When Margarette Nerette arrived in the United States from Haiti, she sought safety and a new start.

The former human rights activist feared for her life in the political turmoil following the military coup that overthrew President Jean-Bertrand Aristide in 1991. Leaving her two small children with her sister in Port-au-Prince, Nerette, then 29, came to Miami a few years later on a three-month visa and never went back. In time, she was granted political asylum.

She eventually studied to become a nursing assistant, passed her certification exam, and got a job in a nursing home. The work was hard and didn’t pay a lot, she said, but “as an immigrant, those are the jobs that are open to you.”

A few years later her family joined her, but her children didn’t want to follow her career path. When she was a teenager, Nerette’s daughter, now 25, would ask, “Mom, why are you doing that?” Nerette said. Her daughter considered the work underpaid and too physical.

After many years, Nerette, now 57, left nursing home work for a job with the Florida local of the labor union SEIU1199, which represents more than 25,000 health workers. As the local’s vice president for long-term care, she is keenly aware of the staffing challenges that have plagued the industry for decades and will worsen as aging baby boomers stretch the limits of long-term care services.

The U.S. is facing a growing crisis of unfilled job openings and high staff turnover that puts the safety of older, frail residents at risk. In a tight labor market where job options are plentiful, long-term care jobs that are poorly paid and physically demanding are a tough sell. Experts say opening pathways for care workers to immigrate would help, but policymakers haven’t moved.

In the decade leading up to 2031, employment in health care support jobs is expected to expand by 1.3 million, a nearly 18% growth rate that outpaces that of every other major occupational group, according to the federal Bureau of Labor Statistics. These direct care workers include nurses of various types, home health aides, and physical therapy and occupational therapy assistants, among others.

Certified nursing assistants, who help people with everyday tasks like bathing, dressing, and eating, make up the largest proportion of workers in nursing homes. In the decade leading up to 2029, nearly 562,000 nursing assistant jobs will need to be filled in the United States, according to a far-reaching report on nursing home quality published last year by the National Academies of Sciences, Engineering, and Medicine.

But as the U.S. population ages, fewer workers will be available to fill those job openings in nursing homes, assisted living facilities, and private homes. While the number of adults 65 and older will nearly double to 94.7 million between 2016 and 2060, the number of working-age adults will grow just 15%, according to an analysis of census data by PHI, a research and advocacy organization for older and disabled people that conducts workforce research.

Immigrants can play a crucial role in filling those gaps, experts say. Already, about 1 in 4 direct care workers are foreign-born, according to a 2018 PHI analysis.

“We do think that immigrants are critical to this workforce and the future of the long-term care industry,” said Robert Espinoza, executive vice president of policy at PHI. “We think the industry would probably collapse without them.”

Nursing homes and other long-term care facilities have long struggled to maintain adequate staff. The problem worsened dramatically during the pandemic, when those facilities became hotbeds for covid-19 infections and deaths. More than 200,000 residents and staff members died during the first two years of the pandemic, representing about a quarter of all covid deaths during that time.

Since March 2020, the long-term care industry has lost more than 300,000 jobs, bringing employment to a 13-year low of just over 3 million, according to an analysis of BLS payroll data by the American Health Care Association and the National Center for Assisted Living.

Immigration policies that aim to identify potential workers from overseas to fill long-term care job slots could help ease the strain. But unlike other countries that face similar long-term care challenges, the U.S. generally hasn’t made attracting direct care workers from abroad a priority.

“Immigration policy is long-term care policy,” said David Grabowski, a professor of health care policy at Harvard Medical School whose research focuses on the economics of aging and long-term care. “If we really want to encourage a strong workforce, we need to make immigration more accessible for individuals.”

Most of the roughly 1 million immigrants to the U.S. annually are family members of citizens, though some come in on employment visas, often for highly skilled jobs.

On his first day in office, President Joe Biden proposed comprehensive immigration reform that would have created a pathway to citizenship for undocumented workers and revised the rules for employment-based visas, among other things, but it went nowhere.

“There hasn’t been a lot of interest or political will behind opening up more immigration opportunities for mid- to lower-level care aides such as home health aides, personal health aides, and certified nursing assistants,” said Kristie De Peña, vice president for policy and director of immigration policy at the Niskanen Center, a think tank.

The Biden administration didn’t respond to requests for comment.

Some local and regional organizations are working to connect immigrants with health care jobs.

Ascentria Care Alliance provides social services, refugee resettlement, and long-term care services in five New England states. With state and private philanthropic funding, the organization is beginning to help refugees from Ukraine, Haiti, Venezuela, and Afghanistan get the supportive services they need — language, housing, child care — to enable them to take health care jobs at Ascentria’s long-term care facilities and those of health care partners.

The group has long helped refugees resettle and find jobs in traditional settings like warehouses or retailers, said Angela Bovill, president and CEO of Ascentria, which is based in Worcester, Massachusetts. “Now we’re looking at what it would take to move them into health care jobs,” she said.

The alliance is applying to the Department of Labor for a grant to scale up the program. “If we get it right, we’ll build a pathway and a pipeline to move at the fastest rate from immigrant to effective health care worker,” Bovill said.

Some long-term care experts say the U.S. can’t afford to drag its feet on putting policies in place to appeal to immigrants.

“We’re competing with the rest of the world, other countries that also want these workers,” said Howard Gleckman, a senior fellow at the Urban Institute.

Canada, for instance, is going all in on immigration. In 2022, it welcomed more than 430,000 new permanent residents, the most in its history. Immigration accounts for almost 100% of Canada’s labor force growth, and by 2036 immigrants are expected to make up 30% of the population, the government said.

In the U.S., immigrants account for about 14% of the population, according to an analysis of census data by the Migration Policy Institute.

Canada’s Economic Mobility Pathways Pilot aims to identify and recruit refugees who have skills Canadian employers need. In January, after visiting a refugee camp in Kenya, recruiters offered jobs in Nova Scotia to 65 continuing care assistants.

In a December survey of 500 U.S. nursing homes, more than half said staffing shortages have forced them to turn away new residents.

These staffing challenges, said industry representatives, are likely to become an even heavier lift, with more closed facilities, units, or wings, after the Biden administration announced last year that it would establish minimum nursing home staffing requirements.

A government mandate alone won’t solve long-standing problems with inadequate training, pay, benefits, or career advancement, experts said.

“Young people aren’t going to clean 10 to 15 patients for $15 an hour,” Nerette said. “They’ll go to McDonald’s. We need to face that reality and come up with a plan.”

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