Federal policy converges on a fragile direct care workforce

Direct care workers — the home health aides, personal care aides, and nursing assistants who help older and disabled Americans with daily living — face a convergence of federal policy pressures. A KFF analysis warns that broad Medicaid changes, including $911 billion in reductions to federal spending and new work requirements, could have implications for a workforce in which three in ten workers are immigrants. Two proposed Department of Labor rules deepen the strain: one would roll back minimum wage and overtime protections for home care workers, while the other would make it easier to classify them as independent contractors, stripping some labor protections entirely.

Immigration policy compounds the risk. A Supreme Court decision in late June cleared the way for the Trump administration to strip temporary protected status from Haitian and Syrian workers, who help fill a persistent caregiving gap: immigrants represent about 30% of the long-term care workforce, with Haitians alone accounting for 7%. Separately, the administration has proposed a rule that could strip wage protections for over 3 million home care workers, in an industry with an annual turnover rate of about 80%.

Demand keeps climbing even as supply thins. Dementia and Alzheimer's disease are projected to cost the United States $818 billion in 2026, with families shouldering more than 80% of societal costs through unpaid caregiving — and one home care CEO warned that home health workers may exit the workforce to become family caregivers themselves, saying, “We’re going to see a workforce reduction,” Flournoy told Home Health Care News. The House passed legislation in April to extend Haitian TPS, but the Senate has not acted, leaving unresolved how much of the caregiving burden shifts further onto families and the workers who remain.