The Brookings Institution has proposed a temporary H-1D visa for employers to sponsor home health aides, personal care aides and nursing assistants. The recommendation is not legislation, and employers cannot use the category now.
Tara Watson, director of the Center for Economic Security and Opportunity at Brookings and the John C. and Nancy D. Whitehead Chair and senior fellow in Economic Studies, published the proposal on September 29, 2026. The Hamilton Project published it as a policy proposal, not a federal rule.
The visa would cover workers in home-based and institutional care. Applicants would need a sponsoring employer and direct-care experience, or equivalent verified coursework or training.
The basic threshold is two years of experience. The proposal also calls for basic English-language literacy and no criminal history.
The proposal covers three direct-care occupations
The recommended category is tailored to home health aides, personal care aides and nursing assistants. Those roles could be performed in private homes or institutional settings, according to the proposal.
The program would add another legal immigration pathway rather than replace existing ones. Brookings says it could serve people arriving from abroad and immigrants already in the United States, including some without lawful immigration status.
During the first three years, workers already in the country would generally have to be recruited directly by a U.S. employer or through a U.S.-based intermediary. The proposal does not make the classification available until lawmakers establish it.
The visa would start small and expand after three years
The proposal sets an initial annual pilot of 30,000 visas. After three years, the cap would rise to 65,000 visas a year, a volume projected to meet about 35 percent of the direct-care workforce growth needed over a decade.
A commission would periodically review the limits and could adjust them as demographic and economic conditions change. Brookings says the proposed ceiling would fall short of meeting the sector’s entire need through immigration, leaving room to build the domestic workforce.
Each worker would receive a three-year initial visa with an option to renew. The design includes dependents and dual intent, allowing workers to pursue permanent residence after six years. Establishing that permanent-residence route would require further changes to immigration law.
The visa would carry an above-market wage floor, protections intended to reduce exploitation, and support for worker training and professional development. Fisher Phillips described the wage standard as pay “near the top of the local market.”
The proposal responds to a growing care-worker gap
Brookings estimates that more than 20 million U.S. adults need long-term care or daily-living support because of disabilities or functional limitations associated with aging. It projects the population age 65 and older will rise from 65.6 million to 77.5 million over the next decade.
The number of people age 85 and older is expected to increase from 6.8 million to 11.1 million. The disabled population age 65 and older is projected to grow by more than 6 million.
The sector will need about 1.28 million additional workers by 2036, an increase of roughly 35 percent from today. Brookings links recruitment and retention problems to low wages and poor job quality, citing understaffing in institutions and unmet demand for home care.
Watson argues that better working conditions and compensation alone will not fill the gap. She wrote that the response “should also include the targeted recruitment of immigrants to work in the U.S. in this industry.”
The proposal also points to immigrants’ disproportionate presence in direct care and research linking their work to better care quality and lower elderly mortality. Watson said a larger workforce could help older and disabled people receive care in both institutional and noninstitutional settings, including the setting they prefer.
Employers would carry added wage and insurance duties
A sponsoring employer would have to provide affordable, adequate health insurance for the worker and dependents. Employers would also guarantee at least 25 hours of work per week.
The wage floor and other protections are intended to prevent the program from becoming a lower-cost labor channel. Crystal Fullilove, SIA’s senior healthcare analyst, said staffing firms could act as sponsoring employers or recruit and screen workers for health systems and facilities.
She said the requirements make the program a supplement to domestic hiring, not a low-wage alternative. Fullilove added that another qualified-worker pathway could ease hiring pressures in long-term and post-acute care, where recruitment and retention remain difficult.
The proposal contemplates staffing companies serving as intermediaries that help health systems and facilities handle program requirements. Their role would depend on the eventual rules and the employer’s responsibilities.
Congress would have to act before employers could sponsor workers
Existing visa categories do not neatly cover these jobs. H-1B generally requires a specialty occupation, H-2B addresses temporary labor needs, and employment-based green-card sponsorship can involve lengthy processing and visa backlogs.
Watson’s proposal instead calls for a category built around caregiving occupations. No legislation has been introduced to create it, and no agency has proposed a rule implementing it.
Watson has also argued that a similar model could eventually address other high-need occupations and help set the stage for broader immigration reform. The proposal leaves the decision with Congress.
