Immigration, the Long-Term Care Workforce, and Elder Outcomes in the US

The U.S. nursing home industry faces severe labor shortages that have worsened following the Covid-19 pandemic. Because nursing homes are highly reliant on immigrant labor, a frequently proposed policy lever to address shortages is to increase national immigration flows. Although debates over immigration remain contentious, existing evidence using geographic-level data indicates that greater immigration increases the supply of nurses and nurse aides with some improvements in nursing home quality. This paper extends earlier work using nursing home- and patient-level data and shift-share analyses to assess the impact of increased immigration on nursing home staffing and care quality. Additionally, we explore heterogeneity in observed treatment effects and potential mechanisms through which changes in patient outcomes occur. In our preferred specifications, we show that increased immigration significantly raises the direct care staffing ratios of nursing homes, with effects concentrated among full-time workers. We then show that this has a robust and very positive effect on a variety of patient outcomes. Effects were strongest from increases in Hispanic immigrants. We find suggestive evidence that immigrants increase both the supply and quality of the nursing home workforce, supporting the critical role that immigration may play in addressing long-standing staffing and quality issues in this industry.