Trump's Medicaid and immigration policies will make home health care more expensive and more rare

As America ages, a globalized future is what keeps us close to home. Every day, the home care system keeps your grandma safe and healthy in her old neighborhood, thanks to the support of someone whose own home lies halfway around the world. But today, her job — and your family member’s care — is threatened by a broken medical system colliding with a broken immigration system

Nationwide, a million immigrants serve as direct care workers, according to the advocacy organization PHI. They are the health aides and attendants who provide essential senior and disability care in our communities. Primarily this involves home-based care, such as managing medication, bathing and helping those with limited mobility or frail health get around from day to day. In several states, these are unionized jobs, mainly funded by extensive Medicaid systems — in large part because community-oriented care is both more dignified and more cost-effective than medical institutionalization.

So of course, that carefully balanced social contract now tops the list of things the White House and Republican Congress are bent on destroying. Not only are conservative lawmakers trying to axe long-term care funding that enables seniors and people with disabilities to live stable lives amid friends and family; they’re attacking the human source of that care — a vast network of workers, predominantly women, who toil in jobs that are both critical and undervalued by society.

Both the Senate and House health care proposals would roll back recent expansions in Medicaid coverage and likely raise insurance and health care costs across the board.

Under the Republican plans to push millions off Medicaid rolls, disability and elder care (including community-based services) would be especially hard-hit, as the plan would impose per capita spending limits that could lead to a massive erosion of both the quality and availability of decent care. Nationwide, these disability and elder care services absorb about two-thirds of all Medicaid spending.

According to the Center for American Progress, "Trumpcare’s" brutal austerity "is a recipe for setting the nation back 50 years, when people with disabilities commonly lived in institutions instead of in their own communities."

Elderly relatives can’t afford to have their health care set back half a century, nor can young people with disabilities who need home care to attend school and work independently. Meanwhile, the projected demand for home care services will soar in the coming years amid a "gray wave" of a rapidly aging low-income population with complex long-term care needs, on top of major deficits community-based support for people with disabilities. Overall, Americans will require an estimated 3 million new direct care workers by 2030. Immigrant workers are critical for filling that gap.

Since a quarter of direct care workers are immigrants, their legal inclusion and protection is a vital matter of both economic and medical justice. Though many care workers — mostly women, largely from the Caribbean and Central America or Southeast Asia — are naturalized citizens, a majority are non-citizens, struggling just like millions of other low-wage workers to support deeply rooted communities.

Contrasting with other industries dominated by immigrants, those in home care have, in recent years, become more established in the U.S. The typical home care worker has lived in the U.S. for 18 years. Also contrary to stereotypes, immigrant home care workers on the whole have above-average education levels and earnings compared to the sector as a whole.

Humane, comprehensive immigration reform, including equal labor rights, would be a major step toward stabilizing the future workforce. According to the National Council on Aging, "legal status would allow for improved background checks of workers, ability of workers to drive legally, opportunities for training and career advancement." Helping immigrants secure stable long-term jobs would additionally boost wages and tax revenues for the entire country.

But as conservative politicians clamp down on migrant rights and propagate xenophobic rhetoric, the political barriers immigrant workers face marginalize their communities, where discrimination looms over both legal and undocumented residents. The systematic abuse of immigrants amounts to another sideways blow to a long-term care system that Trumpcare will unravel for clients and providers alike.

And beyond immigration challenges, all caregivers need justice in the workplace. Both immigrant and non-immigrant workers face high risk of injury and exploitative working conditions. With median incomes of about $15,600 (and even less for the sector as a whole), roughly 20% of immigrant home care workers live households below the poverty line. Over a quarter of their households survive on federal nutrition assistance programs; a third are themselves Medicaid recipients.

The stress and strain of home care work aggravates providers' own health burdens. The sector's occupational injury rates are extraordinarily high. The safety struggles are compounded by outmoded federal laws exempting home carers from basic fair labor measures like the the federal minimum wage and workplace safety protections. Often care workers are denied workers’ compensation because they can’t, for example, prove their back injury happened as they carried a client up the stairs; or maybe they can’t risk losing a day’s wages to see a doctor. Fortunately many workers have improved wages and labor protections over the years through grassroots labor organizing, along with state and local level legislative reforms that provided access to fair wage standards. But turnover remains dangerously prevalent in a labor force that desperately needs stable, deeply skilled personnel.

Health aide surveys show that, while many feel devoted to the profession, they are discouraged from continuing in the job by not just low wages but by the lack of stable benefits and dignified treatment both by their agencies and the households they serve. And now their livelihoods are becoming riskier under the Trump administration, which has deepened their communities' structural hardships and political disempowerment.

When Trump continues to marginalize migrants, undermining their civil rights and scapegoating them for social woes, he attacks the people helping to save what’s left of the healthcare system for millions of families, including our oldest and most vulnerable senior citizens.

Ironically, one of the states projected for especially high increases in the number of low-income elderly residents is Arizona, where pro-Trump politicians have imposed some of the harshest anti-immigrant policies in the country. Trump has praised Arizona for "getting tough" on migrants. But the people who’ll have it really tough are the grandmothers whose caregivers may soon vanish from their lives, and with them, the one critical human bond that keeps them connected to their communities.