New federal policies could worsen shortage of workers who care for older adults in New Jersey

Medicaid cuts and immigration restrictions are threatening an already strained workforce.

The workers who bathe, dress, feed, and provide other essential care to millions of older adults and people with disabilities are already in short supply.

But a series of federal policy changes could make the shortage even worse, particularly in New Jersey, where at least 30% of direct care workers are immigrants.

Medicaid cuts, intensified immigration enforcement, and proposed changes to federal labor protections could further strain the nation’s direct care workforce, according to a new analysis from KFF, a nonprofit health policy research organization.

The warning comes as the United States faces a growing need for long-term care and relies heavily on a workforce that is disproportionately female and immigrant.

In 2024, about 2.3 million direct care workers provided long-term care to people 65 and older and younger people with disabilities, KFF found. They include personal care aides, nursing assistants, and home health aides who help people eat, bathe, dress, manage medications, use the bathroom, and perform other daily tasks.

About two-thirds of direct care workers provide care in home settings. Another 22% work in nursing facilities, and 12% work in residential care facilities.

The work is demanding and often pays poorly. Research has repeatedly found that for-profit nursing homes spend less on staffing and pay lower wages, allowing owners to boost profits while potentially compromising resident safety and care quality.

Two-thirds of direct care workers earn less than $35,000 a year, compared with less than one-third of other adult workers, according to KFF’s analysis of 2024 American Community Survey data. Nearly four out of 10 direct care workers work part time.

About 32% are covered by Medicaid themselves, more than three times the rate among other adult workers. Another 13% are uninsured.

Those economic realities have contributed to long-standing worker shortages and high turnover in home care and institutional settings. Now, researchers warn, federal policy changes could further destabilize the workforce.

Medicaid is the nation’s primary payer for long-term care and also provides health insurance to nearly one-third of direct care workers.

Recent federal policy changes are expected to reduce federal Medicaid spending by $911 billion and impose new work requirements. KFF warned the changes could hit the workforce from both sides, straining the program that pays for much of the care these workers provide while threatening health coverage for workers themselves.

Immigration policies pose another threat.

Immigrants make up 30% of the nation’s direct care workforce, compared with 18% of other adult workers, according to KFF.

New Jersey is among 13 states and the District of Columbia where at least 30% of direct care workers are immigrants, according to KFF’s state-by-state analysis. Nationally, the reliance on immigrant workers is even greater in home care, where one-third of workers are immigrants.

KFF warned that intensified immigration enforcement and more restrictive policies under President Donald Trump could deepen fear among immigrants, reduce future immigration, and worsen existing workforce shortages.

At least one in five immigrant direct care workers comes from a country included in the Trump administration’s immigrant visa pause, KFF found.

Five of the 13 countries that account for nearly two-thirds of immigrant direct care workers are included in the pause: Jamaica, Haiti, Nigeria, Cuba, and Ghana.

Haitian workers are of particular concern following a June 25 U.S. Supreme Court ruling allowing the Trump administration to move forward with terminating Temporary Protected Status for Haiti, a decision that could affect more than 300,000 Haitian TPS holders.

Haitian immigrants account for about 6% of immigrant direct care workers in the United States, according to KFF.

The Long Term Care Community Coalition has warned that losing Haitian health care workers could have serious consequences for nursing home residents. Thw organization pointed out that Haitian workers have been an indispensable part of the long-term care system.

Haitians make up an estimated 6% to 7% of all immigrant caregivers in the U.S. long-term care sector. Haitians form a vital, disproportionate share of the direct care workforce in New Jersey and New York. New Jersey has the fourth-largest Haitian population in the United States. Around 27,000 working-age Haitians live in the state, with thousands employed as nurses, aides, and caregivers.

Many immigrant caregivers have spent decades caring for older adults and people with disabilities, developing experience and relationships that cannot be quickly replaced.

“Their work cannot simply be replaced overnight,” the Long Term Care Community Coalition said in a statement Thursday, noting that continuity of care is particularly important for nursing home residents with dementia and other cognitive impairments, who often depend on familiar caregivers who understand their medical needs, communication styles, routines, and personal preferences.

“Removing experienced caregivers from an already strained workforce risks increasing staff turnover, disrupting continuity of care, and placing additional burdens on the remaining staff,” the coalition statement said.

Those disruptions can lead to poorer care, delayed assistance with daily needs, and a greater risk of avoidable harm, the group warned.

1199SEIU United Healthcare Workers East, one of the nation’s largest health care unions, has also condemned the Supreme Court decision and warned that the loss of Haitian direct care workers could disrupt patient care and trigger a major staffing crisis.

The union told workers Friday that Haitian and Syrian Temporary Protected Status holders remain authorized to work for now while legal proceedings continue. The government extended Haitian work permits until July 24, 2026, and Syrian permits until July 17, 2026, pending formal legal orders.

At the same time, proposed changes to federal labor protections could put additional pressure on the direct care workforce.

Two proposed U.S. Department of Labor rules could affect direct care workers, according to KFF. One would roll back minimum wage and overtime protections for home care workers. The other would make it easier for employers to classify workers as independent contractors, potentially stripping them of some federal labor protections.

The federal Centers for Medicare and Medicaid Services has also delayed enforcement of a requirement that states establish advisory groups to make recommendations on payment rates for direct care workers.

Those changes could place additional pressure on a workforce that already differs significantly from the broader U.S. labor force.

About 85% of direct care workers are women, compared with 47% of other adult workers. Thirty percent are Black, nearly three times the share among other adult workers, and 23% are Hispanic. Direct care workers also tend to be older. About 41% are 50 or older, compared with 33% of other adult workers.

The stakes extend beyond the workers themselves.

More than half of people will use paid long-term care at some point after age 65, including help at home with bathing, dressing, meals, and medications, or care in an assisted living facility or nursing home. More than one-third will receive some care in a nursing home, according to the U.S. Department of Health and Human Services.

People younger than 65 with disabilities also depend on long-term care services. More than half of Medicaid recipients who used long-term care were younger than 65, according to an earlier KFF analysis.

The Long Term Care Community Coalition stressed protecting the workforce is inseparable from protecting the people who depend on it.

“The people most affected by these decisions are nursing home residents – older adults and individuals with disabilities who depend on compassionate, knowledgeable caregivers every day,” the coalition statement said. “Protecting the long-term care workforce is essential to protecting the health, safety, dignity, and quality of life of those residents.”