Photo of Rachel Litchman
In January 2025, just two weeks before President Trump’s second inauguration, I was approved by the state of Wisconsin to receive Home and Community-Based Services (HCBS), a form of long-term care that they called IRIS. A rapid decline in my progressive disability caused me to go into a rehabilitation hospital, and I exited it in August 2024 as a full time wheelchair user. I now needed help with basic personal and home care tasks – bathing, cooking, cleaning, and dragging myself and my forty-pound wheelchair up the twenty steps of my inaccessible apartment’s stairs.
Despite my home care services being approved to begin in January, it still took almost a month before I could find personal care attendants (PCAs). I posted in local Facebook groups, and I asked other disabled people for advice. Yet, I couldn’t find anyone who was able to help. The wages provided by the state were too low – at a maximum of $17/hour. Right now, a single person needs to earn at least $21 per hour to support themselves in Wisconsin, while someone with a family needs to earn much more. I didn’t have anyone in my personal network who could take on this job. Most of my friends were also disabled, or they had full-time employment. When I finally decided to select a care agency to hire workers for me, I thought it would solve my troubles finding support staff. But for almost a month, the agency had such a hard time finding PCAs for me that the agency CEO had to step in and provide caregiving support for me.
Unfortunately, challenges in finding qualified care attendants are the norm. Even before Trump took office, there has long been a severe worker shortage in the home care industry. In my state of Wisconsin, 1 in 4 direct care worker positions are vacant, and nationally, all states surveyed reported a shortage of direct care workers, in some cases leading to care agency closures due to a lack of staff.
Medicaid cuts and immigration raids only make these already pressing issues worse. Thirty-two percent of the home care workforce is staffed by immigrants, and immigrants make up twenty-one percent of staff in nursing homes. Additionally, that percentage has increased over time, as low wages and poor treatment make care work a generally unappealing job. Non-immigrants, who may have more resources to find jobs with better pay, often don’t want to take these roles. Further, there is enormous turnover amongst care workers because they can often get better, more secure jobs in other fields. One recent estimate found that turnover in the home care workforce was close to 75 percent in 2024.
All care attendants deserve better pay and treatment, and care attendants who are immigrants deserve to not feel threatened in the workplace due to increased anti- immigrant enforcement activity. Unfortunately, Trump’s immigration policies, which include visa suspensions for immigrants of color – including Haitians, Somalis, and Afghans – have already affected the long-term care workforce. Immigrants are leaving or disappearing from healthcare jobs and facilities are struggling to find people to hire.
Immigrants, especially non-citizens, have feared showing up to work, knowing they may be targeted for deportation. Even when immigrants have visas or have obtained citizenship, this has proven to not matter to ICE, who has illegally detained citizens and visa-holders, incentivized by quotas that place a bounty over people’s heads. This leaves disabled people without home care, nursing facilities without staff, and care workers and the disabled people who rely on them more susceptible to danger and death.
Immigrants and their families need care too. For disabled immigrants, including those who may be racially profiled regardless of citizenship status, they risk losing access to life-saving care if they are detained and/or deported. Immigrants may also fear leaving their homes or going to the hospital for healthcare, as nursing home staff fear raids from the federal government, and hospitals have already seen ICE agents walk through their doors. Disabled people in ICE detention centers face even more critical threats to their lives, as detainees have reported being denied access to medical care. Finally, for disabled immigrants who rely on personal care attendants, even if their citizenship status may not make them eligible for Medicaid or HCBS, they face the double threat of having their attendants disappeared and detained by the government, and care needs denied if subject to ICE detention.
The broader attack on immigrants combined with Medicaid cuts that are already beginning as a result of HR 1 mean that home and community-based services face a dire threat. Since HCBS is an optional program, it will likely be one of the first programs that states cut when Medicaid dollars decline. Even before Medicaid cuts began, when states faced budget cuts, HCBS was often the first program cut. We recently saw this in both Maryland and New York. Further, when federal Medicaid cuts occurred in 2010, all states made cuts to HCBS, meaning reduced caregiving hours, longer wait lists, and less capacity to take new enrollees.
For people like me who rely on caregivers to remain in the community, assaults on immigrants mean I move closer and closer to institutionalization each day. I am not naïve to the abuses that occur in institutional facilities. I fear what will happen to myself and other disabled people, citizens and immigrants alike, when we are forced out of sight, out of mind.
Rachel Litchman is a cartoonist, writer, and consultant who primarily covers disability, healthcare, and housing policy. She has comics and writing published in The Washington Post, The Nib, The Disability Debrief, and STAT, to name a few places. You can find her on her website racheldl.com or on Instagram as @racheldlart.