This article appears in the August 2025 issue of The American Prospect magazine. Subscribe here.
Nelly Prieto’s home care clients are already afraid. Who will take care of them if they lose her as a caregiver? What will replace the services she provides? The 18-year home care veteran, patient transporter, and immigrant advocate in Washington state said the answers break her heart: no one, and nothing.
For years, the direct care industry, which provides home and community-based services for the elderly and people with disabilities, has struggled to hire and retain workers, and drew heavily from documented and undocumented immigrants. But now, thanks to President Trump’s racist regime and mass deportations, that workforce will shrink even more, just as American society is rapidly aging.
For the next five years, 10,000 people will turn 65 years old every day, according to AARP. By 2040, the number of people aged 80 to 85, who are the likeliest to need direct care, will reach 14 million, a 111 percent increase from 2022, according to federal data. If Trump’s deportation policies stand, there won’t be enough caregivers to meet the demand for help.
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“A lot of clients really are going to lose their lives,” Prieto told the Prospect. She knows that firsthand. When one of Prieto’s clients could no longer use her services because of an insurance change, there was no one else to look after her. “They couldn’t get another provider and my client was left alone. And when she was finally found, she had been left alone for so many days that she was wrapped up in her clothes with her own feces,” Prieto said. The woman was rushed to the hospital. But by then, “she said she didn’t want to live anymore,” and shortly afterward died.
Prieto had cared for the woman for two years. Her voice broke while telling the story.
Advocates, workers, and researchers said the ripple effects of Trump’s deportation policies on the care industry are dire. People who need care but have no one to help them will suffer alone and struggle to maintain their quality of life; some will lose their homes and be driven onto the streets. Americans 50 years and older are the fastest-growing group of people experiencing homelessness, according to the National Alliance to End Homelessness. The number of Americans aged 50 or older who are experiencing homelessness is expected to triple in the next five years.
Direct care added 1.6 million new jobs over the last decade, but workers don’t stick around for long.
Not only older Americans will feel the pain, said Alison Chandra, a pediatric home health nurse in Utah, who accompanies young clients to school and provides constant care “that keeps them safe and loved at home, instead of in institutions.” She has accompanied one client to school each day since kindergarten and is starting fourth grade with him next year. “I’m the reason why he’s in a class with his peers, with his friends, with his community, where he belongs,” said Chandra, who is also a health care and disability justice advocate. The child could go to an institution. But then he wouldn’t get hugs from his neighbor, or see friends from his church, or just exist as a kid. “What’s better for a child?” she said.
Without available caregivers, family members will need to look after their elderly and disabled relatives. More Americans every day become part of the “sandwich generation,” raising children while caring for parents (or even the “club sandwich generation” if they have a grandparent or great-grandparent needing care). Family members may find the effort so demanding that they abandon their jobs; but in addition to the economic impact, trying to care for a loved one can be emotionally harrowing, especially for someone without proper training.
“It takes a long time to get to know your client, because every client has different medical issues. If you’re not trained as a home care provider to handle those issues you’re not going to know how,” Prieto said. “A lot of the clients, they don’t want to let you go, they don’t know how to get along with another caregiver.”
AS WITH OTHER INDUSTRIES THAT RELY on immigrants, including construction, farming, hospitality, household work, and meat processing, mass deportations could bring direct care work to a standstill. Documented immigrants make up 28 percent of the overall direct care workers, who provide hands-on personal care to people with disabilities and chronic conditions and the elderly, such as bathing, dressing, and eating. Documented immigrants make up 32 percent of home care workers specifically, who provide that care in people’s homes, said Kezia Scales, vice president of research and evaluation at care industry researcher and advocate PHI.
There’s no definitive data on the number of undocumented workers in the sector. The American Immigration Council puts the figure at almost 7 percent of the home health aide workforce and 4.4 percent of all personal care aides, but advocates say the number is likely much higher. Those are the workers most at risk in Trump’s America, Scales said, but Trump is also targeting legal immigrants, revoking immigrants’ right to work, and attacking U.S. citizens, too.
“A lot of immigrant direct care workers would not be directly impacted by deportation orders because they have work authorization, but what we think is very likely is that the broader chilling effect of these incredibly drastic and punitive actions will impact [them] as well because many of them live in households with mixed immigration status,” Scales said. A likely scenario is that workers will leave formal employment and provide care services under the table, which leaves workers and patients alike with fewer protections.
“Generally the widespread fear and uncertainty caused by these deportation orders will make individuals leave the workforce, maybe to go into the gray market where they can work under the radar or leave the workforce all together,” Scales said. “What we’ll really see is a contraction of the workforce altogether as those with whatever documentation status opt out because it’s just too uncertain.”
It wouldn’t take much to upend the industry, said elder law attorney Harry Margolis, founder of Margolis Bloom & D’Agostino and writer for the Squared Away blog published by the Center for Retirement Research at Boston College.
“The way economics works, you don’t need a huge change to create a huge problem,” Margolis said. “If you cut the availability of caregivers by 10 percent … it’s going to create huge problems.”
The direct care industry is already contending with huge workforce problems. Though direct care added 1.6 million new jobs over the last decade to stand at five million as of 2023, according to PHI, workers don’t stick around for long. Federal data puts the median hourly wage at $16.78; PHI data shows almost 40 percent of caregivers live in low-income households, and almost half rely on Medicaid, cash transfers, nutrition assistance, or other forms of public help.
The days are physically and emotionally demanding, and the job comes with “heavy workloads, scheduling challenges, inadequate supervision, and limited training and career advancement prospects,” PHI said. There is no comprehensive data on care industry turnover, the group said, but assessments of specific jobs give a clue of the sector’s employee retention. Last year, PHI estimated 80 percent turnover in home care. Between 2017 and 2018, the median annual turnover for nursing assistants in nursing homes was almost 100 percent.
“Because these are low-paid, low-technical-skill, high-personal-skill, high-human-skill jobs, they’re staffed by people who don’t have a lot of bargaining power in the economy, and those are often immigrants,” Margolis said. “And if we make it harder for them to be here or harder for them to work … it’s going to be harder and harder to find care when you need it.”
The industry expects to add more than 860,000 new jobs between 2022 and 2032, the largest growth of any job sector in the country. But workers and advocates say open positions stay unfilled for months, and when someone does get hired, there’s no guarantee that they’ll stay.
“The situation is accelerating because we have more and more people who need the care, and we haven’t figured out how to both increase the supply of workers to meet that need and rationalize services or modernize services in ways that would improve efficiency,” Scales said.
IN JANUARY, TRUMP REVOKED THE GUIDELINES that had earlier forbidden ICE to raid “sensitive areas,” leaving those in schools, places of worship, and hospitals and care facilities vulnerable to immigration raids. Immigration advocates also expect a sharp increase in I-9 audits, “silent raids,” in which federal agents check whether employees have work authorization. The two attacks can bleed into each other, said Marisa Díaz, immigration worker justice program director at the National Employment Law Project.
“What we’re seeing is that even in cases where ICE goes to a workplace to initiate an I-9 audit, we’ve seen a trend where they’ll use that to talk to workers and try to arrest them,” Díaz said. Under the last Trump administration, I-9 audits hit a record high of 6,454, quadruple the number under the Obama administration. There will be at least that many again, Díaz expects.
“There are cases that have been reported in Maryland, Arizona, Texas, and Louisiana, where ICE arrived at a workplace with a Notice of Inspection … it’s not a warrant of any kind, it does not give ICE the right to talk to anyone,” Díaz said. “But they use it as an excuse to talk to workers and arrest them on the spot.”
It’s impossible to quantify the effect for patients when they lose a caregiver, especially if the loss is because of a raid, said Sam Brooks, director of public policy at the National Consumer Voice for Quality Long-Term Care.
“We’re concerned, certainly, that workers that are there now will not want to go to work for fear of being caught up in these raids, but it also has a horrible effect on the residents,” Brooks said. “Imagine if police just wantonly came in and took a resident or a worker, imagine how you would feel … the trauma on people getting care there is severe.”
While Chandra, the nurse and advocate in Utah, is not at risk of deportation herself, she has seen the fear among those she’s connected to through the wider medical community via the nonprofit Heterotaxy Connection, an organization focusing on a condition her son has.
“Just speaking to clinicians in our research consortium, their postdoc students are being stopped on the street and questioned,” she said. “It is medicine as a whole that’s being threatened in this country.”
The result is a crisis at all levels of the medical industry, said Dr. Brett Lewis, resident physician at Boston Medical Center, the largest safety-net hospital in the region.
“From my standpoint, everyone is terrified. My patients are forgoing prenatal care because they’re afraid to come in to the clinic, to the hospital because they’re afraid they’re going to be picked up by ICE on the way. They’re afraid to pick up their blood pressure medications. Staff are afraid, certified nursing assistants, custodial staff who are literally making our hospital run are afraid to come in to work,” she said. In Boston, Lewis explained, many patients and employees are Haitian immigrants, and the Trump administration’s revocation of Temporary Protected Status, which allowed Haitians to stay in the U.S. and work, has caused havoc in the health care community.
SEIU Executive Vice President Leslie Frane sees the deadly GOP spending law as creating far more problems for people needing care and the immigrant workforce. Along with Lewis, Prieto, and hundreds of union members, Frane was in Washington, D.C., this summer to fight unsuccessfully against the legislation. It imposes nearly $1 trillion in cuts to Medicaid and supercharges Trump’s deportation goals, with $170 billion for immigration control, including tripling Immigration and Customs Enforcement’s budget to nearly $30 billion and adding $45 billion for new detention centers.
“It is no coincidence that when Republicans wanted to find money to fund tax cuts for the wealthy, Medicaid is where they went first,” Frane said. “It’s partly because it’s a big budget item. But, frankly, it’s also because the people who rely on Medicaid for care are working people, poor people, seniors, people with disabilities. They are among the most vulnerable people in our society and they are the people that Republicans consider expendable.”
This article appears in Aug 2025 Issue.