Immigrants are critical frontline workers in many industries and face higher risk for contracting COVID-19, especially within the healthcare sector. This piece focuses on an overlooked aspect of the COVID-19 response: how the well-being of immigrant direct-care staff is uniquely coupled to infection control and resident health in long-term care (LTC) facilities. After detailing the heightened risks to immigrant workers from the pandemic, we propose systems-level changes including comprehensive COVID-19 protections, long-term improvements to working standards, and organizing for immigrant workers rights.
Immigrants Are The Backbone Of The Long-Term Care Workforce
LTC facilities have served as the epicenters of fatal COVID-19 outbreaks; by the end of May, over 40 percent of all COVID-related deaths were linked to nursing homes. Staff of LTC facilities are especially at high risk of contracting and spreading COVID-19 due to their direct care roles, in addition to the poor infection protocols and labor and PPE shortages in the facilities. Some workers even reported being asked to care for over thirty residents while reusing a single face mask for 1-2 weeks. Although data on LTC staff infections nationwide is sparse, as of mid-July, over 11,000 staff in LTC facilities in California tested positive for COVID-19 and over 100 have died from complications with the virus.
Immigrants, both legal and undocumented workers, fill integral staffing voids within the LTC workforce. Approximately one in four direct-care workers in LTC facilities were born in a foreign country. Immigrant workers are more likely to work nontraditional shifts and fill key shortages in under-resourced nursing homes. States with some of the highest COVID-19 burdens – New York, California, New Jersey, and Florida – are especially supported by immigrants, who represent over 40 percent of their LTC direct-care workers. Facilities with higher proportions of Black and Latinx residents rely extensively on low-cost immigrant labor to fill gaps in care. Many of these facilities now face disproportionate impacts from COVID-19, especially as a result of health inequities linked to structural racism.
The importance of stabilizing and protecting immigrant staff in the COVID-19 response cannot be understated. LTC facilities have been facing severe personnel shortages since the early 2000’s. Facilities with pre-existing staffing burdens have seen disproportionate infection spread due to high staff turnover, frequent direct contact, and travel between facilities. These effects are especially pronounced in Black and Latinx-predominant facilities. Increased nurse staffing levels, including both registered nurses (RNs) and certified nursing assistants (CNAs), are important for infection control and numerous quality improvements. Destabilizing the pool of direct-care workers may reopen critical labor gaps and impair LTC facilities’ ability to contain COVID-19, particularly in communities of color.
Immigrant Staff Are At Increased Risk For Adverse Health Outcomes
Given that flux in and out of a nursing home is the primary mechanism of outbreaks among residents, protecting direct-care workers from COVID-19 exposure is critical. Yet, longstanding organizational challenges in facilities have disempowered direct-care workers to seek protections against COVID-19. CNAs often express frustration over being kept in the dark about workplace infections and excluded from decision-making processes. Immigrants in particular are less likely to unionize and demand workplace safety measures. Many fear that employers will retaliate by terminating employment or calling immigration enforcement against family members, which may further deter self-advocacy.
Workplace risk is compounded by limited healthcare access. Immigrants face language barriers, low health literacy, and uninsurance rates up to three times higher than those of native-born citizens. LTC workers, especially CNAs and other personal care workers, disproportionately fall within the lowest two wage quintiles, under $30,000 per year. Moreover, 12 percent are uninsured and can face exorbitant bills if hospitalized. Immigrant health, autonomy, and citizenship are thus dangerously intertwined so that it is difficult for workers to advocate for personal safety measures against COVID-19.
These risks are intensified for undocumented workers. Undocumented individuals live in fear that seeking medical care could lead to interactions with the Immigration and Customs Enforcement agency. This anxiety has been worsened by the Public Charge rule, implemented with expansive restrictions by the Trump Administration in late February, such as denying visas to those who have used Medicaid services for over 12 out of 36 months. The U.S. Citizenship and Immigration Services clarified that the “Public Charge rule does not restrict access to testing, screening, or treatment of communicable diseases, including COVID-19.” However, Public Charge and other anti-immigrant measures by the current administration have already deepened mistrust in immigrant communities. Even though healthcare is of utmost importance now more than ever, immigrants are more likely to avoid healthcare services altogether.
Direct care cannot be decoupled from its local environment. Ancillary workers living in at-risk neighborhoods often suffer from underlying health conditions, risk exposure on public transportation, and work multiple front-line jobs. Black direct-care workers, both native and foreign-born, comprise approximately 30 percent of the direct-care workforce and face the highest compounded risk of serious illness due to COVID-19. LTC facilities that routinely staff immigrant workers disproportionately serve Medicaid-insured residents over private-pay patients and thus may lack funds to meet infection control guidelines. These risks translate to devastating mortality rates in Black and Latinx-majority nursing homes.
Yet, immigrant workers do not just experience or exacerbate risks in direct care work. Immigrant workers who share the same ethnic identity with the residents they care for may establish especially meaningful relationships. Urban facilities in New York and Illinois are largely staffed by immigrants from the Caribbean, Mexico, and Central America, who meet cultural and linguistic needs of Spanish and French Creole-speaking residents. At Buena Ventura, a Los Angeles-based home in a 98 percent Latinx neighborhood, one CNA reported to the LAist that she was told by her resident’s family, “I leave my mom in your hands.” These personal connections are especially essential during COVID-19 as many residents are unable to see their families in-person and place immense trust in caregiver teams.
Environmental, legal, and financial barriers have direct implications on immigrant workers’ ability to avoid COVID-related infection and advocate for safer practices. Addressing these barriers would improve immigrant worker livelihood, ameliorate outbreaks in facilities serving vulnerable neighborhoods, and improve residents’ well-being by reducing isolation during the pandemic.
A Policy Framework To Support Immigrant Staff
To encourage LTC facilities to protect their immigrant workforce, we propose a new framework that views immigrant workers’ livelihood as both a human rights issue and a public health good. Systems-level changes benefiting immigrant LTC staff should include the following:
- Immigration reforms that protect workers’ rights
- Protections against COVID-19 with appropriate oversight
- Financing changes to Medicaid policies to support workers
- Opportunities for immigrant organizing through workers center models
Advocacy Against Restrictive Immigration Policies
Federal and state policies must be amended to create a safe and hospitable environment for immigrant workers. Unfortunately, the current administration has cited the pandemic to bolster restrictions on the national immigrant workforce. As a result, immigrants have been caught in a web of uncertainty: separated from family, unable to leave the United States, and faced with visa denials. Many immigrant workers were also excluded from economic relief from the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Anti-immigrant policies have fostered an environment of fear that may have lasting impacts on the hiring of immigrants and individuals’ willingness to work in the United States. Federal agencies must provide clarity to explicitly categorize all LTC facility staff as “healthcare providers,” protecting them from immigration suspensions that increase turmoil in this critical sector that is already facing mass labor shortages. Trade organizations representing the LTC sector must advocate for these changes at the federal level, following the lead of the American Hospital Association, which has advocated against visa restrictions.
In the interim, state and local governments can create initiatives to support immigrants, such as the California Immigrant Resilience Fund, which provides cash assistance to undocumented individuals. Nursing home organizations should assist staff members in navigating confusing immigration policies and clarify their own administrative policies to protect immigrant workers from punitive federal actions.
Accountability For Staffing And COVID-19 Protections
Improved oversight of LTC facilities is crucial now more than ever. Approximately half of all nursing homes did not meet the Centers for Medicare & Medicaid Services (CMS) guidelines for staffing levels before the pandemic, largely due to financial constraints, workforce shortages, and inconsistent enforcement. These issues have only been worsened with COVID-19. Protections against COVID-19 for direct-care workers must take immediate priority, which must be coupled with structural changes for continued accountability. First, LTC staff should receive double-time hazard pay, adequate protective gear, and weekly COVID-19 testing. Other states can follow Washington's lead, which reacted to the large number of nursing home outbreaks by adding LTC providers to the top tier of priority for PPE allocation. Additionally, CMS should improve existing systems to more effectively identify and increase transparency around staffing deficiencies, with provisions to account for higher staffing needs during public health crises. Increased accountability, through attention from local regulators and dedicated follow-up for facilities consistently in violation of staffing requirements, is especially critical. Increased staffing will benefit both LTC workers and residents, as demonstrated by higher quality measures and infection control during COVID-19.
Financial Support For Implementation
The financial burden of change should not fall on LTC facilities without a viable route to implementation. Medicaid remains the primary means of payment for 65 percent of residents and covers up to 45 percent of total costs in skilled nursing facilities. Additional financial support to achieve the proposed goals may take the form of increased federal matching rates for Medicaid expenditures in high-burden states, following from the Families First Act’s 6.2 percent increase in January. CMS has also explored restructuring Medicaid payments to LTC facilities, including tying reimbursement rates to staffing levels and limiting administrative costs. Finally, there may be value in providing state-level Medicaid funded bonuses for direct-care workers, in line with Arkansas‘ budget changes in early April. While challenging to implement, these financial avenues would benefit workers directly and mobilize resources for facilities in underserved neighborhoods that especially rely on Medicaid support.
Expanding The Workers Center Model
Finally, workers themselves play a critical role in improving workplace safety during COVID-19. One avenue to heightening protections for the immigrant labor force is through workers centers, which have flourished in the past 30 years across the United States. Workers centers emerged as an alternative to traditional organizing through labor unions like the AFL-CIO or Change to Win, who for decades focused on protecting their existing members versus expansion (and diversification) through organizing. Workers centers disproportionately serve immigrant populations given these workers often fill jobs explicitly denied protections under the National Labor Relations Act. Workers centers are typically community-based, organized around a particular racial/ethnic group, and offer direct services, advocacy and organizing support. Arguably the best known worker organizing model like this is the New York Taxi Workers Alliance.
Worker mobilization in New Orleans after Hurricane Katrina demonstrates that crisis conditions, such as those wrought by the current pandemic, can trigger new organizing opportunities. The New Orleans Workers Center for Racial Justice (NOWCRJ) was founded after the flood to respond to exploitative actors and conditions pitting immigrant - often undocumented - workers against native-born Black residents in recovery and reconstruction. 15 years on from Katrina, the NOWCRJ is led by a multi-racial, multi-ethnic staff; organizes across industries and ethnic groups; and offers legal and policy advocacy services in New Orleans.
Labor unions have since expanded their commitment to organizing, especially the Service Employees International Union (SEIU), the largest union of healthcare workers in the U.S. Unions have recently been part of broader organizing coalitions to increase workers rights, wages, and benefits. SEIU and its locals are engaged in campaigns and actions to make visible their members as essential but vulnerable workers and win health and safety protections for them. We highlight these efforts not to praise particular unions or campaigns, but to illustrate the importance of collective action for workers rights to improve public health. Unions can explicitly prioritize inclusion of immigrant needs through advocating for leadership training, language classes, and involvement into care management for immigrant staff.
Immigrant Health Is Public Health
Protections for immigrant workers in LTC facilities must include comprehensive COVID-19 protections, long-term improvements to working standards, organizing and advocacy for immigrant workers rights. These policy recommendations aim to provide a sustainable framework to support the diverse needs of staff during and after COVID-19. These are not isolated efforts, but instead exist within an ecosystem where immigrants, LTC facilities, and their communities mutually benefit from efforts to improve the well-being of one another.
Author’s Notes:
The authors are part of a collaboration to address COVID-19 and structural changes in long-term care facilities at Ariadne Labs, a joint center for health systems innovation at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health. Both of the first two authors listed contributed equally to the text.
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