When the Visa Fee Goes Up, the Call Light Stays On Longer

Between 21 and 25 percent of the nursing home workforce in the United States is foreign-born. In some markets, that share reaches 40 percent. In long-term care specifically, immigrants make up almost 30 percent of all direct care workers, including nursing assistants and personal care aides. That is not a footnote. That is the staffing plan.

When federal immigration policy shifts, the effect does not stay in an embassy or a visa processing center. It moves to the floor. To the resident waiting for a turn. To the call light that goes unanswered. To the pressure injury that forms because no one had time to reposition.

Two federal policy decisions, made in 2025, are now converging on the nursing home workforce from different directions. The first is a $100,000 visa fee imposed through a September 2025 Presidential Proclamation, aimed primarily at the technology sector but applied universally. The second is the One Big Beautiful Bill Act, signed July 4, 2025, which cut $911 billion from Medicaid over a decade and delayed federal staffing standards until 2034. Neither policy was designed with nursing homes in mind. Both are landing there.

The daily care in a nursing home is delivered primarily by certified nursing assistants and licensed practical nurses. These roles do not require a bachelor’s degree and do not qualify for H-1B visas. The foreign-born workers filling these positions arrived through different pathways: permanent residency, family sponsorship, refugee status, or Temporary Protected Status, known as TPS.

TPS is a federal program that allows nationals from designated countries facing unsafe conditions to live and work legally in the United States. Haitian immigrants are among the most heavily represented TPS holders in long-term care. One in five Haitians in the United States works in healthcare. In states like Massachusetts, immigrants make up nearly 40 percent of health aides. In Florida, that figure reaches 48 percent of health aides and 64 percent of home health aides.

As of March 2026, the Trump administration had ended or attempted to end TPS designations for 13 of 17 countries with active designations. That includes Haiti, whose TPS termination was set to take effect in September 2025 before being temporarily blocked by federal courts. The legal status of Haiti TPS remains in active litigation before the Supreme Court as of May 2026.

Some nonprofit nursing home providers report facing the loss of 8 percent or more of their entire workforce in a single day if TPS terminations proceed. These are not projections about future hiring. These are workers already on the floor, already caring for residents, already known by name to the families who visit on weekends. Losing them does not leave a vacancy. It leaves a gap in care that existing staff must absorb immediately.

Research from PHI, a nonpartisan workforce organization, notes that immigrant direct care workers remain in their positions longer than US-born workers, providing the continuity of care that is hardest to replace in a sector defined by chronic turnover. When TPS holders leave, facilities do not lose interchangeable positions. They lose institutional knowledge, trusted relationships, and years of consistency that no staffing agency can replicate overnight.

The H-1B visa program is designed for specialty occupations requiring at least a bachelor’s degree. Standard CNA and LPN roles do not qualify. The September 2025 Presidential Proclamation imposing a $100,000 fee on new H-1B petitions was explicitly framed as a response to technology companies using foreign labor to replace American workers. The fee was applied universally. A rural nursing home in Michigan is subject to the same $100,000 requirement as a software firm in Silicon Valley.

For large hospital systems, academic medical centers, and research institutions, the H-1B program is essential for recruiting physicians, researchers, and highly specialized clinicians. That is where the fee lands hardest and most visibly. Nursing homes are not the primary users of the H-1B program, and most coverage of this issue has missed what the fee actually does to smaller long-term care facilities.

What the fee does to nursing homes is more specific and more structural. Nursing homes do use H-1B visas for roles that require advanced degrees, including nurse practitioners, clinical nurse specialists, physical and occupational therapists, care plan coordinators, and nurse administrators and managers. These are the clinical leaders who oversee entire nursing staffs, manage quality compliance, and allow a facility to meet the staffing ratios required to keep its beds certified.

A $100,000 fee per petition does not slow that recruitment. It ends it. In Texas, the fee represents nearly two years of Medicaid revenue from a single resident bed. A facility operating at a negative margin on its Medicaid population, which is most facilities, cannot absorb that cost. The result is not a delayed hire. It is a vacant leadership position that cascades down to the floor, affecting every CNA and every resident the missing manager was supposed to oversee.

The fee also blocks the H-1B as a bridge pathway. Internationally trained registered nurses seeking permanent residency through the EB-3 visa face backlogs of two to four years due to retrogression. The H-1B has historically allowed these nurses to enter and begin working while their green card application is pending. That bridge is now priced out of reach for any facility without the financial reserves to absorb a six-figure upfront cost.

This is the right question. The answer is not about preference. It is about supply, geography, and wages.

On supply: in the 2024 to 2025 academic year, more than 65,000 qualified candidates were turned away from nursing programs in the United States. Not because they were unqualified. Because there were not enough faculty or clinical placement sites to train them. The domestic pipeline is not producing enough graduates to meet current demand, and that gap is projected to reach 250,000 RNs by 2030.

On geography: the facilities most dependent on foreign-born workers are rural facilities. A domestic nurse with options chooses a hospital in a city, where pay is higher, conditions are better, and career advancement is available. Rural nursing homes cannot compete on any of those dimensions. The workers who fill those roles in rural communities often do so because of ties to the region or because the sponsorship pathway brought them specifically to that location. When that pathway closes, the rural facility does not get a different applicant. It gets no applicant.

On wages: the One Big Beautiful Bill Act, signed July 4, 2025, cut $911 billion from Medicaid over ten years. Medicaid funds the majority of long-term care in the United States. When reimbursement rates do not cover the actual cost of care, facilities cannot raise wages to compete with retail, food service, or any sector that does not require lifting, turning, and providing intimate personal care for medically complex residents. The OBBBA did not create that gap. It widened it at a moment when the workforce was already shrinking.

The nursing home workforce is not one group. It is layered. Each layer is being hit by a different policy through a different mechanism. All three layers share the same floor.

At the leadership level, the $100,000 H-1B fee has ended international recruitment for nurse managers, nurse practitioners, and specialized therapists at facilities that cannot absorb a six-figure upfront cost. When a facility cannot fill a nurse administrator position, it cannot maintain the clinical oversight required to keep its beds certified. Beds get decertified. Admissions freeze. The facility shrinks or closes before it runs out of CNAs.

At the frontline level, TPS terminations and the broader enforcement climate are removing CNAs, aides, and personal care workers who have been in their roles for years. These are not people awaiting work authorization. Many have been legally present and continuously employed for a decade or more. When their status becomes uncertain, some stop showing up before termination takes legal effect. The gap appears on the floor immediately.

At the financial level, the OBBBA’s Medicaid cuts prevent facilities from raising wages to attract and retain domestic workers. CNA turnover reached 42.34 percent in 2025. The facilities that want to compete for domestic workers cannot afford to. The facilities that are losing TPS workers cannot replace them. The facilities that need specialized clinical leaders cannot recruit them.

The connection between staffing levels and resident outcomes is one of the most consistently documented relationships in long-term care research. Residents who are not repositioned develop pressure injuries. Residents without meal supervision aspirate. Medications arrive late or not at all. These are not worst-case scenarios. They are the documented outcomes of understaffing, across facilities, across states, across decades of inspection records.

The residents most affected are the residents least able to advocate for themselves. They are cognitively impaired, medically complex, or both. They cannot advocate for policy change. They depend entirely on the person who walks through the door at the start of a shift. When that person does not exist because the facility could not recruit them, could not retain them, or could not afford to keep them, the resident absorbs the absence.

The sector was already under pressure before 2025. Between 2015 and 2025, registered nurse care hours dropped 19 percent. CNA hours dropped nearly 7 percent. The number of CMS-certified facilities fell by nearly 6 percent. These numbers reflect a decade of structural erosion. The policies of 2025 did not create the problem. They accelerated it at a moment when acceleration is the one thing the system cannot absorb.