By Melissa Bailey | Kaiser Health News

BOSTON — The two women have been together since 2011, a 96-year-old originally from Italy and a Haitian immigrant who has helped her remain in her home — giving her showers, changing her clothes, taking her to her favorite parks and discount grocery stores.

“Hello, bella,” Nirva greets Isolina Dicenso, using the Italian word for “beautiful.”

“Hi, baby,” Dicenso replies.

But changes to federal immigration policy are putting both at risk. Haitian caregivers like Nirva, who got temporary permission to stay in the United States after the 2010 earthquake destroyed much of their homeland, now face a July 22, 2019 deadline for returning. If they and tens of thousands of other immigrants with similar jobs and tenuous legal status are forced to leave the country, Americans living with disabilities, serious illness or, like Dicenso, the frailties of old age could find themselves with few options besides nursing homes.

And many of those facilities could themselves be caught short of staff, at a time when more of the country’s aging baby boom generation could need care.

The situation reflects the crosscurrents that often roil immigration debates, with a central question being how many Americans are willing to fill the arduous, low-pay positions that immigrants often work. The expected fallout offers a glimpse into how such policy changes under President Trump will affect older Americans nationwide, especially those in large cities.

Some 59,000 Haitians live in the United States under temporary protected status (TPS), a humanitarian program that has given them permission to live and work in this country since the earthquake. Many are nursing assistants, home health aides and personal care attendants — the trio of jobs that often defines direct-care workers.

The Trump administration decided last November to curtail that protection, saying the country no longer faced the same adverse conditions and giving the immigrants until mid-2019 to leave or face deportation. In Boston, the city with the nation’s third-highest Haitian population, the action has prompted panic from TPS holders and pleas from health-care agencies that rely on their labor.

The decision “will have a devastating impact on the ability of skilled nursing facilities to provide quality care to frail and disabled residents,” Tara Gregorio, president of the Massachusetts Senior Care Association, warned in a letter published late last year in the Boston Globe. Nursing facilities in the state, which already are grappling with a shortage of several thousand workers, employ about 4,300 Haitians, according to Gregorio.

Nationwide, 1 in 4 direct-care workers are immigrants, said Robert Espinoza, vice president of policy at the New York-based Paraprofessional Healthcare Institute.

It’s not clear how many of those workers rely on the TPS program, but the Institute calculates that there are 34,600 who are non-U.S. citizens from Haiti, Nicaragua (for which TPS will end in January), El Salvador (in September 2019) and Honduras (in July, unless the Trump administration decides to renew protected status for individuals from this country). TPS decisions cannot legally take economic considerations into account, a Department of Homeland Security official said.

In addition, another 11,000 workers come from countries affected by Trump’s travel ban, primarily from Somalia and Iran, and about 69,800 are non-U.S. citizens from Mexico, according to the Institute.

Even immigrants with secure legal status may be affected when family members are deported, Espinoza noted: Under Trump, noncriminal immigration arrests have doubled. The “totality of the anti-immigrant climate” threatens the stability of the workforce — and “the ability of older people and people with disabilities to access home health care,” he said.

The Federation for American Immigration Reform, which supports more restrictive immigration policies, disputes such dire scenarios. Since three-quarters of direct-care workers are U.S. citizens, spokesman David Ray argues, then “these are clearly not ‘jobs that Americans won’t do.’ ” He does the math this way: The country has 6.7 million unemployed people, and if the health-care industry can’t find enough workers to replace those who lose TPS and other protected statuses, “then it needs to take a hard look at its recruiting practices and compensation packages.”

Yet nursing homes in Massachusetts are already losing immigrant workers who have left the country in fear, because of the White House’s immigration proposals and public remarks, according to Gregorio. Nationally, thousands of Haitians have fled to Canada.


“What people don’t seem to understand is that people from other countries really are the backbone of long-term care,” said Sister Jacquelyn McCarthy, chief executive of Bethany Health Care Center in Framingham, Mass., which runs a nursing home with 170 patients. She has eight Haitian and Salvadoran workers with TPS, mostly certified nursing assistants, who show up reliably for 4:30 a.m. shifts and never call out sick, she said. She already has six CNA vacancies and can’t afford to lose more, she said.

“There aren’t people to replace them if they should all be deported,” McCarthy said.

Nirva, who asked that she be identified only by her first name, works 70 hours a week taking care of senior citizens, sick and disabled patients. She started working as a CNA shortly after she arrived in Boston in March 2010 with her two sons.

She said she chose this work because of her harrowing experience in the earthquake, which destroyed her home and killed hundreds of thousands, including her cousin and nephew. After the disaster, she walked 15 miles with her sister, a nurse, to a Red Cross station to try to help survivors. When she got there, she recounted, the guards wouldn’t let her in because she wasn’t a nurse.

“So, when I came here — I feel, people’s life is very important,” she said. But at first, caring for elderly patients was difficult. “At the beginning, it was very tough for me,” she acknowledged, especially “when I have to clean their incontinence. . . . Some of them, they have dementia, they are fighting. They insult you. You have to be very compassionate to do this job.”

Nirva, 46, works with a soft voice, a bubbling laugh and disarming modesty. She says her faith in God — and a need to pay the bills to support her sons, now in high school and college — help her get through each week.

She started caring for Dicenso in her Boston home as the older woman recovered from surgery in 2011. With support from Nirva, another in-home aide and her daughter, Dicenso has been able to continue living alone. She now sees Nirva once a week for walks, lunch outings and shopping runs. The two have grown close, bonding in part over their Catholic faith. At home, Dicenso proudly displays a bedspread that Nirva gave her, emblazoned with the word LOVE.

Nirva also fills three shifts a week at a chiropractor’s office as a medical assistant. Five nights a week, she does an overnight shift at a Boston rehabilitation center.

The Trump administration’s immigration restrictions may exacerbate a serious shortage of direct-care workers, warns Paul Osterman, a professor at the Massachusetts Institute of Technology’s Sloan School of Management. He forecasts a national shortfall of 151,000 workers by 2030 and of 355,000 workers by 2040. If immigrants lose their work permits, the gap would widen further.

“People aren’t going to be able to have quality care,” he said. “They’re not going to be able to stay at home.”

Angelina Di Pietro, Dicenso’s daughter, worries about who could help her mother if Nirva can’t. “There’s not a lot of people in this country who would take care of the elderly,” she said. “Taking care of the elderly is a hard job.”

“Nirva, pray to God they let you stay,” said Dicenso, sitting in her living-room armchair after a long walk and ravioli lunch. “What would I do without you?”


Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.