Skip to main content
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Jan 1.
Published in final edited form as: Health Aff (Millwood). 2024 Jan;43(1):108–117. doi: 10.1377/hlthaff.2023.00881

Nursing Home Staffing: Share Of Immigrant Certified Nursing Assistants Grew As US-Born Staff Numbers Fell, 2010–21

Hankyung Jun 1, David C Grabowski 2
PMCID: PMC10824124  NIHMSID: NIHMS1958663  PMID: 38190591

Abstract

Nursing homes have long faced a shortage of direct care workers, a problem which has been greatly magnified during the COVID-19 pandemic. Using nationally representative data from three sources, we find that a significant portion of the certified nursing assistant (CNA) workforce in the United States is filled by immigrant labor. The number of native-born CNAs has been declining rapidly since the mid-2010s, while the count of foreign-born CNAs has remained relatively constant. During the first two years of the pandemic, the share of immigrant CNAs employed by nursing homes surged, explained by a drop in native-born staff. Staffing shortages observed during the pandemic would have been far worse if not for foreign-born CNAs remaining in the workforce. However, the share of foreign-born CNAs varies considerably across states from less than one percent in West Virginia to over 70 percent in Hawaii. In an analysis of pre-pandemic data, we find that nursing homes in regions with a higher share of immigrant CNAs were associated with more direct care staff hours per resident day and better nursing home quality performance. With the growing demand for long-term care, creating pathways for job-seeking immigrants to fill the gaps in direct care will be crucial in meeting future staffing needs.

INTRODUCTION

The immigrant population in the United States has been increasing dramatically, yet the nation’s stance on immigration policy remains deeply divided. State legislative activity on immigration issues began to increase around 2005 before exploding in 2007, and the immigration debate remains highly visible today.1 Recently, 22 states filed lawsuits or appeals to block immigration actions led by the Biden administration.2 Although both political parties agree that the current immigration system has flaws, the differing political ideologies combined with the current challenges in the Southwest border region have led to little progress in modernizing the nation’s immigration laws. Nonetheless, the number of foreign-born persons living in the US hit another record high, climbing to nearly 48 million in September 2022.3

The primary appeal of immigration, both legal and undocumented, is better economic opportunities. In the post-pandemic era, private job openings increased rapidly in the United States, reaching 10.8 million jobs in March 2022.4 Compared to most Latin American countries, for example, the wage gain for immigrants is around four to ten times greater, even when factoring in the higher cost of living in the US.5 With this financial incentive, low-wage immigrants are often willing to take on labor-intensive jobs and nontraditional shifts that many native-born Americans forgo.

An area that significantly benefits from immigrant labor is the nursing home sector. Nursing homes have chronically endured staffing shortages and high staff turnover rates,68 with the COVID-19 pandemic placing additional pressure on an insufficient workforce.9 The industry has particularly suffered from a lack of direct care workers, such as certified nursing assistants (CNAs),6,9,10 who provide basic care to nursing home residents. CNAs earn lower wages and face harsh working conditions, contributing to higher turnover rates.10 Inevitably, staffing voids involving CNAs were also more pronounced during the pandemic.9

The lack of CNAs is detrimental to nursing home residents’ health and psychological well-being. Compared to other staff, CNAs interact and communicate more with residents, and their absence means residents wait longer periods to be fed, bathed, dressed, or transferred, creating substantial psychological stress.11 Labor shortages are also associated with increased use of psychotropic drugs in nursing homes, also known as “chemical restraints.”12 With staffing levels considered an essential element of nursing home quality,13 addressing the gaps in direct care is crucial.

Fortunately, immigrant workers have been filling the workforce gap in the nursing home industry. Nearly a quarter of CNAs are foreign-born, including both legal and unauthorized immigrants,14 and many are immigrant women from the Caribbean, Central America, and Southeast Asia.15 Facilities with higher shares of Black and Hispanic residents particularly rely on immigrant labor.16 Recent studies have found that CNA hours increased in regions with immigrant inflows,17,18 and that the increase even improved the quality of care provided in nursing homes.18

However, the nursing home industry still suffers from labor shortages with considerable variation across states. In states with large immigrant populations, foreign-born workers comprise nearly half of the direct care workforce, which includes CNAs, home health aides, and personal care aides.15 By contrast, in around one-third of states, including states like Oklahoma and Montana, which have among the highest nursing home staff turnover rates in the US,6 immigrants make up five percent or less of the total direct care workforce.15

Last year, the Biden administration announced its plan to establish minimum nursing home staffing requirements.19 States with more aging residents and smaller immigrant populations may face greater challenges in meeting these conditions. Nevertheless, little information exists on how states vary regarding the level of immigrant staffing in nursing homes. We also do not know whether a greater share of immigrant CNAs can affect care levels. Therefore, this study examines trends in the percentage of immigrant CNAs who worked in nursing homes from 2000 to 2021 by state. We further estimate whether a higher percentage of immigrant CNAs is associated with improved quality of care in nursing homes.

STUDY DATA AND METHODS

Data sources

We analyzed state-level data by using information from three different sources. First, we used annual information on foreign-born status and occupation from the American Community Survey (ACS) from 2000 to 2021, extracted from IPUMS.20 The ACS is a nationally representative survey conducted by the Census Bureau that provides information on each respondent’s characteristics, including demographics, socioeconomic status, geographical region, place of birth, and current occupation.

Next, we used the Minimum Data Set 3.0 (MDS) from the Centers for Medicare & Medicaid Services, which contains information on nursing home residents’ health and demographics in all Medicare and Medicaid certified nursing homes. For quality monitoring and reimbursement, nursing homes in the US are required to complete assessments on every resident upon admission and quarterly thereafter, with in-between updates as needed. We used information on resident demographics and variables representing nursing home quality from 2010 to 2018.

Further information on nursing home characteristics was obtained from LTCFocus from 2010 to 2018. The dataset is administered by the Brown University Center for Gerontology and Healthcare Research and it is partially supported by the National Institute on Aging. It contains information on nursing facilities by merging data from different sources. We used facility-level information on direct care staff hours per resident day, the number of beds, for-profit status, and whether the facility was part of a chain.

Measures

We first identified survey respondents from the ACS who worked in nursing homes, including skilled nursing facilities, based on the Census industry code. Among those who worked in nursing homes, we further distinguished participants who worked as CNAs using the Census occupation code. We focused on CNAs because nursing homes in particular suffer from CNA shortages,6,9,10 and the gaps are often filled by immigrant labor.14 We then identified immigrants using information on their place of birth. A respondent was considered an immigrant if the individual reported being born outside of the US and US territories, and we used the terms immigrant and foreign-born interchangeably throughout the paper. As described in the limitations section, we assumed most immigrant CNAs were legally documented immigrants. We calculated the total, native-born, and foreign-born CNAs in each state to estimate the percentage of immigrants among CNAs who worked in nursing homes. We did not include Alaska and Washington D.C. in our analysis due to the lack of data on immigrant CNAs.

To analyze the relationship between the share of immigrant CNAs and nursing home quality, we used the following six measures that typically represent quality of care: the average direct care staff hours per resident day, the summary score of the Patient Health Questionnaire-9 (PHQ-9) that measures depressive symptoms, the percentage of residents who have recently fallen, the percentage of residents who have experienced weight loss, the percentage of residents with a new stage 2 to 4 pressure ulcer, and the inappropriate use of antipsychotics. Details on the construction of these measures are in the online appendix.21

Statistical analysis

The first half of the study analyzed trends and state variation of foreign-born CNAs who were employed by nursing homes before and during the COVID-19 pandemic, while the latter half focused on the relationship between the share of foreign-born CNAs and nursing home quality measures prior to the pandemic. We used national-level data to analyze overall trends and state-level data to analyze variation across states. For the regression analysis, we used state-metropolitan statistical area (MSA)-level data and included state fixed-effects, which allowed us to use a larger sample size. An MSA is a geographical region with a relatively high population density and close economic ties throughout the area. Around 20 MSAs crossed a state line, which were divided, mostly into two, based on the state it was crossing. Nursing homes that did not belong to an MSA were dropped. We first aggregated the individual-level data from the MDS to the facility-level, which was further aggregated to the state-MSA-level and then to the state-level.

We extrapolated the national number of CNAs and immigrants in each state using sampling weights in the ACS, including COVID-19-specific weights for 2020. In states with a relatively lower foreign-born population, the sample size of immigrants working as CNAs in nursing homes was small, and annual trends were sometimes inconsistent even after applying weights. Instead of using yearly trends for the state-level analysis, we calculated the average share of immigrants among CNAs for each decade to compare ten-year trends (i.e., the average from 2000 to 2009, and from 2010 to 2019). We calculated the average of 2020 and 2021 to check how the value changed during the COVID-19 pandemic. We also categorized states into three groups (low, medium, and high) based on the tercile of the immigrant share among CNAs.

We plotted national time trends in the number of CNAs by birthplace from 2006 to 2021. To improve accuracy, we averaged the data for every two years (e.g., from 2006 to 2007, 2008 to 2009, etc.). We used two-year averages instead of ten years for this variable because the national sample of CNAs was larger and more consistent than state samples.

To analyze the association between immigrant shares among CNAs and nursing home quality, we first plotted a two-way scatter plot of the states for each quality indicator in 2018. We then applied the state-MSA-level data from 2010 to 2018 to a linear regression model to regress each quality measure on the average percentage of immigrants among CNAs. We included the following covariates to the model: the average age of residents in each facility, the percentage of male residents, the percentage of Black residents, the percentage of Hispanic residents, the percentage of residents dually eligible for Medicare and Medicaid, the percentage of for-profit facilities, the percentage of multichain facilities, and the logarithm version of the total number of beds. We included state fixed-effects to control for state-specific unobservable factors and year fixed-effects to control for time trends. Compared to the state-level scatter plots, the regression model used more granular data to exploit variation across smaller regions within a state. The variation allowed us to compare areas with possibly similar characteristics. Although our model does not indicate causality, using state-MSA-level data with state fixed-effects may have reduced the possible bias caused by unobservable factors that we were unable to control for in the state-level analysis.

We tested the sensitivity of our results by running the model on different samples and variables. Hawaii can be an outlier, with around 70 percent of CNAs being foreign-born, so we estimated models excluding Hawaii. Next, we included the number of total CNAs in each state-MSA as an additional control variable. Prior studies have found that higher immigrant inflows can increase the CNA workforce and improve quality of care.17,18 Keeping the absolute level of CNAs constant in our model would further allow us to focus on how the share of immigrant workers, not the level of staff, is associated with changes in nursing home quality. We also ran models including covariates that could affect the direct care labor market in each state-MSA. We included the unemployment rate, the percentage of the native-born that are Black because most native-born direct care workers are African American, and the percentage of the state-MSA population who are aged 85 and over. Lastly, we controlled for state-MSA specific time trends in addition to state fixed-effects and year fixed-effects. These trends can control for MSA-specific factors affecting immigrants’ decisions to work in that area.

Limitations

Our study had several limitations. First, the sample of immigrant CNAs in the ACS was small and sometimes zero in certain state-years, particularly in states with a smaller foreign-born population. For example, the number of foreign-born CNAs in nursing facilities in Kentucky was 326 workers in 2001, zero in 2002, 585 in 2003, and then increased throughout the years. Similarly, in Montana, zero immigrant CNAs were sampled in 2006, while the rest of the years had samples. The inconsistency made it challenging to analyze yearly trends; therefore, we averaged the share of immigrants among CNAs for ten-year periods and compared trends over the following decades. We also applied person-level weights to make the values nationally representative. The ten-year averages allowed us to analyze trends and variations across states over each decade.

We only used two-year averages from 2020 to 2021 for the COVID-19 pandemic. A larger sample size using future data will reduce variation of our state averages, yet we believe it was necessary to report the results of the first two years of the pandemic. Nursing homes suffered greatly during the pandemic, with significant drops in staffing levels across the country.9 Immigrant workers may have been less likely to leave their jobs due to restrictions related to their immigration status and lack of social benefits, which may be reflected in the immigrant CNA shares during that period.

Second, ACS does not report documentation status, so we were unable to distinguish between authorized and unauthorized immigrants. Unauthorized immigrants in some states can apply for professional state licenses using an Individual Taxpayer Identification Number (ITIN) instead of a Social Security Number, such as the case noted in California’s Senate Bill 1159. However, we do not know the exact share of unauthorized immigrants in our foreign-born sample, and our data might underreport the percentage of immigrants working in nursing homes if undocumented immigrants were reluctant to participate in surveys. However, a prior study reported that profiles of the unauthorized workers were similar in several cross-sectional survey and population data.22 Also, a prior study reported that most direct care workers were documented immigrants: around 14 percent were naturalized citizens, nine percent were legal noncitizen immigrants, and five percent were unauthorized immigrants in 2017.14 Based on these studies, we assumed immigrant profiles of our sample were similar to the total population and that most immigrant CNAs were legally documented immigrants.

Finally, our regression results analyzed the association between the share of immigrant CNAs and nursing home quality indicators and did not indicate causality. Also, our analysis was restricted to 2018, prior to the pandemic. Nevertheless, our sample included more than 330 state-MSAs comprised of more than 10,000 nursing homes over a nine-year period and was well suited to test how the variation in the percentage of immigrant CNAs was associated with differences in direct care staff hours and quality of care in nursing homes before the pandemic. We plan to investigate how the association changed during the pandemic in future studies.

STUDY RESULTS

The absolute number of CNAs working in nursing homes declined during the past years from 2010 to 2021 (exhibit 1). The drop was primarily due to a large decrease in native-born staff. The number of foreign-born CNAs has also been declining but to a much lesser extent. The average number of native-born CNAs from 2010–2011 was around 763,000, before dropping to around 519,000 from 2018–2019, a 32 percent decrease. During the same period, foreign-born CNAs decreased from 162,000 to 128,000 workers. Only 468,000 native-born CNAs remained during the pandemic, a 39 percent decrease compared to the 2010–2011 time period. The number of foreign-born CNAs decreased slightly in 2020–2021 but it dropped by less than 10,000 workers compared to the previous couple of years.

Exhibit 1.

Exhibit 1.

Trends in certified nursing assistants by place of birth, 2006–2021

From the 2000s to 2021, the US experienced growth in immigrant labor among the CNA workforce, although there was considerable variation across states, as shown in exhibit 2 (aggregated statistics) and exhibit A1 (full list of states). For the entire US, the percentage of foreign-born CNAs in nursing homes increased from 13.6 percent in the 2000s to 16.5 percent in the 2010s and jumped to 19.1 percent during the pandemic. Dividing states into three groups based on the terciles of the immigrant share, we found that, in the 2010s, states in the higher share group had an average of 36 percent of nursing home CNAs who were immigrants, which was around ten times higher than that of states in the lower share group (3.7 percent). The percentage point growth of immigrant shares from the 2000s to the 2010s and to the pandemic was also highest in states with a greater share of immigrant CNAs. In Hawaii, California, New Jersey, Massachusetts, New York, and Florida, more than 40 percent of CNAs were foreign-born. On the contrary, in 15 states, five percent or less of the CNA workforce was foreign-born, with Louisiana, Mississippi, and West Virginia having the lowest percentages of foreign-born CNAs.

Exhibit 2.

Percentage of foreign-born workers among certified nursing assistants in nursing homes by state, United States, 2000–2021

2000–2009 2010–2019 2020–2021
mean mean p.p. growth mean p.p. growth
United States 13.6 16.5 2.9 19.1 2.6
Low share states 2.5 3.7 1.2 4.0 0.3
Medium share states 7.8 10.6 2.8 14.3 3.7
High share states 31.1 36.0 4.9 40.0 4.0

Source: Authors’ analysis of data from the 2000 to 2021 American Community Survey.

Notes: Data was weighted to be representative of the US population. States were categorized into low, medium, and high shares based on terciles of the percentage of foreign-born among certified nursing assistants. Alaska and Washington D.C. were not included due to lack of data. P.p. = percentage point.

During the COVID-19 pandemic, there was a nationwide increase in the share of immigrants among CNAs in nursing homes, although we cautiously note that some values might have been affected by sampling errors as described in the limitations. Rhode Island experienced the highest growth of 22.9 percentage points. Several states that did not have very high shares of immigrant CNAs before the pandemic experienced a sudden spike in their share of immigrant CNAs of more than ten percentage points, including Idaho, North Dakota, Oregon, Virginia, Utah, Arizona, Delaware, Minnesota, and Washington. States that experienced a drop in their immigrant CNA shares were mostly those that belonged to the lower share group.

We additionally examined the state-level change in the overall foreign-born population share, shown in Exhibit A2 in the online appendix.21 We found that states that experienced an increase in the share of immigrant CNAs did not always experience an increase in the share of foreign-born persons in the state (e.g., Arizona, Colorado, Delaware, etc.). During the pandemic, the share of foreign-born persons in the US remained relatively constant, possibly due to travel restrictions and the shutdown of the US Citizenship and Immigration Services agency; however, the share of foreign-born CNAs increased from 16.5 percent to 19.1 percent. Our exhibits show that the increase was not caused by new immigrant inflows, but because foreign-born CNAs, compared to native-born CNAs, were less likely to leave their positions during the pandemic.

Exhibit 3 plots the correlation between the percentage of foreign-born CNAs in nursing homes and direct care staff hours per resident day by state. Scatter plots of the other nursing home quality measures are noted in the online appendix, Exhibit A3.21 The quality indicators and staff hours are from 2018, and the share of foreign-born CNAs is the average value from 2010 to 2018. States with a higher share of immigrant CNAs had longer direct care staff hours per resident day. Having more immigrant CNAs was correlated with a lower probability of resident falls, weight loss, pressure sores, inappropriate use of antipsychotics, and lesser depressive symptoms.

Exhibit 3.

Exhibit 3.

Correlation of the percentage of foreign-born workers among certified nursing assistants and direct care staff hours per resident day, 2018

Exhibit 4 notes the estimated coefficients of the regression model, with and without covariates, using data at the state-MSA level. The share of foreign-born CNAs in nursing homes was estimated by averaging values from 2010 to 2018. Estimates of the covariates and the standard errors, clustered at the state-MSA level, are shown in the online appendix, Exhibit A4.21 Like the state-level correlations in exhibit 3, unadjusted estimates (panel A) show that higher shares of foreign-born CNAs were associated with improved quality measures. When adjusting for regional factors and variables that could affect nursing home quality (panel B), the magnitude of the association increased for direct care staff hours and the share of residents that experienced falls, weight loss, and pressure ulcers. For example, a ten percentage-point increase in the share of immigrants among CNAs was associated with 0.02 higher direct care hours per resident day. Sensitivity analyses using different models showed similar results (see Exhibit A5 in the online appendix).21

Exhibit 4.

Change in US nursing home quality measures associated with the percentage of foreign-born CNAs, 2010–2018

Direct care staff hours per resident day PHQ-9 summary score Falls Weight loss Pressure ulcers Inappropriate use of antipsychotics
Sample mean 3.78 2.45 13.91 7.60 31.04 7.41
Panel A. Unadjusted estimates
Foreign-born CNAs, % 0.01*** −0.02*** −0.09*** −0.01*** −0.15*** −0.04***
Observations 2,986 2,989 2,989 2,989 2,989 2,989
Panel B. Estimates adjusted for nursing home resident and facility characteristics
Foreign-born CNAs, % 0.02*** −0.00 −0.18*** −0.09*** −0.29*** 0.02
Observations 2,986 2,989 2,989 2,989 2,989 2,989

Source: Authors’ analysis of data from the 2010 to 2018 American Community Survey, 2018 Minimum Data Set 3.0., and 2018 LTCFocus.

Notes: All variables are constructed at the state-MSA-level. We used the average of 2010 to 2018 for the percentage of foreign-born CNAs, which are noted in ten percent units. Models in panel B include covariates and year and state fixed-effects. Estimated coefficients and standard errors of the full model are shown in the online appendix, Exhibit A4 (see note 21 in text). PHQ-9 = Patient Health Questionnaire-9; CNAs = certified nursing assistants.

***

p < 0.01.

DISCUSSION

Our study analyzed trends and state variation of foreign-born CNAs in nursing homes, and whether a higher share of foreign-born CNAs were associated with better nursing home quality. We found that native-born direct care labor has been decreasing in nursing homes from 2010 to 2021, while the share of immigrant CNAs has increased. With fewer native-born workers employed by nursing homes as CNAs, a larger share of these positions has been filled by foreign-born labor. Despite nursing homes experiencing significant drops in staffing during the pandemic,9 we found that the percentage of immigrant workers increased in most states. Our results suggest this was largely due to foreign-born CNAs remaining in the workforce, while many native-born CNAs exited.

Most countries, including the US, imposed travel restrictions in 2020, suggesting that the influx of new immigrants to the country was very low. Thus, our results largely reflect foreign-born CNAs remaining in their jobs versus new entry to the workforce. Generally, immigrant workers have stronger incentives to maintain their current position because of visa or permanent residency restrictions. Immigrants also tend to have more difficulties finding new jobs due to visa status or language barriers, making them less likely to quit. Financial reasons could be another explanation, especially because many immigrants were ineligible for unemployment benefits or direct relief payments during the pandemic.

We found wide variation across states regarding the share of immigrant CNAs. States with the lowest shares of immigrant CNAs also experienced slower increases in their immigrant CNA shares. With the aging US population, states will need more immigrant labor to meet staffing needs, particularly because long-term care employment has not yet recovered to pre-pandemic levels.23 Compared to other states, for example, Rhode Island, Mississippi, Alabama, Michigan, and North Carolina have fared worse in terms of staffing recovery.23 These states, except for Rhode Island, had relatively lower shares of foreign-born CNAs: Mississippi (1.4 percent in 2020–2021), Alabama (2.9 percent), Michigan (3.0 percent), and North Carolina (6.0 percent). Because native-born CNAs are less likely to return to their previous employment, states with fewer foreign-born employees may find filling the vacancies harder.

Another noteworthy finding was that, prior to the pandemic, having a higher share of immigrant CNAs was associated with more direct care staff hours per resident and better nursing home quality performance. Although our estimates do not indicate causality, the estimates remained significant when we controlled for the total number of CNAs in each region, implying that immigrant workers do not only increase the amount of direct care but also improve the quality of care. Immigrant workers tend to work longer shifts than native-born workers24 and may have stronger incentives to maintain their jobs, thus reducing turnover rates. Immigrant staff may also provide better quality of care because wage levels in the US tend to be higher than their home countries.5 Although language and cultural barriers can create inefficiencies in providing care, our results show that the benefits likely outweigh the costs. Although the estimates were restricted to the pre-pandemic period, we plan to check whether nursing homes with more immigrant CNAs were associated with longer staff hours and improved care levels during the COVID-19 pandemic in future studies.

Policy Implications

One policy solution that could help both nursing homes and “less skilled” job-seeking immigrants is creating a new visa category for foreign direct care workers. Typically, there are two types of employment-based visas in the US—temporary and permanent—and both are mostly reserved for “skilled” immigrants: professionals with advanced degrees or immigrants of specific occupations. Only one permanent work visa category covers all types of workers (EB-3), but only 10,000 EB-3 visas are given to workers each year, shared across different industries.25 For temporary non-immigrant visas, the only option is an H-2B visa that covers non-agricultural work. However, most H-2B workers are landscapers, forest or conservation workers, and housekeepers.26 Most direct care workers arrive through visa classes for family reunification or asylum rather than through employment,27 which limits opportunities for immigrants to work in states with smaller immigrant populations because many tend to live near families.

Historically, federal policies on immigration visas have effectively impacted the labor market. In 1989, an H1-A visa category was created for foreign-trained registered nurses to address the nursing shortage in the US. More than 24,000 immigrant nurses entered the country that year, the majority from the Philippines.28 The H1-A program expired in 1996, and an H-1C visa was created three years later for nurses to work in approved hospitals with nursing shortages.29 The H-1C program allowed temporary employment of 500 foreign nurses each year between 2000 and 2004, and after it ended, Congress reauthorized it for another three years from December 2006 to 2009. A similar strategy can be applied to direct care workers in the long-term care sector. More visas can be issued in states that expect greater challenges in meeting staffing requirements. Additional policy options may include creating pathways to obtain permanent residency status, as discussed in prior studies.15

We also recognize that other countries are looking to attract immigrants to work in long-term care settings. For example, Canada is launching a new fast-track immigration system to attract more health care workers to the country.30 For the US to remain competitive, there is a need to reform immigration policies but to also improve the pay and working conditions for nursing home jobs. Immigration reforms would be part of a larger set of policies directed at growing the workforce.

CONCLUSION

In conclusion, our study found that the share of foreign-born CNAs in nursing homes has been increasing, and a higher share of foreign-born CNAs were associated with better care levels in nursing homes. Our findings have important implications for both the long-term care sector and immigration policy. The number of older adults needing long-term care services is anticipated to reach 19 million in 2050, which is more than double the number in 2000.31 The current immigration system provides few opportunities for low-wage foreign workers to enter the US. With the aging population, creating pathways for foreign direct care workers to enter the industry may help address the direct care shortage and provide legal opportunities for immigrants who want to enter the country.

Supplementary Material

Appendices

Contributor Information

Hankyung Jun, Harvard Medical School, Boston, Massachusetts.

David C. Grabowski, Harvard Medical School, Boston, Massachusetts

NOTES

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendices

RESOURCES