By Shannon Pettypiece - NBC News
Nurses and other health care workers who have been brought to the United States from abroad to fill thousands of vacant positions say in some cases they have been subjected to unsafe working conditions, wage theft and threats of tens of thousands of dollars in debt if they quit or are fired.
In interviews, more than a dozen immigrant health care workers from across the country described being placed in jobs where there were so few staff that they could not meet patients' basic needs and feared for their physical safety.
They also described being paid less than their American counterparts – despite laws prohibiting it – working unpaid overtime and being cheated about promised benefits such as free accommodation.
But when workers tried to leave their jobs before the expiration of multi-year contracts, they faced paying tens of thousands of dollars in fines from their employers, were forced to go through arbitration proceedings or were sued, in some cases for more than $100,000, according to a review of employment contracts. lawsuits and other documentation obtained by NBC News.
As a result, workers said they felt caught between two paths: continue in unsustainable jobs or risk financial ruin.
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"These unconscionable contracts effectively trap these workers in debt bondage, preventing them from leaving their jobs," Martina Vandenberg, president of the Human Trafficking Law Center, said in congressional testimony last month on what she sees as a broader problem: "Workers are bound by their debts, they can't run away."
The Labor Department has alleged that some of the tactics used to keep nurses in their jobs are illegal, and in March sued a nursing staffing agency. The argument: that the penalties imposed on workers for leaving their jobs early amounted to a violation of fair wage laws.
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A federal court ruled in 2019 that $25,000 contract penalties set by a New York nursing home operator violated human trafficking laws.
But those employment practices have continued, falling into a gray area in terms of regulations, and this may become even more prevalent given the dearth of Americans willing to work in health care jobs with difficult conditions and relatively low wages, said advocates for workers, specifically in the nursing sector.
Ghel Pecjo is a physical therapist from the Philippines who now lives in Abilene, Texas.Zerb Mellish for NBC News
"[This] impacts me as much as the cases of children working the night shift in slaughterhouses and states reinstating child labor laws," Vandenberg told NBC News.
While healthcare workers have been coming to the United States from abroad for decades, they have played an increasingly important role in the health care system after roughly 100,000 nurses left the industry during the COVID-19 pandemic, many citing stress and burnout, according to a 2022 survey.
Nursing homes, which typically pay lower wages than hospitals, have been particularly hard hit, losing more than 200,000 workers, including nurses, physical therapists and more support staff, since the start of the pandemic.
That has prompted health care systems, employment agencies and international recruiters to pressure Congress to increase the number of foreign-trained workers who can come to the United States.
But as demand for foreign-trained health care workers has increased, recruiters and employment agencies have used more aggressive tactics to keep workers in their jobs with longer contracts and higher reimbursement rates, said Polly Pittman, director of the Center for Health Workforce Research at George Washington University.
"If you're an employment agency, you basically have a financial incentive to stay with you forever," he said.
"A hook with deception"
Thousands of foreign-trained nurses arrive in the United States each year, mostly from the Philippines, where training programs are similar to those in U.S. schools, dating back to the U.S. colonization of the Philippines in the late nineteenth century. During that time, the United States established several hospitals and medical schools in the country that used the American method to train nurses.
Jeddalyn Ramos was hired in the Philippines and began working in August 2022 at Baldwin Health Center in Pittsburgh, owned by nursing home operator CommuniCare, which provides recovery and rehabilitation services to seniors.
Ramos signed a three-year contract that required her to pay a prorated amount of $16,000 if she resigned or was fired before the deadline expired. The agreement said the money was for expenses related to his relocation, including certain filing fees, hiring and agency fees, legal costs and temporary housing. The contract said the costs were "advances and relocation assistance that could be forgiven during a period of continuous employment."
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Once Ramos started working in the United States, she was often the only nurse for up to 30 patients, which usually prevented her from giving them their medications on time or protecting them from falls, Ramos said in a lawsuit. The high number of patients per nurse put those people in danger, she alleged, and she risked losing her nursing license herself.
In one case, he recalled, a patient who had had his leg amputated pressed the call button for help going to the bathroom, he said in a written statement given to his attorney that was provided to NBC News. Ramos was treating patients at the other end of the hall and couldn't respond immediately. He said he assumed the nursing assistant on the floor would respond, but when he didn't, the patient tried to get to the bathroom on his own and fell. Eventually, social services staff found the patient, alerted Ramos to what had happened and asked for his help. She said she ran to the patient's room and found him crying on the bathroom floor.
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"The patient was crying and asking for help," Ramos wrote, "my heart broke for the patient and for me because we weren't supposed to be in that situation."
To meet the needs of the patients he was assigned, he had to work during his breaks and stay past the end of his shift, overtime for which he was not paid, he said in his lawsuit.
After less than two months on the job and despite the financial penalty he knew he would face, Ramos said he resigned. Shortly after leaving the job, Ramos received a letter from the facility's owner, CommuniCare Family of Companies, demanding payment of $15,555 stipulated in his employment contract. Two days later, he sent the company a check for the full amount, according to documents he shared with NBC News.
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Still, CommuniCare sued her for $100,000 or more on the grounds of damages for breach of contract, unjust enrichment and fraudulent conduct, according to court documents.
Ramos is among more than a dozen nurses sued since early 2022 by CommuniCare — each for $100,000 or more — for quitting their jobs before the end of the three-year agreement they had signed, according to a review of legal documents in Hamilton County, Ohio, where the company is headquartered.
Ramos and other nurses have filed counterclaims claimingCommuniCare violated fair wage laws by failing to pay overtime, and that the $16,000 in alleged costs the company seeks to recover violates the law by using the threat of serious financial harm to force them to keep working. . Ramos' counterclaim said the company "knowingly used such threats to pressure the defendant to continue working for the plaintiff and prevent him from seeking employment elsewhere."
CommuniCare did not provide a detailed list of its costs in its lawsuit, but two CommuniCare nurses who had signed contracts with the $16,000 reimbursement requirement said CommuniCare paid for their flight, a month of temporary housing while they had no income and waited in the U.S. to be assigned to jobs, and for their visas and medical exams. The company also paid visa filing fees, which can run as high as $2,500, and which the employer must cover under U.S. law.
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The nurses, who earned several hundred dollars a week in the Philippines, said they paid for the nursing and English exams they took in the Philippines, as well as daily expenses in the United States, while waiting for more than a month with no income before being assigned to a job.
Working 55 hours and getting paid 40
Ariane Rose Villarin, another nurse who worked with CommuniCare, filed a lawsuit against CommuniCare and WorldWide Health Staff Solutions — a recruiter the company works with in the Philippines — in federal court in March. In the complaint, he made accusations similar to Ramos'.
Villarin, who began working in July 2022 at CommuniCare's Green Park Senior Living Community in St. Louis, said she had to care for up to 40 patients who required extended care without adequate nursing assistants. He said he often worked during his meal breaks and worked extra hours before and after his shift to complete all his tasks, which amounted to working 50 to 55 hours a week even though he was only paid for 40 hours, he said in the lawsuit.
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Fearing the overwhelming workload could put her at risk of losing her nursing license if she made a mistake, she quit the job after about two months, she said in the lawsuit.
"They bring these nurses, they promise them the American dream, but it's a hook with deception," said Magen Kellam, a Florida immigration attorney who has represented dozens of foreign-educated nurses and is one of the attorneys representing Villarin. "They arrive here and many times the jobs are very different from the idea they were sold. But that's where this debt-based servitude comes in, where they can't leave even if conditions aren't safe, and they are robbed of their wages and exploited in their working hours."
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Nurses who come to the United States arrive with residency, also known as EB-3 visas, so their immigration status is not tied to their employer and they can leave their jobs without their immigration status affecting them, unlike other workers on temporary visas such as H1-B.
CommuniCare afirmó en un comunicado que no podía comentar sobre los detalles del litigio en curso, pero que consideraba “una rareza estas acusaciones sobre maltrato a trabajadores o violación de los términos de los acuerdos con nuestros empleados internacionales”. La compañía dijo que las enfermeras tienen la libertad de irse siempre y cuando reembolsen a la compañía el monto que pagó en honorarios al Gobierno y terceros.
“Desafortunadamente, algunas de las enfermeras manipularon el sistema para ingresar a los Estados Unidos y luego buscaron oportunidades mejor pagadas”, aseguró CommuniCare en un comunicado.
La compañía, que tiene más de 18,000 empleados, indicó que había enfrentado escasez de personal, en parte por los efectos continuos de la pandemia, y “después de agotar todas las opciones” recurrió a la contratación de trabajadores en el extranjero para cubrir esas vacantes laborales.
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Ramos dijo que se había comunicado en varias ocasiones con CommuniCare para pedirle que retire la demanda, basado en el hecho de que le había devuelto dinero a la empresa después de que la queja fue presentada en corte en octubre de 2022. Cuando la empresa no lo hizo, presentó en enero su contrademanda.
Aproximadamente dos semanas después de que Ramos presentó su contrademanda, CommuniCare le envió un correo electrónico en el que le dijo que discutir sobre su despido y llegar a un acuerdo, según un intercambio de correo electrónico proporcionado por CommuniCare. En el intercambio, Ramos respondió que aceptaba retirar su contrademanda si le devolvían los 15,555.45 dólares que pagó y le otorgaban 78,000 dólares por daños emocionales.
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Un portavoz de CommuniCare afirmó que la compañía trató de retirar la demanda después de descubrir “un error administrativo” y alegó que Ramos “se negó a comprometerse razonablemente” con la compañía.
La mayoría de los estados no tienen cifras obligatorias de personal para los centros de atención médica, pero la escasez de personal ha sido una preocupación cada vez mayor de las enfermeras en el país desde el comienzo de la pandemia y una razón clave para que abandonen la profesión, aseguró Cheryl Peterson, vicepresidenta de programas de Enfermería de la Asociación Estadounidense de Enfermeras.
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Pero en lugar de mejorar las condiciones de trabajo para atraer a las enfermeras estadounidenses, los empleadores buscan ocupar esos puestos con personal extranjero, que no tiene la misma libertad para renunciar debido a los contratos que han firmado, afirmó Peterson.
“El miedo es la clave”
Los documentos en corte arrojan luz sobre lo ocurrido con las enfermeras que renunciaron y fueron demandadas, pero no sobre la situación de las que han seguido trabajando, temerosas de las consecuencias de abandonar sus puestos de trabajo.
Otra enfermera filipina en Maryland, quien pidió permanecer en el anonimato por temor a represalias de su empleador, afirmó que volvió a trabajar pese a temer por su bienestar físico, después de que su empleador la amenazó con una demanda de más de 100,000 dólares cuando trató de renunciar antes de que se cumplieran sus tres años de contrato, revelaron documentos revisados por NBC News.
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Contó que ella y otra enfermera tenían la tarea de cuidar a más de dos docenas de pacientes con problemas mentales y de adicción a las drogas que necesitaban supervisión constante, en una instalación que no tenía personal de seguridad. Amplió que temía por su seguridad cada vez que entraba y salía del lugar después de que ocurrió un tiroteo cerca de la instalación y de que entraran a robar en varios autos de empleados. Relató que había conseguido otro trabajo en un hospital cercano, pero que había rechazado la oferta después de que fue amenazada con una demanda.
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Otro enfermero reclutado en Filipinas que comenzó a trabajar en 2022 en un hogar de ancianos en Connecticut, quien tampoco quiso ser identificado, aseguró que le gustaría dejar su empleo por lo que consideraba prácticas laborales injustas que incluían un salario más bajo que su compañeros de trabajo y horas extras no pagadas, pero que su gerente le dijo que iba a enfrentar una multa de 45,000 dólares si rompía su contrato de cinco años después de haber trabajado sólo uno.
“Es una sensación de que estás en una celda y no puedes hacer libremente lo que quieres”, afirmó.
El enfermero dijo que cuando fue reclutado le ofrecieron alojamiento gratuito y le prometieron que iba a trabajar en una instalación en la ciudad de Nueva York, donde estaría cerca de su familia, que vive en Nueva Jersey. Pero cuando llegó el año pasado, lo enviaron a una instalación a dos horas de Nueva York. Y el alojamiento gratuito resultó ser en realidad una habitación en el hogar de ancianos.
El miedo es lo que permite que estas empresas se salgan con la suya”
DavId Seligman Director de Towards Justice
Vivió allí durante cuatro meses. Después de inspectores de Salud llegaron a revisar las instalaciones, finalmente fue trasladado a un apartamento. También supo que su salario de 34 dólares por hora era menos de lo que recibían sus contrapartes estadounidenses en la misma institución. Una revisión en el sitio de internet Indeed.com reveló numerosos trabajos similares en hogares de ancianos, donde el salario es de 37 dólares por hora. Ello equivale a más de 8,000 dólares adicionales al año por semanas laborales de 40 horas. Otros, incluso, llegar a pagar hasta 50 dólares por hora.
A diferencia de sus colegas estadounidenses, el enfermero filipino fue clasificado como contratista independiente, aunque había sido empleado directamente por la agencia de empleo y no por el hogar de ancianos y, además, no recibió seguro médico ni de liability (responsabilidad profesional).
“El miedo es la clave, porque el miedo es lo que permite que estas empresas se salgan con la suya al pagar salarios muy por debajo de lo que tendrían que pagar en el mercado si estuvieran compitiendo de manera justa”, afirmó David Seligman, director ejecutivo Towards Justice, un grupo de defensa de los trabajadores. “Estas empresas han podido monetizar el miedo”.
La fisioterapeuta filipina Ghel Pecjo.Zerb Mellish for NBC News
Los empleadores están obligados a pagar a las enfermeras inmigrantes el salario establecido por el Departamento de Trabajo para cada región. Sin embargo, tres abogados que representan a enfermeras con quienes NBC News habló dijeron que los empleadores a menudo usan prácticas engañosas para determinar esos salarios.
Una enfermera en Nueva Jersey aseguró que su pago por hora estaba basado en el salario promedio de las enfermeras en la parte más rural del estado, en comparación con el área de mayor salario, donde había sido ubicada, más cara cerca de la ciudad de Nueva York.
Dijo que los 3,800 dólares de salario neto al mes que recibía no eran suficientes para que su familia de tres personas pudiera cubrir los gastos de alquiler y seguro médico, además del automóvil que necesita para ir al trabajo. Como resultado, tuvo que pedirle dinero a su familia en Filipinas.
Estamos atrapados porque no tenemos otra opción, porque no tenemos los fondos para devolver el dinero”
Enfermera en Nueva jersey
Cuando le preguntó a su empleador qué podía pasar si se iba antes de que terminara su contrato de tres años, un gerente le dijo que tendría que pagarle a la empresa 100,000 dólares, por lo que decidió quedarse en el trabajo. El contrato de trabajo con la compañía, que fue revisado por NBC News, no establecía un monto específico en dólares que tendría que ser reembolsado si la enfermera no trabajaba durante todo el período, pero decía que la enfermera tendría que compensar a la compañía por la inversión que había hecho en la capacitación y contratación, además de las pérdidas asociadas con la renuncia de la enfermera y los perjuicios a los pacientes. El acuerdo indicaba que la compañía presentaría recursos legales para recuperar esas pérdidas.
Como resultado, la enfermera dijo que decidió quedarse en el trabajo. Para cubrir sus gastos, recientemente asumió un segundo trabajo de enfermería a tiempo completo. Ahora trabaja de 7:00 p.m. a 7:00 a.m. seis días a la semana.
“Estamos atrapados porque no tenemos otra opción, porque no tenemos los fondos para devolverles el dinero”, comentó la enfermera de Nueva Jersey, quien pidió que no se revelara su nombre porque temía a represalias de su empleador.
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“Buena fe y sensatez”
Kaye Mendoza se había graduado recientemente de la escuela de Enfermería cuando asistió a una feria de reclutamiento en Filipinas por sugerencia de su tía. Después de hacer una breve entrevista, le ofrecieron un trabajo y le presentaron un contrato de tres años en un hospital de Harlem, Nueva York. Relató que firmó el contrato a pesar de no entender completamente lo que decía, dado que el inglés era su segundo idioma y no estaba familiarizada con los términos legales estadounidenses.
“Todo lo que sabía sobre Harlem tenía que ver con [el equipo de baloncesto] los Harlem Globetrotters”, afirmó Mendoza.
Llegó a Nueva York en 2006. Su reclutador le había dicho que le iba a dar alojamiento y que su nuevo trabajo comenzaría pronto. En cambio, no le ofrecieron una vivienda y pasaron cuatro meses antes de que le dieran una fecha de inicio para trabajar, aseguró. Con sólo 200 dólares en ahorros y sin ingresos –relató–, tuvo que quedarse con parientes en Nueva Jersey y Maryland mientras esperaba.
Otra enfermera con un niño, que llegó en la misma fecha, terminó quedándose en la casa del reclutador durante meses, aseguró Mendoza.
Entiendo por lo que pasaron porque yo pasé por lo mismo, y esto debería terminar”
Kaye Mendoza enfermera y activista
Debido a su difícil comienzo en Estados Unidos, Mendoza se convirtió en defensora de un número cada vez mayor de enfermeras filipinas, docenas de las cuales la encontraron a través de un grupo de Facebook y se acercaron a ella para pedirle ayuda tras experimentar situaciones similares.
En los últimos meses, Mendoza se ha reunido con funcionarios filipinos y estadounidenses para crear conciencia esta situación.
“Entiendo por lo que todos pasaron porque yo pasé por lo mismo y hay que ponerle fin a esto”, declaró. “La situación está empeorando”.
Not all hospitals and health care facilities use foreign nurse hiring practices like those disclosed here, said Virginia Alinsao, who worked as an international recruiter for Johns Hopkins Hospital.
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She currently works as a recruiter for Henry Ford Health System in Michigan, where she strives to fill hundreds of open positions with foreign-trained nurses. Those professionals are employed directly by the hospital, not a staffing agency, and are paid the same as their U.S. counterparts, he said.
Henry Ford nurses have furnished accommodations, training and a local network of other Filipino nurses they can connect with as soon as they arrive in the United States, Alinsao explained. She added that she even makes sure her nurses have rice and a pot to cook it when they first arrive at the home she assigns to them, a gesture that seeks to help them adjust to their new home with some of the cuisine from their home country.
The employer invested money to bring them. They receive residency in the United States, so they can basically go anywhere. I think it's fair to ask that they reimburse, at least, the direct costs."
Virginia Alinsao recruiter
Alinsao said it's fair to require nurses to reimburse their employer for direct immigration costs, such as exam fees, which can add up to several thousand dollars, if they leave before a certain period of time. But he said fees should be reasonable and not cover business overhead, indirect costs or lost revenue.
"I think it's fair to ask the nurse to pay the direct costs of bringing them in. The employer invested money to bring them. They receive residency in the United States, so they can basically go anywhere. I think it's fair to ask that they reimburse, at least, the direct costs," said Alinsao, who said those costs can reach several thousand dollars.
Nurse and industry groups have tried to establish guidelines through agreements on the hiring process, and have tried to open nurses' eyes to be alert to unfair hiring practices. The Philippine Nurses Association in the United States has conducted webinars and published an advice sheet for nurses. In addition, it encourages them to use only recruiters authorized by the Philippine government.
The American Health Care Recruiting Association International, the trade group that represents about half of recruiters, also has its own code of ethics and expels members who violate it.
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"We believe international nurses should be treated with dignity," James Richardson, a spokesman for the American International Health Care Recruitment Association, said in a statement. "Membership is conditional on compliance with a strict code of ethics administered by an independent review board."
The group's code says its members will use "good faith and good sense in pursuing fees for breach," and that breach of contract fees should not be used for "punitive purposes." It also states that its members must make "reasonable efforts" to ensure that workers are assigned to "workplaces that are safe and that can perform such work without harm to themselves or others."
But neither group's guidelines prohibit the use of financial penalties for nurses who quit before the end of their contracts.
A problem with a solution
At the federal level, the employment of foreign-trained nurses largely falls into a regulatory gray area, where several agencies oversee a portion of the process, but none has full oversight. The State Department has jurisdiction over the visa process, even when nurses apply for residency. But once in the country, the Department of Labor monitors that labor laws are not violated.
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A State Department spokesperson said that while he could not comment on any pending litigation, "all allegations of forced labor, worker abuse, and fraud are taken seriously, and we work to ensure the integrity of U.S. visa adjudications and all consular services we provide around the world."
Acting Labor Secretary Julie Su has taken some recent action against the alleged abuses. In March, the Department of Labor filed a lawsuit in federal court against the employment agency Advanced Care Staffing, alleging that the reimbursement provision in nurses' contracts amounted to a form of lobbying that violates the Fair Labor Standards Act.
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The lawsuit said Advanced Care Staffing forced nurses who tried to leave before their contracts ended to go through a private arbitration process, and required them to return tens of thousands of dollars in future profits the company expected to make from employees, as well as the amount of costs for arbitration proceedings and attorneys' fees.
Advanced Care Staffing did not respond to requests for comment via email and voice messages.
Nurses have had some success in court. A judge ruled in 2019 that the operator of a nursing home, SentosaCare, and a recruitment agency it used in the Philippines violated the Trafficking Victims Protection Act by threatening financial damages when it included a $25,000 damages fine on immigrant nurse contracts, and filed lawsuits against nurses for $250,000 for breaching their contracts.
Sentosa argued in court that the $25,000 sum was "for damages," not a penalty, and that his efforts to collect the amount were within his contractual rights. The parties reached a $3.2 million settlement in March 2022.
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But that ruling and others in favor of nurses haven't stopped dozens of other lawsuits against nurses in state courts across the country, Kelam said.
Vandenberg recently raised the issue during a congressional hearing on reauthorizing the Trafficking Victims Protection Act. He said he would like Congress or the Biden Administration to take action to prohibit the use of contract sanctions against workers who are brought to the United States.
"It looks like a small policy change could solve these problems in the United States," Vandenberg said. "It really wouldn't take much work to figure this out."