Immigration Enforcement and the Quality of Home Health Care

• In Event: The Consequences of Decentralized Immigration Enforcement

Abstract

As the U.S. population ages, the demand for home health care is rising, with immigrants playing a crucial role in delivering these services (Butcher, Moran, and Watson 2021). Simultaneously, immigration enforcement has intensified, potentially disrupting labor markets and affecting the availability and quality of caregiving. Prior research links immigrant labor supply to improved nursing home care quality (Furtado and Ortega 2023) and reductions in the likelihood of elderly individuals moving into nursing homes (Almuhaisen, Amuedo-Dorantes, and Furtado 2024). However, little is known about how immigration enforcement influences the provision of home-based medical services, a rapidly growing sector critical to both health policy and the needs of an aging population. This study examines the extent to which immigration enforcement affects the quality of care provided by Home Health Agencies (HHAs), using Secure Communities (SC) as a case study and testing the robustness of findings to later enforcement programs.

SC, rolled out in U.S. counties between 2008 and 2013, provides a useful setting for estimating causal effects, as its staggered county-level implementation helps mitigate endogeneity concerns (Amuedo-Dorantes and Lopez 2015). Immigration enforcement may affect HHA care quality in multiple ways. First, by reducing the supply of licensed home health workers, particularly among immigrant populations, it may lead to understaffing, higher caseloads, and lower quality care. Second, it may disrupt complementary caregiving roles, such as personal care aides, that support patient recovery at home (East and Velásquez 2022). These labor market shifts could result in reduced workforce availability, higher turnover, and worse patient outcomes, raising concerns for both elderly care policy and workforce planning.

To assess these effects, we merge CMS Home Health Compare data, which tracks key quality indicators—including patient mobility improvements, pain management, and hospital readmissions—with county-level SC activation dates and demographic controls from the ACS. Using a staggered difference-in-differences framework, we compare care quality before and after SC’s activation across treated and control counties, accounting for potential confounders such as labor market conditions and concurrent policies. We also examine heterogeneity by HHA ownership type, as for-profit and nonprofit agencies may respond differently to labor shortages. Finally, we test for similar effects under post-SC enforcement programs to assess whether more recent policies continue to shape labor supply and care quality in the home health sector.

Preliminary findings suggest that SC lowered overall HHA care quality, particularly among for-profit agencies, with increases in hospital readmission rates, a key indicator of poor health outcomes. These results underscore the unintended consequences of immigration enforcement for elder care access, Medicaid spending, and broader health policy decisions. Given the expansion of Medicaid-funded home health services and ongoing state-level restrictions on immigrant labor, these findings highlight a growing policy tension. Ensuring an adequate supply of home health workers is critical to meeting the needs of an aging population, controlling healthcare costs, and maintaining high-quality, accessible care.

Author

• Catalina Amuedo-Dorantes, UC Merced
  Presenting Author