September 19, 2017 | Lisette Roman

DREAMers are Key DOers in the ACO Model

Recent, highly publicized communications from the Trump Administration have stirred uncertainty about the future of the Deferred Action for Childhood Arrivals (DACA) initiative. The Administration’s decision to end DACA would disproportionately impact the home health services industry [1], an industry that Accountable Care Organizations are increasingly relying on to provide care in the community. In this post, we focus on the potential impact of rescinding DACA on the long term support services (LTSS) workforce and downstream effects for Accountable Care Organizations (ACOs).

DACA recipients provide a strong workforce for home and community-based health services.

Authorized immigrant labor, such DACA-permitted employment, is a resource that enables organizations to provide culturally competent care. Approximately 20% [2] of the 800,000 [3] DACA recipients (called “DREAMers” [4]) work in healthcare and education in roles such as community health workers and home health aides. Kathee Jordan, EVP/CEO of Seven Hills Foundation, one of the largest and most comprehensive health and human service agencies in the Northeast, noted recently, “At Seven Hills Foundation, our workforce is made up of nearly 4,000 individuals from 46 countries representing more than 20% of our workforce.  The ability to recruit and attract these staff, including those who came here as Dreamers, is vital to our ability to support the most vulnerable individuals in our care.”

Moreover, more than 98% of DACA recipients are bilingual, providing a workforce that can deliver culturally competent care. This capability is particularly important to individuals with LTSS due to the intensive nature of assisting individuals with self-care and attending to their daily needs and preferences [5]. This workforce is the community partner that ACOs have been increasingly teaming with to deliver the right care to patients to whom these organizations are now accountable (see Figure 1).

ACOs are increasingly dependent on community-based care providers.

A successful ACO model of care must include community partnerships with LTSS organizations to provide care in the community setting and out of the hospital.  Because the incentives to reduce costly utilization have been so effective, state interest in capitated managed Medicaid LTSS programs has grown. Specifically, states have leveraged 1115 waivers as vehicles to increase access to home and community-based services for these beneficiaries [6]. Not surprisingly, 4 of the 5 states that stand to gain the most economically from passing the DREAM Act [7] – to the tune of $10+ billion by 2030 [8] – comprised 82% of all enrollment in 1115 MLTSS waivers in 2016 [9]. Even in states with more modest estimated economic impact from the DREAM Act, like Massachusetts, Medicaid waivers are heavily invested in connections with community partners. In Massachusetts, the MassHealth waiver requires Medicaid ACOs to contract with and work closely with these groups (see Figure 1).


What LTSS employers can do now.

It is important to know that if the DACA initiative were to be terminated, employers would shoulder the burden of employee attrition. The onus would be on employers for identifying that the employee’s DACA work permit has expired, and the employer would ultimately absorb the financial and company morale cost of turnover for those employees. However, the good news is that the Administration has, at this time, reversed their stance on the program. During this time of uncertainty, employers can help current DACA employees stay employed and productive now if they educate employees with DACA work permits expiring between now and March 5, 2018, on the October 5, 2017 deadline for a two-year renewal [10]. ACOs are well-positioned to provide education and support to their community partners.




[3] and Studies/Immigration Forms Data/All Form Types/DACA/daca_performancedata_fy2017_qtr2.pdf

[4] Acronym comes from the Development, Relief, and Education for Alien Minors Act



[7] Development, Relief, and Education for Alien Minors Act