“We Make All the Work Possible”: Home Care Workers Speak Out About Coming Medicaid Cuts

July 30 will mark the 60th anniversary of President Lyndon Johnson’s signing legislation establishing Medicare and Medicaid, an unprecedented and popular extension of the American safety net. It’s a shame that in its anniversary month, Medicaid, the health insurance program for low-income Americans, got slashed more than ever in its history by Republicans desperate to give tax cuts to the wealthy, as well as build up the staffing and facilities of Donald Trump’s deportation regime.

The verdict is still out on how the bill will cut Medicare, the landmark program for seniors, but it’s safe to say that healthcare cuts this deep will hurt it too. Not to mention that Yale Public Health scholars predict the cuts will kill 51,000 people annually whose deaths could have been prevented had they been able to access healthcare.

While drama over the bill’s passage was a top story for weeks —would Republicans block these cuts that hurt even their own constituents? Rather predictably, almost none even tried—once Trump signed the bill, its provisions, and the human suffering it will cause got much less attention. Every day we learn more names of famous men, including Trump, who signed convicted sex offender Jeffrey Epstein’s 50th birthday book, and that’s important. But we’re hearing much less about the victims of this coming safety-net apocalypse.

It’s tough to single out one group of Americans who will suffer most from the shameful “Build Prisons, Slash Billionaires’ Taxes, Kill Poor People” law. But we know already that among those who will struggle are the nation’s exhausted, underpaid home healthcare workers and in-home childcare workers, roughly a third of whom are also immigrants.

Many of the in-home healthcare workers, mostly paid through Medicaid, will lose their jobs when the full impact of cuts come down, beginning after the 2026 midterms. They, as well as privately paid in-home childcare workers, and some workers in childcare and nursing home facilities, will also likely lose their own Medicaid healthcare coverage. Many make too little to afford private insurance.

Of course, the next tier of victims are their clients, the disabled and the elderly, mostly women, who will lose their care thanks to these Medicaid cuts. ​​At least 17 percent of assisted-living community residents were Medicaid beneficiaries as of 2022. Immigrants make up 28 percent of the direct care workforce for long-term care services, according to KFF. More than a third of them are not citizens. They play an even larger role in the home-care workforce—one in three workers there are immigrants.

Children will suffer too, from both Medicaid cuts and cuts to their caregivers. Fully 40 percent of all American births are covered by Medicaid, and in some states, Medicaid covers decent postpartum benefits to families too. Trump’s deportation regime will also hurt them and their caregivers: According to the National Women’s Law Center, immigrants make up at least 20 percent of “early educators,” a category that includes preschool teachers, childcare center workers as well as in-home nannies. The percentage of nannies who are immigrants is higher than that. Though childcare workers typically are paid privately, and thus won’t lose jobs due to Medicaid cutbacks, many will lose their own Medicaid insurance—or may get deported, as the immigrant nannies I spoke to said they increasingly fear, with ICE raids metastasizing around the country.

But there’s another tier who will suffer: the people employing these women, who can currently go to work, because they know their children or their elders or disabled relatives have care. When that support disappears, these potential caregivers will likely have to give up or cut back on paying work, or time with their children, to pick up the caregiving slack.

Again, mostly women.

“We are disproportionately relying on immigrants to take care of the people we love in this country,” says Ai-Jen Poo, executive director of the National Domestic Workers Alliance (NDWA) and the political group Care in Action. “Families across the spectrum are going to be devastated.”

The right-wing assault on reproductive health has hurt innumerable women—and it continues in this bill with a one-year ban on Medicaid funding for reproductive healthcare institutions that provide abortions, even if, like Planned Parenthood, routine healthcare facilities have been separated over the years from their abortion providers. But when the big ugly bill’s cuts roll out, they will hurt many more than we know now.

The NDWA connected me with three women active in its network who shared their deep concern about what’s coming.

Roxana (a pseudonym) is an East African immigrant who has “legal status,” she says, although she is not yet a US citizen. The Houston-based nanny calls the parents she works for “good employers.” But escalating ICE raids and the recent detention of an immigrant neighbor panicked her. She told her employers she needed to stop picking up their kids from school. They said of course—and then cut her wages.

“I mean, they needed to hire someone to do that,” she says, with patient understanding.

Roxana is paid by her employers, but she relies on Medicaid for healthcare, and so do most of the nannies in her network. They are constantly worried about getting sick. “Remember, the minute you’re not in good health, you can’t work. When you work with children, the parents are very careful. You don’t want a sick person with your children.”

Roxana spends only a minute on those minor, to her, complaints. Most of her sadness comes from being isolated from her nanny community—parks, museums, even churches. Her job is now lonely, she says.

“First and foremost, you wake up to uncertainty,” she told me over the phone. “You wake up, you’re worried. Is this a day that you or somebody close to you will be raided? You wake up wondering, do I still have a job?

“And then there’s the community that we used to have at the parks. You know you’re going to meet so and so, they have a love with their kids and your kids. Now we’re only doing playdates if people have a playroom in their building. Mostly, we’re home alone.” She adds, “It’s very sad. People are looking for live-in nanny jobs where they do not have to commute. Because they’re feeling unsafe going out.”

For all of her caution to avoid authorities, Roxana had a recent scare. She was driving the children she cares for, and the police stopped her. Despite her legal status, “still there was fear in me. Everything was okay. They just asked for my driver’s license, and I was let go.”

Roxana has no idea why she was pulled over.

“But now people like me do not want to drive around. They are fearful.”

Denise Lugo is an in-home healthcare worker in Fayetteville, North Carolina. She wants to use her real name, she says, because she’s outspoken in her community, and she was born in this country, of African American and Latino descent, in New York. A nursing home worker for 20 years, she now works for individual families, paid by Medicaid, which she prefers. She watched her mother, a certified nurse’s assistant, work in New York hospitals until “she just couldn’t work anymore. That’s where I got my love for this work from and my passion from.”

Worried about how the Medicaid cuts will affect her job, Denise says her employers are already fretting too. One of her patients is “very worried, because she has specialists she has to go to. She needs her medications, especially her insulin. She feels the anxiety.”

Denise is most concerned about losing her own Medicaid coverage. North Carolina only recently opted into the Medicaid expansion enabled by the Affordable Care Act. Plagued with chronic health issues, “Medicaid helped me tremendously,” she said. “Without it, I wouldn’t be able to go to the specialists I need to go to right now. It would be harder to know that I could get to work.”

But if the Medicaid cuts are already worrying her employers, not only Denise herself, are they speaking out about it publicly? “Like everybody else, they are just praying that it really will backfire and it won’t happen.” She is too, she admits.

Denise wonders about the people “in charge,” she says, who voted for these cuts to vulnerable people. “Could they think about, if it affected their family, what would they do?

“It’s like people up there, in their offices, they don’t care about life itself.”

Lorena (a pseudonym), who works as a nanny in New York City, worries about the entire community of caregivers. “It’s not only nannies. It’s people who take care of the elderly. We are workers who are needed every day. We make all the work possible.” She adds: “We make all the world possible.”

Like Roxana, Lorena has watched her group of immigrant nanny friends essentially go into hiding. “Going to the museum, going to parks, to the Y, everywhere they would go taking the children, they’re a little skeptical doing that now.” They feel isolated, she says. “People are not sleeping properly. People are having anxiety. People are suffering mentally. And when I talk to nannies, it’s like they’re going to work, they’re fearful on the train, they go back home, fearful. And that’s their life.” She has a friend who is “deporting herself,” she tells me, “because of the anxiety, the frustration: ‘If I’m out of a job, will anybody will hire me?”

Lorena says Medicaid cuts will hurt not only women who are currently covered by it but also immigrants who aren’t covered yet and get care at public hospitals and clinics when they’re sick. “Medicaid ultimately pays for that. But nannies aren’t doing that so much now,” she tells me, more because they fear ICE than they’ve heard about looming Medicaid cuts. “People don’t even want to go to the hospital. They’re putting their health in jeopardy because they not sure if they go, if ICE will be showing up there.”

But Lorena is most disappointed by the passivity of parents who employ immigrant nannies now, whatever the worker’s status. “I wonder if parents could have it in their mind or their heart to see if they can protect their workers. Parents always say, ‘You’re part of the family. We love you.’ But being part of the family, isn’t this something that they would maybe worry about?

“My employer never had that conversation with me, to sit and say, ‘Lorena, how do you feel? Because of what is happening?’ I think because I have legal status she maybe thinks I’m safe, but I’m not safe, and she has never had that conversation with me. Maybe ask, for example, ‘How do you feel with all the ICE agents on the street? Is there any way for me to help keep you safe? Is there anything that we can be doing? Do you need to change your routines? Would you like not to go certain places?’ I don’t know of parents who are having that kind of conversation.”

It’s still hard to accept that just about a year ago, Democrats chose a presidential nominee who was a loyal friend to careworkers, who regularly did shifts in the SEIU’s “Walk A Day In My Shoes,” serving days in various carework routines. Kamala Harris routinely saluted the care workers who made her dying mother’s days more bearable, and promoted a “Medicare at Home” benefit that would have had Medicare, and not the more routinely threatened Medicaid program, pay for the in-home care more of us will need as we age, or as our parents age do.

Most American voters rejected her in favor of the man who just gleefully cut the safety net, after promising not to. It wasn’t a landslide, it wasn’t a mandate, but Trump won. And millions of American people have lost.

Ai-Jen Poo says that while most of the Medicaid cuts won’t become official for more than a year, their effects are making themselves plain at the state level, where Medicaid funds are important—Maine, with one of the nation’s oldest populations, gets almost a third of its budget from Medicaid—as well as within public and private healthcare institutions. “Hospitals are going to have to figure out a way to start preparing for the massive hell that the cuts to Medicaid are going to create in their revenue streams. And there’s no way that some states can replace that funding.

“So there’s both going to be a loss of services when it comes to healthcare and home care, but it’s also going to mean cuts to vital services like transportation, education, infrastructure, food banks. Everything is going to be impacted, because states are going to have to figure out how to manage this massive hole in their budgets, immediately.”

On Wednesday night, a coalition of caregivers’ advocates began a 60-hour vigil on the National Mall in Washington, DC, commemorating the 60th anniversary of Medicare and Medicaid. On Saturday, the groups, including Ai-Jen Poo’s Care in Action and the National Domestic Workers Association, unions like SEIU and AFSCME, Planned Parenthood, Moms Rising, MoveOn and others, are sponsoring “Families First” rallies in all 50 states, with a flagship gathering in Washington, bringing together thousands of people who’ve been hurt by the cuts to Medicaid, food assistance, and reproductive health, to demand that Congress restore those programs.

Hopefully these events will remind media outlets to bring the stories of these many victims back to the headlines. They shouldn’t have to wait until the stories of “preventable deaths” caused by these cuts unfold—and neither should we.