Amanda Karomba’s family fled the 1994 genocide in Rwanda and immigrated to Maine when she was an infant. Three decades later, Karomba operates nearly 30 group homes in the Lewiston-Auburn area serving adults with intellectual and developmental disabilities, staffed primarily by people of color who are recent immigrants and identify as “New Mainers.”

Karomba’s organization, Happy Haven, is an example of the growing racial and ethnic diversity of Maine’s health care workforce.

Between 2014 and 2024, the number of Black, American Indian, Asian and Native Hawaiian or Pacific Islander employees across the health care sector increased 143 percent, while the number of White employees increased by less than half a percent, according to a Maine Monitor analysis of data from the state Department of Labor and U.S. Census Bureau. People of color — who made up about 4 percent of the workforce in 2014 — now make up 10 percent.

Experts and health care providers said this trend mirrors the state becoming more racially diverse, driven largely by an influx of new immigrants who often turn to health care as a way into the workforce, drawn by flexible hours and lower barriers to entry.

And it comes at a time when Maine is facing a severe shortage of health care workers — particularly direct care workers, who assist people with hands-on personal care like bathing, eating, housekeeping and managing medications.

“Without New Mainers, we wouldn’t be able to uphold our workforce,” Karomba said.

Karomba and her husband were working as direct support professionals caring for adults with intellectual and developmental disabilities when they decided they wanted to improve services for people with complex, high-risk behavior. The couple opened Happy Haven almost eight years ago, and now employ nearly 200 people, many of whom speak multiple languages. The Maine Department of Health and Human Services was very supportive of her work, Karomba said, providing technical assistance and translating regulations. 

While there are occasionally friction points between residents and staff of different cultural backgrounds, Karomba said she sees most of those as due to ignorance, and views them as an opportunity to bridge the divide between cultures.

“In talking to my colleagues around the country, Maine is actually doing more to support New Americans, whereas other states are just getting started,” she said.

Maine’s health care workforce remains overwhelmingly White, with 90 percent of the workers surveyed in 2024 identifying as “White Alone.” Workers The Monitor spoke to said it can be challenging to be a person of color working in one of the whitest states in the country, particularly as the Trump administration has de-emphasized diversity, equity and inclusion while pursuing stringent anti-immigration policies.

Health care system heading toward “collapse”

Emily Skyers’ dream of working in health care was first sparked while she was caring for her grandmother in Jamaica, who was diabetic and had high blood pressure. Skyers’ grandmother taught her to respect her elders; she was also raised in a tight-knit community, expected to greet older neighbors and ask if they needed help.

When she moved to Maine 2012, Skyers worked in hotels. Soon, however, she moved into health care, beginning with a job at a nursing home. She now works as a certified residential medication aide at an assisted living facility in Cape Elizabeth. Skyers said she is passionate about the work and doesn’t mind the long hours. 

“I am going to go whole-hearted in this work because you have a lot of residents that (are) really genuine to you,” she said. “You build a bond with them.”

Skyers has seen her industry struggle to find workers in recent years. She recalls one nursing home she worked at hiring 20 people in a month, none of whom ended up staying. Some, said Skyers, would show up for orientation and never return. Another came for three days to collect her check and never came back.

Maine’s health care industry has been struggling to fill positions at nearly every level. A Maine Hospital Association report released in March found that hospitals are actively recruiting for 4,227 budgeted positions, the majority of them full-time. Nurses and certified nurse assistants are in greatest demand, but there are challenges in every specialty, particularly as the state’s health care workforce ages.

Some of the largest gaps are in care for older adults, both in facilities and at home. A 2024 report estimated the state needs an additional 2,300 full-time care workers to meet demand for home care services. The Maine Center for Economic Policy report found 23,500 hours of approved home care for older adults are not fulfilled each week.

When DHHS unveiled new staffing requirements for assisted living facilities, there was an outcry from providers who said it was already impossible to find people to hire, taking months and sometimes years to fill positions. 

Meanwhile, demand for care is growing and the state’s health care workforce is aging. The number of Mainers over the age of 65 is projected to increase 36.2 percent by 2030, according to the Maine Office of the State Economist. 

“This demographic shift presents one of the most significant challenges we will face over the next five to ten years,” the Maine Hospital Association report noted.

Jess Maurer, executive director of the Maine Council on Aging, which advocates for older Mainers and those who care for them, said there is a lot of work being done at the state and industry level to address the workforce challenges. But if Maine doesn’t figure it out, Maurer said, the entire health system is heading towards “collapse.”

“We’re not making more people and our workforce shortage is just going to grow and we have more care needs,” she said. “We’re going to be in a world of hurt if we don’t figure this out: how to grow a seriously robust, diverse care workforce.”

MaineHealth, the state’s largest health system, said it has seen a “steady increase” year-over-year of employees identifying as Black, Indigenous or other people of color and last year non-White employees made up about 8 percent of its care team. 

Statewide, the number of health care employees identifying as Non-White has increased relatively steadily over the past decade, between 5 and 11 percent annually, before jumping 17 percent each year in 2023 and 2024, according to a Maine Monitor analysis of U.S. Census data.

Helene Kennedy, vice president of talent acquisition and workforce development for MaineHealth, said that while the primary driver is the state becoming more diverse, MaineHealth has also been intentional about expanding recruitment efforts to reach diverse workers, especially immigrant populations, as a necessary strategy given the severe workforce shortages. Other health administrators also told The Maine Monitor they actively recruit in diverse communities as part of their broader efforts to address severe workforce shortages.

State lawmakers are also looking into ways to reach new health care workers, and are currently considering bills that would create sponsorship programs for foreign-trained physicians to get their credentials in Maine and establish a medical training residency fund in rural and underserved communities.

They are also looking at legislation that would provide MaineCare reimbursement for nursing homes to provide English as a second language training for nonnative English speaking employees, costs for interpreter services and translations of written certified nursing assistant exams.

As Maine diversifies, so does health care

Experts attributed the diversification of the health care workforce in part to Maine’s demographic shift overall. While the state remains overwhelmingly white (91 percent of Mainers identified as “White alone” in the 2020 census, down from 95 percent a decade earlier), an influx of immigrants in recent years has started to shift the dynamic.

According to the 2023 American Community Survey 5-year estimate, about 4 percent of the state’s workforce — roughly 31,400 people — was foreign-born. And of those workers, about a third are in the health and education sector.

The Maine Department of Labor said it did not have a more detailed breakdown of the workforce by immigration status; other groups contacted by The Monitor said they also do not track the immigration status of workers.

As deaths have outpaced births in Maine in recent years, net migration into the state has contributed to sustained population and job growth, according to the Department of Labor. Nearly a fourth of the net migration to the state since 2020 was from international migration.

Jake McDonald, senior policy advocacy specialist with PHI, an organization that advocates on behalf of direct care workers, said direct care across the country has historically been racially diverse and primarily women of color. Maine had been an outlier as a primarily white state, so it’s not surprising, he said, that over time as the state diversifies, so does the health care sector. 

“Maine really fits into that same trend that we’re seeing elsewhere, and one reason we see that is that many immigrants have fewer options available to them and so they often get funneled into lower quality jobs that other folks don’t want to take,” McDonald said.

Mufalo Chitam, executive director of the Maine Immigrants’ Rights Coalition, said immigrants are drawn to the health care sector because of the flexible hours and round-the-clock nature of the job allows them to pick up additional shifts or work overnight, either as an additional job or after their kids go to bed. 

In addition, the work is “more technical than verbal,” Chitam said. As long as someone knows some English and knows how to care for their client or patient, they don’t need the same level of English that would be required at a job where they need to write emails or make phone calls, she said.

Patience Success Juwah noticed communication was less of a barrier for her working in health care. Her first job in Maine after moving from Nigeria in 2017 was as a customer service representative for a transportation company. She was drawn to Maine because it was a very welcoming state and a great place to raise children, but  said customers sometimes found her accent difficult to understand.

Communication became less of a problem when she got an entry-level position in health care, where language can be less of a barrier in certain jobs. Juwah now works as a certified residential medication aide for adults with disabilities, some of whom are nonverbal. She said the most important thing is to understand what they need, which might be communicated through body language.

“We have people from different countries living here in Maine and I feel like language, it’s not a barrier working in the health care system,” she said.

Juwah added that the hours in health care are helpful because she could work night shifts and be home during the day to avoid paying for childcare.

Miyabi Yamamoto, executive director of Portland Adult Education, said there’s been a shift in the demographics of their health care workforce training programs. The last few years they’ve had 20 to 25 CNAs-in-training, all of whom were foreign-born immigrants.

Several workers told The Monitor that their integration into the health care system had not been seamless, and that they had experienced friction and racist comments from colleagues and patients.

Emily Skyers, who works in assisted living, said a resident recently called her a racial slur. At a previous job, Skyers said she had a coworker who refused to be in the breakroom with any coworkers who were people of color and would not accept items they tried to hand to her. (A manager ended up intervening.)

Skyers said she tries not to take it personally when older residents say racist things because many have dementia. While it’s difficult, she handles it instead by stepping away. Racist comments from coworkers are much more offensive, she said. Skyers and others suggested that allowing workers to highlight their culture, food, music and language could create a more welcoming environment. 

Alison Chow Palm has worked as a travel nurse for nearly three years in at least five other states. She’s talked to other travel nurses who aren’t white who find it difficult to work in Maine and don’t want to stay.

She plays a game when she starts in a new place: How long will it take for someone to say something racist. In Mississippi, it took two months. In Northern Virginia, it took a month and a half. In Washington D.C., it took three weeks. In Washington State it took a day and a half. When she came back to Maine in 2023, it took eight hours.

As a nurse at Pen Bay Hospital, she said has experienced a range of racist encounters. A coworker greeted her with “Hi, Sandra Oh,” a Korean-Canadian actress. A patient threw a telephone at her and yelled, “Get out of my room, you Japanese (expletive).” A patient with dementia would shout “traitor” every time he saw her.

“It’s going to be pretty hard to recruit a solely white workforce with the demographic age shift we’re having here,” she said.

Racism doesn’t naturally take care of itself, said Yamamoto, of Portland Adult Education, and tackling it requires a thoughtful approach from dedicated leadership.

The de-emphasization of diversity, equity and inclusion  and the pursuit of stringent anti-immigration policies by the Trump administration has also emboldened some people to say hurtful things, said Chitam, of the Maine Immigrants’ Rights Coalition, including to those who are caring for them. And when the people providing the care are immigrants, they might hesitate to speak up about it out of fear of making themselves a target.

Ryan Polly, vice president of inclusion and leadership development with MaineHealth, said racism has been a problem during his 20-year career in health care.

“This is not a new trend but it is something that I think we in health care are getting more sophisticated in learning how to address,” he said.

MaineHealth partners with the Immigrant Welcome Center to reach New Mainers and provides support through language programs and translated training materials. Polly said MaineHealth also has policies in place for when an employee faces racism about how to address the discrimination in the moment and how to support the employee going forward.

“Diversity is important for good quality patient care,” Polly said. “We know that the more that our employees mirror our patients, the better outcomes our patients have.”

This story was originally published by The Maine Monitor, a nonprofit civic news organization. To get regular coverage from The Monitor, sign up for a free Monitor newsletter here.