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| A New Recommendation to Support an Aging Population

| Shalini Kathuria Narang

| While the nation waits for a comprehensive immigration reform, a proposal for a temporary visa, the H-1D visa, by Tara Watson, Director for Economic Security and Opportunity at the Brookings Institution, offers a targeted immigration channel that is designed to address the specific and immediate need for direct care workers in the U.S.

Watson’s proposal makes this visa available to foreign-born people entering the U.S. or to immigrants already in the U.S. who work in direct care. It is likely to include those who have no legal status, either due to entry without inspection or due to an expired status, and those with some measure of temporary protection but no clear path to permanency, such as those under the Deferred Action for Childhood Arrivals (DACA) Program, those admitted under humanitarian parole, or those in the asylum queue.

This proposal also aims to encourage existing U.S.-based direct care workers to stay in the field. It would facilitate the normalization of status among those who meet other requirements.

A direct care worker visa policy to support
the aging US population | Brookings

Here, Watson outlines the proposal and discusses her approach. This interview has been edited for length and clarity.

What is the primary purpose of the proposed visa?

The proposal is for a specific visa that would allow people with direct care experience to come to the U.S. It would also allow people who are currently in the U.S., but without a secure status, to be a part of the program. They would have a temporary visa for three years, renewable for another three. It would allow them to eventually become legal permanent residents.

The main goal is to try to address the direct care workforce issues that we have in this country. There are insufficient numbers of staff in a lot of nursing homes. Home care is difficult to come by. We’re already facing a pretty serious challenge, and it is clear that it’s gonna get much worse over the coming decade, because the population is aging, and specifically, the baby boom generation is entering their mid-80s, which is the time that people tend to need more help. We foresee a need for many more direct care workers. Our estimates suggest about 1.3 million additional positions in the direct care industry relative to today in the next 10 years. The current direct care workforce is itself aging, and many will retire. We also have a declining U.S. population. Even if immigration resumes to more normal levels than it is right now, the numbers just won’t be big enough to fill this direct care workforce gap.

Can you speak about a rollback of the 2024 federal rule?

It’s well understood that staffing matters a lot to nursing home quality. Not having enough staff is associated with more mortality among nursing home patients. There’s a lot of interest in making sure nursing homes have enough people. It’s a sector where it’s hard for patients to advocate for themselves. There’s a need for some government intervention to make sure that patients are getting high-quality care. There are some efforts that have been underway to have designated staffing ratios. Many people of different types need to be in a nursing home at an appointed time. Those have been really curtailed, because nursing homes rightly say they can’t staff at the levels that are being required by the proposed rules. There was this pretty big effort under President Biden that eventually didn’t go anywhere, because there just weren’t enough people to work in the industry. Many would agree the 2024 federal rule recommendations were reasonable staffing requirements. They’re only unreasonable because we have this workforce shortage. We can’t even really make the policies that we want to make, because of the workforce issues.

Can you tell me more about the use of technology in nursing homes?

Technology is moving very quickly in a lot of areas, and it’s very likely that technology will help solve part of this problem. One thing that is possible is health workers using AI tools to deliver better service. There’s some promise, but it’s not realistic that this will mean that we no longer need more direct care workers. In Japan, it seems like [technology] hasn’t decreased the number of direct care workers. It just helped them do their jobs better. I think direct care is an area where human touch is more important than in many other fields, as people need human contact and care.

The H1-B Visa has come under a lot of scrutiny. Since your proposed visa has many similarities to H1-B, what are some of the precautions that you propose?

I’ve addressed some concerns that have been raised about the H1B. A big one is the fear that companies are bringing in low-cost workers that are undercutting the wages of U.S. workers or incumbent workers. I propose setting a wage that’s actually pretty high. It’s at the 75th percentile of direct care workers in the local area. And this was designed specifically to try to ward off criticism that this will further depress wages of direct care workers.

Direct care is also different from the high-tech space, because much of the wage and compensation is driven through Medicaid programs, so it’s kind of government-set. There’s not as much wiggle room for it to go up or down as there is in the private sector. I wanted to really guard against that. I have also proposed that the workers have access to health insurance, which currently in the field is not the norm. All this is meant to be a way of protecting both the workers who will come and workers who are already here from downward pressure on their wages or compensation. As part of the proposal, I make the point that the current wages are pretty low. While adopting some immigration reform, we should also try to improve working conditions. It would have to be via Medicaid.

Can this new visa act as a model for more comprehensive reform?

There’s always this tension in immigration policy about whether you go big and try to solve everything at once, or you go small and risk just solving the most acute problems and leaving the rest to never get resolved. I am taking this track of trying to focus on a very narrow and acute problem, where I think there’s a lot of political consensus that this is a challenge that needs to be solved. I’m not doing [immigration reform], because I only want to solve this one little problem in the immigration space, but I think it’s a place to start, and we have tried comprehensive immigration before many times. It has never been successful in decades. I fear that Congress has kind of given up on this policy space. They view it as more politically advantageous to just not act than to act. I hope that once we can successfully do one thing where everyone can agree, then politicians from all over the political spectrum will be hearing from their constituents. If we can get one little part of the immigration puzzle solved, people may start talking more about it and realize that if it works for the direct care workers, we could expand it to a broader sector of workers. This is a way to try something different.

Some people think the proposal should be much bigger than what I have proposed. The proposal could potentially be made as an economic case for something much bigger, but I think politically, it wouldn’t make sense to be bigger than, for example, the H1-B program. I ended up with a sort of modest compromise.

How’s your proposal different from the others?

There have been a few out there. There’s this Vasquez proposal [from Representative Gabe Vasquez of New Mexico] that is trying to do something pretty similar. It makes some trade-offs in different places than I did. For example, it does have a bigger number [of direct care workers required] in there [in the proposal] than I do, a bigger total piece of limit that’s probably economically justified, because Vasquez proposal also includes childcare workers in the scope. I think it’s just not politically a viable start.

The other thing is, my sense from that proposal is it was more focused on workers who are already here, but maybe don’t have a [legal] status, as opposed to people coming from abroad. I tried to include both. One reason is it’s very sensible to say there are a lot of people here; a lot of them have direct care work experience and would like to continue working. It seems crazy not to let them do that. But on the other hand, having new people come in is part of what needs to happen as well.

We need more immigration than we’re currently seeing. My proposal is a little more on the side of bringing people in from abroad, in addition to having some people transition into this visa who are already here.

Shalini Kathuria Narang is a Bay Area-based independent writer and software professional. She writes about health, wellness, education and technology.