Who will take care of us when we get old?
· Vox
Unlike projecting how many jobs AI may eliminate over the next 10 years, or what a country’s birth rate might look like, there’s far less debate among policymakers about how large America’s older population will be in a decade’s time, and how many of them are likely to need direct care for disabilities.
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By 2036, as the baby boomers continue to retire, the US population 65 and older is expected to grow from 65.6 million to 77.5 million people, according to the Congressional Budget Office. The number of people 85 and older is also expected to nearly double in that time, from 6.8 million to 11.1 million.
The question of whether the United States will have enough direct care workers — an umbrella term that refers to home health aides, personal care aides, and nursing assistants — looms large. These are workers, primarily women, who help older adults and people with disabilities bathe, dress, eat, take their medication, and generally get through a day, either in a nursing home or in someone’s own home. It’s a massive, often ignored workforce (the American Community Survey estimates there were 3.62 million of them in 2024) and it’s paid for largely by Medicaid, the joint federal-state health insurance program that most people associate with coverage for impoverished Americans but which is actually the dominant payer for long-term care in this country.
Key takeaways
- By 2036 the US will need 625,000 to 1.3 million more direct care workers, and policymakers across the aisle agree the demand is real and coming.
- Three bipartisan-friendly proposals — the Dignity Act, the Careworker Visa Act, and a Brookings caregiving visa — would bring in immigrant caregivers with built-in protections learned from past programs.
- With around 40 cosponsors from both parties and Problem Solvers Caucus backing, the Dignity Act has more bipartisan traction than most immigration bills in years. Trump has also expressed new openness to immigration reform.
Depending on which researcher you ask, the US will need somewhere between 625,000 and 1.3 million additional direct care workers over the next decade to keep pace with the growing number of older and disabled Americans — and that’s just to maintain today’s level of care as the population ages, not to fix the shortage that already exists. If you’ve talked to anyone currently trying to coordinate long-term care, you probably already know the country is understaffed as it is.
To close the gap, policy experts say the United States should bring more immigrants into a sector that’s already about one-third immigrant, while also protecting the roughly 12 percent of current direct care workers who are noncitizens, some of them undocumented. PHI, a national nonprofit that researches and advocates for the direct care workforce, projects 9.6 million direct care job openings between 2025 and 2035, the bulk of which will come from existing workers changing fields, retiring, or otherwise leaving the workforce.
“We can’t do it with the current US-born workforce,” Amy Robins, the senior director of policy at PHI, told me. “We need to have mechanisms where people can come into this country and do this work.”
Immigration reform has felt politically impossible in Washington for years, but after the brutal defeat Republicans suffered in the midterms, there’s a suddenly a much stronger case that this corner of the fight is different. Days after the election, President Donald Trump gave an interview saying his deportation policy was “too tough” and he’d be open to some sort of immigration reform deal to protect workers. In September 2025, Sens. Kevin Cramer (R-ND) and Dick Durbin (D-IL) reintroduced a bill to recover green cards that went unused in earlier years and redirect them to nurses and doctors. Coordinating care for older adults is a problem that reaches families in every corner of the country, and even comfortable households wonder whether they can secure a dignified life for an aging parent, or, eventually, for themselves.
With family caregivers growing in number and nursing homes turning residents away because they can’t find staff, caregiving may be the one corner of immigration policy Congress is actually willing to fix.
A growing menu of options
Over the last year or so, three different proposals have emerged that suggest that caregiving is the immigration battle Washington is finally ready to fight.
In July 2025, Reps. María Elvira Salazar (R-FL) and Veronica Escobar (D-TX) introduced the Dignity Act, which pairs tougher border enforcement with legal status for undocumented immigrants who’ve been in the country since before 2021. It also offers permanent residency for Dreamers and a handful of green card reforms. Salazar herself has pitched the bill partly as a remedy for the same aging-population squeeze driving the caregiver shortage, and eldercare groups such as LeadingAge and the American Seniors Housing Association have thrown their support behind it.
The legislation rests on an idea at the center of the caregiving political fight, which is that immigration enforcement alone won’t get the US the labor it needs.
Since then, the Dignity Act has gathered around 40 cosponsors, split nearly down the middle between the parties, and this spring it won the endorsement of the Problem Solvers Caucus, a group of roughly 60 members whose mandate is passing legislation both sides can live with. Following Trump’s recent comments that he’d be open to an immigration deal, Salazar praised him on X, urging him to throw his weight behind the Dignity Act. “You can surpass Reagan’s legacy by delivering a historic immigration reform,” she posted. “This is your moment.”
There are other ideas on the table, too. Over the summer, Rep. Gabe Vasquez (D-NM) introduced the Careworker Visa Act, a bill that would create a new temporary visa allowing up to 100,000 immigrants a year to work in childcare, eldercare, and home-based disability care. It would also let some immigrants already living in the US obtain work authorization through the program and give participating workers a pathway to permanent residency.
“We all know that immigrants are already taking on these jobs in large numbers,” Vasquez told me. “One of the conversations we’re having amongst the Democratic coalition is how to craft meaningful immigration-related legislation that can be bipartisan on a couple specific issues. And certainly this bill rises to the very top of that conversation.”
And the most recent entry came in September, from Tara Watson, an economist at the Brookings Institution. In a new caregiving visa proposal, she offers the idea of a visa open to immigrants with at least two years of direct care experience who want to come to the US to work as home health aides, personal care aides, or nursing assistants. It would start at 30,000 visas a year before rising to 65,000 after three years, and employers would have to pay above-market wages and provide health insurance.
Learning from what didn’t work
Neither of the two dedicated caregiving visa proposals is starting from scratch. In 1999, Congress created a visa for nurses to work in understaffed hospitals, but the process had such strict eligibility rules that fewer than 15 hospitals nationwide ever qualified to use it. And it was burdensome for qualifying workers, too: If a nurse ever wanted to switch their hospital, they had to start their visa certification process all over again. Over the course of a decade, barely a thousand visas were ever issued, and lawmakers let the program expire in 2009.
Other countries have gone the opposite direction. The UK made care workers eligible for its Health and Care Worker visa in 2022, and the numbers took off almost immediately, with 106,000 visas granted in 2023 alone. But exploitation was rampant. Some contracts required workers to repay thousands of pounds to their employer if they left before their visa term was up — one worker’s contract demanded more than 11,000 British pounds — which made leaving a bad job financially impossible for people who’d often already gone into debt just to get the job in the first place. More than 43,000 workers were affected when their employers’ sponsor licenses were revoked amid widespread reports of exploitation. The UK ended overseas recruitment for care workers in 2025, though the broader Health and Care Worker visa remains in place.
Both experiments reflected the fact that workers often had no way out, no matter how poorly an employer behaved. Watson and Vasquez say they kept that front of mind when crafting their proposals, both of which allow workers to switch jobs rather than staying locked to whoever sponsored them.
“You really do see this tension — the more you try to make sure the workers are protected, the more onerous it becomes for the employers,” Watson told me. “You’re choosing between scale and some of those restrictions. I’m trying to hit somewhat of a middle ground.”
Vasquez pointed to the H-2A visa program for farmworkers, which he said has also had real, ongoing problems with employers abusing the system.
“Anytime that we are creating new programs for immigrant workers in which their job status depends on them achieving legal status, we should always be aware that there may be bad folks that are seeking to abuse that system,” he told me. “That’s going to require some thoughtful support for the Department of Labor for enforcement of laws just like this.”
States can’t fix this alone
These federal ideas build on top of a patchwork of state-level attempts to raise direct care wages in order to incentivize more people living here to enter and stay in the field. Yet for all the state mandates, bonuses, and training programs, care programs are usually among the first casualties when money gets tight. And even in states that have pulled off real wage increases, inflation has frequently swallowed those gains before they could do much to close the gap.
LeadingAge, which represents nonprofit nursing homes, assisted living communities, and home care agencies, says no single state’s budget can fix this. Linda Couch, the organization’s senior vice president of policy, says states are now facing significant cuts to their Medicaid funding under last year’s federal budget law, which will squeeze what providers can pay their staff.
“Federal policymakers hold a lot of the cards for systemic change to meet the needs of older adults,” Couch told me. “Without action to secure immigration reform and reverse Medicaid cuts, we’re putting access to aging services at risk for older adults across the country.”
LeadingAge’s members are already feeling this. Couch said one of its Massachusetts members, Hebrew SeniorLife, had to let go of nearly 40 Haitian workers this year after their Temporary Protected Status ended, some of whom had worked there for more than a decade. A Florida provider lost 10 workers from Cuba and Haiti after a humanitarian parole program shut down.
Congressional Republicans to date have primarily rallied around tax credits and retirement protections for the nation’s 63 million family caregivers. Robins of PHI, though, doesn’t see the two approaches as inherently at odds.
“There are way more family caregivers in this country than there are direct care workers, and that will always be true,” she told me. It’s a “yes, and” when it comes to supporting family caregivers, she said, and direct care workers are a “fundamental way that we support family caregivers who are taking on tremendous care responsibilities in our country right now.” A paid home health aide coming a few days a week, in other words, can be what lets a daughter or spouse keep working, or just get a full night’s sleep, while still caring for a parent at home.
The population who will need this care by 2036 is already here. It may not be much, but caregiving, as Watson said, is “low-hanging fruit, if there is any low-hanging fruit.” In an immigration debate this stuck, that counts for something.