WASHINGTON — Nurses and other health care workers who have been brought to the U.S. from overseas to fill thousands of vacant jobs say in some instances they’ve 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 was so little staff that they weren’t able to meet patients’ basic needs and feared for their physical safety. They also described being paid less than their American counterparts despite immigration laws that require they be paid the local prevailing wage, working unpaid overtime and having been misled about benefits, such as free housing, which in one case amounted to a vacant room in the nursing home where the nurse worked.
But when the workers tried to leave their jobs before the expiration of multi-year contracts, they were faced with paying tens of thousands of dollars in penalties to their employers, forced into arbitration or 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, the workers said they felt trapped between continuing in untenable jobs or risking financial ruin.
“These unconscionable contracts effectively trap these workers in debt bondage, making it impossible for them to leave their jobs,” said Martina Vandenberg, president of the Human Trafficking Legal Center, in congressional testimony last month about what she sees as a wider problem. “The workers are handcuffed by debt, unable to flee.”
Some of the tactics used to keep nurses in their jobs have been alleged to be illegal by the Labor Department, which in March sued one nurse staffing agency, saying its penalties imposed on workers for leaving their jobs early amounted to kickbacks that violated fair wage laws. A federal court ruled in 2019 that contract penalties of $25,000 by a New York nursing home operator violated human trafficking laws. But the employment practices have continued, falling into a regulatory gray area, and stand to become even more prevalent given the shortage of Americans willing to work in a growing number of health care jobs with harsh conditions and relatively low pay, said labor and nursing advocates.
“It is as shocking to me as children working the overnight shift in slaughterhouses and states rolling back child labor laws,” Vandenberg told NBC News.
While health care workers have been coming to the U.S. from overseas for decades, they have played an increasingly vital role in the health care system after an estimated 100,000 nurses left the industry during the Covid-19 pandemic, with a growing number of nurses citing stress and burnout from the heavy workload they are given, according a 2022 survey by the American Nurses Foundation. Nursing homes, which typically pay lower wages than hospitals, have been hit particularly hard, losing more than 200,000 workers, including nurses, physical therapists and other support staff, since the start of the pandemic.
That has health systems, staffing agencies and international recruiters lobbying Congress to increase the number of foreign-trained workers who can come to the U.S. But as the demand has increased for foreign-trained health care workers, recruiters and staffing agencies have employed more aggressive tactics to keep workers in their jobs with longer contracts and bigger repayment fees, said Polly Pittman, director of the Health Workforce Research Center at George Washington University.
“If you’re a staffing agency, you basically have a financial incentive to have them stay with you forever,” said Pittman.
‘A bait and switch’
Thousands of foreign-trained nurses arrive in the U.S. each year, the majority coming from the Philippines where nurse-training programs mirror those of American nursing schools, a system dating back to the U.S. colonization of the Philippines in the late 19th century. During that time, the U.S. set up a number of hospitals and medical schools in the country that borrowed the American system for training nurses.
Jeddalyn Ramos was recruited from the Philippines and started working in August 2022 at Baldwin Health Center in Pittsburgh, which is owned by nursing home operator CommuniCare and provides long-term and short-term recovery and rehabilitation services to seniors.
Ramos signed a three-year contract that required her to pay back a pro-rated amount of $16,000 if she quit or was fired before the term was up. The agreement said the money was for expenses related to her immigration, including certain filing fees, recruitment and agency fees, legal costs and temporary housing. The contract said the costs were “advancements and relocation assistance eligible to be forgiven over a period of continued employment.”
Once Ramos started working in the U.S., she was often the only nurse for as many as 30 patients, which often prevented her from getting to patients fast enough to give them their medications on time or to protect them against falls, Ramos said in a lawsuit. The high nurse-to-patient ratio put the patients in danger, she alleged, and put herself at risk of losing her nursing license should a patient be harmed on her watch.
In one instance, she recalled, a patient pressed the call button seeking help in going to the bathroom, she said in a written statement to her lawyer that she provided to NBC News. She was caring for patients at the other end of the hallway and could not immediately respond. She said she assumed the nursing assistant on the floor would respond, but when the assistant didn’t, the patient attempted to get to the bathroom on their own and fell. Eventually, social service staff found the patient and went to alert Ramos to what had happened and get her assistance. She said she ran to the patient’s room and found the patient on the bathroom floor crying.
“The patient was crying and asking for help,” Ramos wrote. “My heart breaks for the patient and for me because we should not be in that situation.”
To meet the needs of the patients she was assigned, she had to work through her breaks and stay past the end of her shift, extra hours she wasn’t paid for, she said in her lawsuit.
After less than two months on the job and despite the financial penalty she knew she would face, Ramos said she quit. Shortly after leaving the job, Ramos received a letter from the facilities owner, CommuniCare Family of Companies, demanding she pay $15,555 stipulated in her employment agreement. Two days later, she sent the company a cashier’s check for the full amount, according to records she shared with NBC News.
Still, she was sued by CommuniCare for $100,000 or more, alleging damages from a breach of contract, unjust enrichment and fraudulent conduct, according to court filings.
Ramos is one of more than a dozen nurses sued since the start of 2022 by CommuniCare, each for $100,000 or more, for leaving their jobs before the end of the three-year agreement they had signed, according to a search of legal filings in Hamilton County, Ohio, where the company is based.
Ramos and several other nurses have filed countersuits saying CommuniCare violated fair wage laws by not paying overtime and that the $16,000 in alleged costs the company seeks to recoup from them in their contracts violates trafficking laws by using the threat of serious financial harm to coerce them to continue working. Ramos’ countersuit says that the company “knowingly used such threats to exert pressure on Defendant to continue working for Plaintiff and to prevent her from seeking employment elsewhere.”
CommuniCare didn’t provide a detailed listing of its costs in its lawsuit, but two former CommuniCare nurses who had signed contracts with the $16,000 repayment requirement said CommuniCare paid for their one-way flight, one month of temporary housing while they had no income and waited in the U.S. to be assigned to jobs, and their visas and medical screenings. The company also paid for visa filing fees that can be as much as $2,500, which the employer is required to pay for under U.S. law.
The nurses, who were making several hundred dollars a week in the Philippines, said they paid the cost for their required nursing and English examinations taken in the Philippines as well as their daily living expenses in the U.S. while they waited for more than a month with no income before being assigned to a job.
Another former CommuniCare nurse, Ariane Rose Villarin, filed a lawsuit against CommuniCare and WorldWide HealthStaff Solutions, a recruiter it works with in the Philippines, in federal court in March, making allegations similar to Ramos' and seeking class-action status.
Villarin, who started working in July 2022 at CommuniCare-owned Green Park Senior Living Community in St. Louis, alleged in court records that she had to care for as many as 40 long-term care patients at a time without an adequate number of nursing assistants. She often worked through meal breaks and worked additional hours before and after her shift to complete all her tasks, routinely working 50 to 55 hours a week despite being paid for 40 hours, she said in her lawsuit.
Fearing the overwhelming workload could put her at risk of losing her nursing license if she made an error, she quit the job after about two months, her lawsuit says.
“These nurses are brought over, they’re promised the American dream and it’s a bait and switch,” said Magen Kellam, a Florida immigration lawyer who has represented dozens of foreign-educated nurses and is one of the lawyers representing Villarin, speaking about wider trends she has seen. “They get here and oftentimes the jobs are much different than the idea that they were sold. But that’s where this debt bondage comes into play, where they can’t leave even if the conditions are unsafe, and there’s wage theft and exploitation of their work hours.”
The nurses coming to the U.S. arrive with green cards, also known as EB-3 visas, so their immigration status isn’t linked to their employer, and they can leave their jobs without affecting their immigration status, unlike other workers with temporary visas, such as H1-B visas.
CommuniCare said in a statement that it cannot comment on the specifics of ongoing litigation but that it takes “exception to these accusations of mistreating workers or violating terms of agreements with our international employees.” The company said the nurses are free to leave so long as they reimburse the company for the amount it paid in government and third-party fees.
“Unfortunately, some of the nurses have manipulated the system to get into the United States and then looked for higher paying opportunities,” the company said in a statement.
The company, which has more than 18,000 employees, said it had faced staffing shortages, in part from the lingering effects of the pandemic, and “after exhausting all options” turned to hiring workers from overseas to fill those job vacancies.
Ramos said she repeatedly reached out to CommuniCare asking it to dismiss the case, citing the money she had repaid the company after its lawsuit was filed in October 2022. When the company didn’t take any action, she filed her countersuit in January.
About two weeks after Ramos filed her countersuit, CommuniCare emailed her saying it wanted to discuss a settlement and dismissal, according to an email exchange provided by CommuniCare. In the exchange, Ramos responded that she would agree to drop her countersuit if she was reimbursed the $15,555.45 she paid and awarded $78,000 for emotional damages.
A CommuniCare spokesperson said the company sought to drop the lawsuit after discovering “a clerical error” and alleged that Ramos “refused to reasonably engage” with the company.
Most states do not have mandated staffing levels for health care facilities, but understaffing has been a growing concern raised by nurses in the U.S. since the start of the pandemic and a key reason for nurses leaving the profession, said Cheryl Peterson, vice president of nursing programs for the American Nurses Association.
But rather than improving the working conditions by raising staffing levels to attract American nurses, employers are looking to fill those jobs with nurses from overseas who don’t have the same freedom to quit because of multi-year contracts they have signed, said Peterson, speaking broadly about the practices she has seen.
“The U.S. has over 5 million nurses in our workforce, and we have a fairly robust pipeline of nurses coming into the profession. So why don’t they want to work in our institutions? It’s because they’re not very good environments to work in,” said Peterson. “So when I think about where I’d like to see the hospital and the health care industry invest its time and energy it would be to make your work environment and your pay to where nurses want to work in your institutions and so that you’re retaining the nurses that you have.”
‘You become paralyzed’
Gelenie Pecjo Fulo had dreamed of coming to the U.S. from the Philippines to work ever since she graduated from a physical therapy program in her home country in 1997 in the hope of providing a better life for her and her two children. In 2016, she signed a contract in the Philippines with a recruiter who agreed to place her in a full-time physical therapy job.
But when she arrived in the U.S., the experience wasn’t what she was expecting. Fulo said she was given a $150-a-month stipend from the recruiter and placed in an apartment with five other Filipino health care workers for months as she waited to pass the required examination and be assigned to a job. Once she started working in December 2019 at a nursing home, she bounced between assignments as she struggled to find temporary housing. Twice a staffing agency she was assigned to work for had its contract canceled by the nursing home she was working in, leaving her with periods where she wasn’t working.
Tired of the inconsistent work and hearing from other physical therapists that she could be making between $42 and $70 an hour — rather than the $30 an hour she was being paid — she said she decided to find another job.
But she said she was terrified to leave because she had signed a contract with the recruiter requiring her to work 6,000 hours, about three years of full-time work. If she left before then, the contract threatened her immigration status, saying the employer would inform U.S. Citizenship and Immigration Services and “revoke its sponsorship and petition of employment,” according to a copy viewed by NBC News.
Her struggles in coming to the U.S. are like those of the nurses. Other immigrant health care workers who are eligible for green card visas have also been required by their employers to sign multi-year contracts stipulating they pay their employers for alleged costs, in some cases totaling more than $40,000, if they leave before the end of their contracts.
Under her EB-2 visa, Fulo was legally allowed to change jobs without it affecting her immigration status, but she said she and her colleagues didn’t fully understand their legal rights. She’d also heard stories about another worker who left before the contract expired and was sued for $45,000.
“It was so traumatic and so stressful physically, mentally, emotionally. It was terrible,” Fulo said.
Fulo decided to take the risk and leave. After finding a new job while she was between assignments, she cut off all communication with her old employer and her former colleagues, fearing some form of retribution, she said.
“There was always that fear, but at every point I was thinking about my kids, about my mom and my family, so all those things pushed me,” Fulo said. “I felt like I was a criminal, like I did something wrong, and I had to hide from them.”
About a year after leaving, she was sued by the recruiter, Overseas Manpower Solutions, which alleged she owed the company $42,231 for what it would have made off the remaining hours she was required to work under the contract, and $4,704 for what it had spent on her immigration process, according to the lawsuit.
“I was literally trembling,” Fulo said when she received the lawsuit. “I was just so scared, you get so scared you become paralyzed, that was how I felt. I saw my whole future start crumbling down right before my eyes.”
Fulo hired a lawyer and reached a settlement in the case in 2021. She is barred from talking about the terms of the agreement. She is now continuing to work as a physical therapist in Texas, where she plans to stay longer term.
Since suing Fulo, Overseas Manpower Solutions has sued at least three other physical therapists and a nurse for breach of contract, seeking repayments for lost profits and immigration costs ranging from $12,264 to $43,723, court records show. Three of the cases have been settled and one remains in litigation.
Overseas Manpower Solutions didn’t respond to emails and a voicemail seeking comment.
‘Fear is the point’
There is a legal paper trail for the nurses who have left and been sued. But not for the nurses who have remained, fearful of the repercussions of quitting.
Another Filipino nurse in Maryland, who asked to remain unnamed for fear of retaliation from her employer, said she went back to work after she was threatened with a more than $100,000 lawsuit by her employer when she tried to leave before the end of her three-year contract, despite fears for her physical safety, according to documents reviewed by NBC News.
She said she and one other nurse were tasked with caring for more than two dozen patients with mental illness and drug addiction disorders who needed constant monitoring, with no security on site to help. She feared for her safety when entering and exiting the facility after a nearby shooting and after employees’ cars had been broken into. She said she had gotten another job at a nearby hospital but declined the offer after the lawsuit threat.
Another nurse recruited from the Philippines who began working in 2022 at a nursing home in Connecticut, who also didn’t want to be identified, said he would like to quit his job over what he viewed as unfair labor practices that included lower pay than his co-workers and unpaid overtime, but he said he was told by his manager that he would face a $45,000 penalty for breaking his five-year contract after one year.
“It’s this feeling of being in a cell and not being able to freely do what you want,” the Connecticut nurse said.
When being recruited, the nurse said he was offered free housing and was told he would be working at a facility in New York City, where he would be close to family in New Jersey. But when he arrived last year, he was sent to a facility two hours away from New York City. The free housing was actually an empty room in the nursing home.
He lived there for four months — it wasn’t until health inspectors came to inspect the facility that he was finally moved to an apartment. After arriving on the job, he also learned that his $34-an-hour wage was less than what his American counterparts made at the same facility. A search on the website Indeed.com showed numerous similar nursing home jobs requiring the equivalent level of experience in the area paying more than $37 an hour — which could total more than $8,000 a year in additional wages for working a 40-hour week — with some paying as much as $50 an hour.
Unlike the American employees, he was classified as an independent contractor employed directly by the staffing agency that recruited him, not the nursing home, and was not given health insurance or professional liability insurance.
“The fear is the point because the fear is what allows these companies to get away with paying wages that are so far below what the market would pay if they were competing fairly,” said David Seligman, executive director of the worker advocacy group Towards Justice, regarding the practices he has seen by employers in lawsuits he’s worked on. “These companies have been able to monetize their fear.”
Employers are required to pay immigrant nurses the prevailing wage set by the Labor Department for a specific region. But three lawyers representing nurses whom NBC News spoke to said employers often use deceptive practices in determining those wages.
One nurse in New Jersey said her hourly pay required to be paid under U.S. immigration rules was based on the prevailing wage for all nurses in a more rural, low-cost part of the state compared with the more expensive area near New York City, where she was assigned. She said her $3,800 a month in take-home pay wasn’t enough for her family of three to live on with the cost of rent, health insurance and the car she needs to get to her job. As a result, she had to ask her family in the Philippines to send her money.
When she asked her employer about leaving before the end of her three-year contract, she said she was told verbally by a manager that she would have to pay the company $100,000, so she decided to stay in the job. The company’s employment agreement, a copy of which was reviewed by NBC News, didn’t state a specific dollar amount that would have to be repaid if the nurse didn’t work for the full term, but said the nurse would have to compensate the company for the investment it made in training and recruiting the nurse along with lost profits associated with the nurse leaving and damages the nurse’s departure would have on its relationship with clients. The agreement said the company would pursue legal remedies to recoup those losses.
As a result, the nurse said she decided to stay in the job. To cover her bills, she recently took a second full-time nursing job and now works from 7 p.m. to 7 a.m. six days a week.
“We’re trapped because we don’t have a choice because we don’t have money to pay them back,” said the New Jersey nurse, who asked that her name not be used because she worried about retaliation from her employer.
‘Good faith and reasonableness’
Kaye Mendoza had recently graduated from nursing school when she attended a recruiting fair in the Philippines at the suggestion of her aunt. After doing a brief interview she was offered a job on the spot and presented with a three-year contract for a job at a hospital in Harlem, which she said she signed despite not fully understanding what it said given English was her second language and she wasn’t familiar with American legal terms.
“All I knew about Harlem was the Harlem Globetrotters,” Mendoza said.
When she arrived in New York in 2006, she had been told by her recruiter that housing would be provided and her new job would start soon. Instead, she said there was no housing and it was four months before she was given a start date. With only $200 in savings and no income, Mendoza said she had to stay with relatives in New Jersey and Maryland while she waited. Another nurse with a child who arrived at the same time ended up staying in the home of the recruiter for months, Mendoza said.
Because of her difficult start in the U.S., Mendoza became an advocate for a growing number of Filipino nurses, dozens of whom have found her through a Facebook group for Filipino nurses, and have reached out to her for help with stories of abusive work environments and contracts they feel trapped in. Over the past several months she has been meeting with Filipino and U.S. officials to raise awareness about the issues she sees.
“I understand what everybody went through because I went through it, and this should stop,” said Mendoza. “But this is getting worse. I can see this getting worse rather than getting better.”
Not all hospitals and health care facilities have hiring practices for foreign nurses like those discussed here, said Virginia Alinsao, who worked as an international recruiter for Johns Hopkins Hospital — a nonprofit facility — until 2008, where she recruited about 300 nurses.
She is currently working as a contract recruiter for Henry Ford Health System in Michigan as it makes a push to fill hundreds of vacant jobs with foreign-trained nurses. Those nurses are employed directly by the hospital, not a staffing agency, and are paid the same as their American counterparts would be, she said.
The Henry Ford nurses are set up with furnished housing, training and a local network of other Filipino nurses they can connect with as soon as they arrive in the U.S., Alinsao said. She said she even makes sure her nurses have rice and a rice cooker when they first arrive at their assigned housing — a move that is meant to help them adjust to a new home with some familiar cuisine since rice is a staple of many Filipino dishes.
From the employer perspective, Alinsao said she thinks it’s fair to require nurses to repay their employer for the direct immigration costs, such as filing fees and examination fees that can total several thousand dollars, if they leave before a certain period of time. But she said the fees should be reasonable and not cover broad business expenses, indirect costs or lost profits that can range into the tens of thousands of dollars.
“I think it is fair to ask the nurse to pay for the direct expense to petition them because the employer spent money for them to come and then they get a green card and they can basically go anywhere. So I think it is fair to ask them to pay for at least the direct costs,” said Alinsao, who said those costs can total several thousand dollars for various filing fees.
Nursing and industry groups have tried to put voluntary guidelines in place on the recruiting process and raise awareness among nurses about questionable hiring practices. The Philippine Nurses Association of America has held webinars and put out a tip sheet for nurses and encourages them to use only recruiters licensed by the Filipino government.
The Alliance for Ethical International Recruitment Practices, a division of the nonprofit organization that accredits foreign-educated nurses seeking jobs in the U.S., has established voluntary guidelines for recruiters to follow and said about 60% of nurses coming to the U.S. go through a recruiter following its code. The American Association of International Healthcare Recruitment, the trade group that represents about half of recruiters, also has its own code of ethics and expels members who are found to have violated it.
“We believe international nurses should be treated with dignity,” James Richardson, a spokesperson for American Association of International Healthcare Recruitment, said in a statement. “Membership is conditional on adherence to a strict code of ethics administered by an independent review board.”
The group’s code says that its members will use “good faith and reasonableness in pursuit of breach fees,” and that contract breach fees shouldn’t be used for “punitive purposes.” It also says its members should use “reasonable efforts” to ensure workers are assigned to “work sites that are safe and that they can perform such work without harm to themselves or others.”
But neither group's guidelines prohibit the use of financial penalties for nurses who leave before the end of their contracts.
“The way immigration works to the United States with the employer sponsorship model means that there’s a lot of upfront costs that have to be borne to get someone here,” said Mukul Bakhshi, director of the Alliance for Ethical International Recruitment Practices. “There’s a fundamental economic model that essentially requires that even with what we call the ethical actors, they require people to work for them for a certain amount of time and pay breach fees in the tens of thousands of dollars if they leave early.”
In the case of CommuniCare, Bakhshi said the $16,000 fee wasn’t out of line with what other companies have included in their contracts to cover immigration costs. But he said the allegations by the nurses, if true, of an unsafe work environment and the seemingly punitive nature of the lawsuits appears to violate his organization’s code of ethics.
On the federal level, the employment of foreign-trained nurses largely falls in a regulatory gray area where multiple agencies oversee a piece of the process, but no one agency is tasked with complete oversight. The State Department has jurisdiction over the visa process, including when nurses are applying for green cards. But once in the country, the Labor Department has oversight for making sure labor laws aren’t violated.
A State Department spokesperson said that while it can’t comment on any pending litigation “it takes all allegations of forced labor, worker abuse and fraud seriously and works aggressively to ensure the integrity of U.S. visa adjudications and all consular services we provide worldwide.”
Acting Secretary of Labor Julie Su has taken some recent steps to crack down on alleged abuses. In March, the Labor Department filed a lawsuit in federal court against the staffing agency Advanced Care Staffing, alleging that the repayment provision in nurses’ contracts amounted to a form of kickbacks that would violate the Fair Labor Standards Act by bringing the hourly wages the employee earned under what was required by federal law.
The lawsuit alleges Advanced Care Staffing has forced nurses who tried to leave before their contract was up into private arbitration, requiring them to pay back tens of thousands of dollars in future profits the company was projected to earn from the employees as well the cost for the arbitration proceedings and attorneys fees.
Advanced Care Staffing didn’t respond to email and voicemail requests for comment.
Nurses have had some success in the courts. A judge ruled in 2019 that nursing home operator SentosaCare and a recruitment agency it used in the Philippines violated the Trafficking Victims Protection Act by threatening financial harm when it included a $25,000 liquidated damages penalty in the contracts for immigrant nurses and filed lawsuits against nurses for $250,000 for breaching their contracts. Sentosa argued in court that the $25,000 sum was a “liquidated damages provision,” not a penalty, and their efforts to collect the amount was within their contractual rights. The parties reached a $3.2 million settlement agreement in March 2022.
But that ruling and several others in nurses’ favor haven’t stopped dozens of other lawsuits against nurses in state courts across the country, said Kellam.
Vandenberg recently raised the issue during a congressional hearing over the reauthorization of the Trafficking Victims Protection Act and would like to see Congress or the Biden administration take steps to prohibit the use of contract penalties for workers being brought to the U.S. from overseas.
Among the struggles she has dealt with in the world of human trafficking, the labor practices involving immigrant nurses “feels eminently fixable” compared with the trafficking of people working on the black market, like sex workers, or other exploited workers.
“It feels like a little policy change could resolve these issues in the United States,” Vandenberg said. “It really would not take very much work to resolve this.”