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Sixty-five-year-old Kristy Madden works to coordinate government-funded assistance for disabled people and others in need of in-home care. But while she loves her job, she worries that, if the Trump administration has its way, access to this essential aid may be eliminated.
“I have muscular dystrophy (MD) and live with my younger sister who also has MD,” Madden says. As the membership coordinator for California’s In-Home Supportive Services Consumer Alliance — and as someone who relies on in-home care — Madden knows that a lot is at stake.
“We employ two workers who help us transfer from our beds to our power wheelchairs, bathe, and then get dressed and ready for work,” she tells Truthout. “Our workers also do cleaning, laundry, meal preparation, grocery shopping, and other chores, including vehicle maintenance.”
But because Madden’s aides are immigrants, albeit naturalized U.S. citizens, Madden fears that Immigration and Customs Enforcement (ICE) will grab and detain them. “There are lots of rumors about what ICE is doing, and we know that some people have left the country, self-deported, and others are too afraid to leave their homes,” she says. “People who lose their in-home care workers end up in nursing homes and it is terrible.”
This struggle has prompted a range of responses. Madden reports that some employers have offered to share their homes with their workers. “They’ve said, ‘Look, if you feel like you can’t go home because of ICE, you can stay here. Consider this your second home,’” Madden says. “Still, everyone, employer and employee, is constantly on edge. For me, my biggest fear as a disabled adult is that our home care workers will just suddenly be gone.”
Madden is far from alone. Although in-home supportive services are restricted to low-income seniors and people with disabilities who are Medi-Cal eligible, in January 2026 the program served 897,224 people statewide; they were cared for by 803,609 caregivers. In Los Angeles County, where Madden and her sister live, personal care assistants and direct service workers earn $19.64 an hour but salaries vary by county.
Looming Crisis
According to the American Business Immigration Coalition (ABIC), one in four long-term care workers and 30 percent of nursing home support staff in the U.S. are immigrants. Immigrants are also heavily concentrated among staff working in private homes and assisted living facilities.
Still, even without ICE raids, staff shortages and constant turnover have been apparent for years thanks to low wages and minimal job security in the eldercare industry. And it is getting worse: ABIC estimates that by 2030, 3.5 million additional health care workers will be needed to care for those with disabilities and those aged 65 and older.
Demographic changes have made the crisis more acute: By 2030, more than 20 percent of U.S. residents — 73 million people from the “baby boomer” generation born between 1946 and 1964 — will be 65 or older, and more likely to need care. Yet between 2020 and 2025, 770 nursing homes closed. Cuts in Medicaid and Medicare funding could mean more closures if federal reimbursement rates do not keep pace with inflation and if staffing shortages persist because of immigration policing and other barriers.
Jonathan Gruber, professor and chair of the economics department at the Massachusetts Institute of Technology, has studied the contribution of immigrant workers to the provision of health care. “Immigrants are an integral part of caring for the nation’s elders,” Gruber tells Truthout. “Based on the evidence, my colleagues and I forecast that if Haitian health care workers, (thousands of whom work in elder care and assist the disabled at home and in care facilities), most of whom lost their temporary protected status in February, are deported, there will be 9,000 premature U.S. deaths among those who depend on the assistance of these workers.”
Moreover, the severe labor shortage in nursing homes and other health care centers has been exacerbated not only by immigration policing, but also by the Trump administration’s threat to deny minimum wage and overtime protections to personal care assistants and home health aides who work in private homes. On top of approximately $911 billion in Medicaid cuts over 10 years, from 2025 to 2034, and massive staff layoffs at the Administration for Community Living — the agency that oversees independent living centers, senior centers, and Meals on Wheels — the poorest and most medically fragile seniors are already losing access to the help they need.
Some will inevitably end up in institutional care — or, as Gruber warns, will die earlier than expected.
We know that that institutional care is often riddled with problems, too.
MB, who asked to be identified only by her initials, works in a New York group home assisting six developmentally and physically disabled adult men between the ages of 62 and 99. She acknowledges that the small residence is a last resort for those with neither money to hire help nor family to assist them, and says that staff often feel ill-equipped for the direct care work they were hired to do.
“We don’t get enough support or training. It is a very demanding job and in the 14 months I’ve worked in the house, I’ve seen about 15 people come and go. People quit because one of the men living in the house self-harms and injures others. He is supposed to have a one-to-one aide, but because of staff shortages, this is not provided,” MB tells Truthout. “The salary, $21 an hour, is also insufficient and the house is in disrepair. In addition to taking care of the patients, we have to deal with leaks, mold, mice, and ant infestations.”
Money Is Not a Panacea
But even seniors who are able to pay for care out of pocket are facing troubling times. First there’s the cost: The national median cost of a private room in a nursing home is $129,575 a year while a semi-private unit can run $114,972. For those who opt to remain at home and are over the income threshold to qualify for Medicaid, non-medical care averages $6,673 a month, much of it paid to referral agencies rather than to the actual caregiver.
These staggering costs don’t faze the right wing, though. In fact, conservatives consistently call on family members — typically daughters, wives, and mothers — to step in and provide unpaid care to their aging and disabled loved ones.
“Individuals and their families need to assume the primary responsibility for the financing and delivery of long-term care, not government officials and taxpayers,” writes Robert Moffit, senior research fellow on health and welfare policy at the Heritage Foundation, the outfit responsible for the Project 2025 plan that has guided the second Trump administration. “The problem today is that millions of individuals and families are failing to plan or prepare for a life-altering event such as a stroke, dementia, or some major mental or physical disability which can wreak havoc on family life, personal wealth and social relations,” Moffit writes.
Unsurprisingly, there is no mention of ICE, budget cutbacks, or the need for paid labor in his analysis.
Pushback From Employers Builds Solidarity
Hand In Hand, a community of private employers that works to improve working conditions for domestic laborers and push for a robust national care system, is encouraging those who employ immigrants to make a plan with their employees. Amid growing ICE raids, the organization recommends making sure to offer paid leave on days that the worker feels the need to shelter at home; creating a safe transportation plan to enable the employee to get to and from work, including paying for taxis or accompanying an aide to a bus stop; and donating to community relief funds. Having an emergency plan in place, Hand in Hand materials say, is essential. Furthermore, this plan should ideally center the safety, dignity and humanity of the home care workers, while simultaneously protecting the client’s safety.
Brittanie Hernandez-Wilson is Hand In Hand’s lead home care organizer in California, and is reliant on an aide whose services she pays for herself.
She is proud that the organization is standing with immigrant workers. “Hand In Hand started the Sanctuary Homes project in 2016, during the first Trump administration,” Hernandez-Wilson tells Truthout. “I have a friend who made a plan with her workers to take their kids if they are kidnapped by ICE.”
Overall, she says that group members generally understand what needs to be done to protect the in-home workforce, but she also recognizes that not everyone is comfortable talking to their employer about their immigration status. At the same time, Hernandez-Wilson knows what it is like to be dependent on a caregiver. “It is a really big deal if a client can’t get out of bed because their caregiver did not show up for their shift,” she says. “Still, we know that home care workers are often devalued and exploited, so at Hand In Hand we try to bridge the gap between home care workers and their employers and promote living wages and adequate benefits for all employees.”
Then there’s the organizing that Hernandez-Wilson does to ensure that the needs of those who rely on in-home assistance are met. “I teach people who receive care to form networks to share information and find people who can send their attendant to their home in the event of an emergency,” she explains. She also recommends that those needing care line up people who can come over in a pinch to help them get out of bed if a worker fails to show up. “Our mutual aid tends to develop organically, and is made up of people we meet at disability events or that we see in our neighborhoods,” she says.
The goals, she adds, are both personal and political, and include calling out the political systems that are actively hurting elderly and disabled people. Similarly, she says that forming coalitions to bring disability justice and immigrant rights issues to public attention is imperative.
“Yes, there is a lot of fear because of ICE, cutbacks, and the racialized oppression that is disabling all of us, but when we pass the knowledge we’ve accumulated on to others, when we have open conversations and make plans for what we can and will do, it gives us strength,” Hernandez-Wilson says. “As disabled people who have always had to fight for what we have, we’re just doing more of what we’ve had to do for millennia.”
Eleanor J. Bader is a Brooklyn, New York-based freelance writer who focuses on domestic social issues and resistance movements. In addition to Truthout, she writes for The Progressive, Ms. Magazine, Lilith, The Indypendent, New Pages and other progressive blogs and print publications.
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