump) noted in an op-ed in Time, an aging workforce and population, a shortage of nurse educators, and high rates of turnover are leaving the nation woefully short on nurses.53
Immigration can be used as one component of an overall strategic plan to address the workforce challenges in the health care industry—but it is not the only tool that can be used to fix these challenges. Increasing the supply of the domestic workforce should include expanding access to education, institutional partnerships at the state and local levels, and funding the National Health Care Workforce Commission.54
To read more policy proposals to address the nursing shortage with the domestic labor force:
There are a range of estimates for direct care shortages, but one example estimated a national shortage of 151,000 direct care workers by 2030, with that number more than doubling by 2040.55 Specifically, the U.S. Bureau of Labor Statistics projected that from 2022 to 2032, employment in home health and personal care aide occupations is projected to increase 22 percent—much faster than average job growth.56 Furthermore, there will be 684,600 openings in these occupations every year on average over the same period.57
Besides the value of immigrant health care workers in staving off stress from increased demand, they also contribute to their local economies through taxes paid and spending on goods and services. In a recent survey conducted by the Commission on Graduates of Foreign Nursing Schools—the USCIS-credentialing organization—immigrant nurses reported that they spent 60 percent of their income in their communities and 25 percent on taxes. Extrapolating from these results, the study estimated that immigrant nurses send more than 10 percent to 15 percent of their income to their home countries as remittances, leaving about $46.9 billion to be spent in their local economies in the United States.58
Additionally, in 2019, the IRS reported that close to 2.5 million tax returns were filed using an individual taxpayer identification number, which is generally used by individuals who do not have a Social Security number, amounting to nearly $6 billion in taxes.59 In 2017, the Institute on Taxes and Economic Policy estimated that undocumented immigrants pay $11.7 billion in state and local taxes annually.60
Policy recommendations
It has been three decades since U.S. immigration laws have been updated to expand migration pathways for undocumented immigrants as well as clear existing backlogs. These outdated laws are unresponsive to the contemporary labor needs of the United States. Any reforms to respond to the workforce challenges in the health care industry should place improving overall working standards and achieving pay equity at their forefront.
Below are select policy recommendations to modernize immigration policy and improve the lives of immigrant workers, which would ultimately lead to better health care services for all. These policies can complement other much-needed actions to improve job quality, including better working conditions and fair compensation.61
Federal policy recommendations
Immigration laws in the United States are the sole purview of the federal government. The U.S. Congress and federal agencies also affect and determine a wide array of working conditions in the health care industry and the overall workforce. Several select recommendations for Congress and these agencies include:
- Expand access to durable immigration pathways for future immigrants who seek to bring their talents to the United States: Currently, there are only a limited number of oversubscribed pathways available for future immigrants, regardless of skill, to work and live in the United States permanently or even temporarily. There are only 140,000 employment-based visas, plus additional unused visas, divided among various visa categories to immigrate permanently to the country.62 Nationals from countries with a large number of applications may have to wait many years before a visa becomes available for them. Given the increases in demand and worker supply issues for many of these occupations, such as in the education and health care industries,63 there are just not enough viable immigration pathways available for U.S. businesses and industries to secure enough workers. Congress should work to modernize and expand the immigration pathways so that the U.S. can better respond nimbly to changing labor market needs, and Congress should also adopt complementary policies to improve working conditions and wages.
- Establishing oversight and accountability of immigrant worker recruitment and staffing agencies: Given the prevalence of foreign-educated nurses using recruitment and staffing agencies to immigrate and work in the U.S. health care system, the U.S. Department of Labor should create a new interagency body to closely monitor and scrutinize their operations.64 According to a 2022 statement from the Nurses Union to HHS, “There is no systematic mechanism for detecting forced labor in the healthcare field.”65 These recruitment agencies should be held accountable for the welfare of the nurses they employ, including ensuring that wages and benefits are on par with U.S.-born nurses and that their work environment is safe and free from discrimination and harassment. The interagency task force’s oversight activities should prioritize investigation and enforcement actions in cases of contract-breach fees, wage theft, unsafe work conditions, and other violations of human rights and labor rights laws.
- Provide a pathway to citizenship for undocumented immigrants, including DACA and TPS holders: With hundreds of thousands of undocumented immigrants working as essential workers in health care settings, particularly as direct care workers, Congress should pass legislation that provides a pathway to citizenship that protects these workers from unscrupulous employers. Previous research by CAP unequivocally shows that a path to citizenship for undocumented people would boost economic growth.66 Legislation such as the bipartisan American Dream and Promise Act of 2023, a version of which passed the U.S. House of Representatives in 2021, would have provided a pathway to citizenship for Dreamers—including DACA recipients—who were brought to the United States as children, and longtime TPS holders.67
- Provide tailored support for immigrant workers in the direct care workforce: HHS and the U.S. Department of Labor should work collaboratively with community and worker organizations, as well as on their own, to ensure access to health care services, provide immigrants with legal services, ensure that they know their rights regarding employment and wages, and help workers integrate better through services that help with language barriers and cultural differences.68
Conclusion
In the face of increasing labor demand in the U.S. health care industry, immigrant women continue to fill essential and critical roles, often as registered nurses and direct care workers. Especially in the health care sector, if workforce needs are not handled creatively and fairly through holistic solutions that support both U.S.-born and immigrant workers, the consequences could prove dire for all Americans.
A broad suite of policies is needed to improve overall job quality and boost wages tailored to the challenges faced by immigrant workers, especially immigrant women who are overrepresented in the U.S. health care workforce. Policymakers need to engage with these issues now if they want to encourage an immigration system that supports the needs of the country for years to come. The proposed policies in this chapter are in line with a long pattern of attracting qualified people from all over the world to support Americans’ health in hospitals, homes, and communities.
The author would like to thank Debu Gandhi, Nicole Rapfogel, Rose Khattar, Sara Estep, Karla Walter, Mia Ives-Rublee, Beth Almeida, Sabrina Talukder, Will Roberts, and Emily Gee for their helpful feedback and Bela Salas-Betsch and Kennedy Andara for their research assistance.