According to recent news reports, the families of about 400 children with disabilities who are enrolled in Tennessee’s Children’s Special Services (CSS) program received notices from the state health department in early June stating that if their child continued to remain enrolled in CSS beyond June 30, 2026, their information would be reported to a central state immigration enforcement agency. However, following a lawsuit filed by physicians in the state, a judge issued a temporary restraining order on June 24, 2026, to prevent this data sharing from taking place. Tennessee is one of at least six states that have taken actions as of June 2026 to require state agencies to report applicants or recipients of Medicaid and/or other public benefits whose immigration status could not be verified and/or who were verified to not have lawful presence with immigration enforcement authorities. Under longstanding federal law, Medicaid and other federally funded health coverage are already limited to lawfully present immigrants.

In Tennessee, the legislation requires every state governmental entity, local governmental entity, and local health department to verify that each applicant who is 18 years of age or older and applies for a federal, state, or local public benefit is a United States citizen or lawfully present immigrant. It also requires these entities to report all identifying information for individuals who are not lawfully present and who receive federal, state, or local public benefits to the state’s centralized immigration enforcement division and makes it a criminal offense for an employee or official to intentionally fail to report an individual who is not lawfully present.

Tennessee has interpreted this law to include its CSS program, although Tennessee Representative Steve Cohen wrote a letter to Governor Bill Lee indicating that the law reads as limited to applicants who are at least 18 years old. Tennessee’s CSS program provides care coordination and payment assistance for certain services to people under age 21 whose family income is at or below 225% of the federal poverty level and who have a physical disability, such as cerebral palsy, cystic fibroses, sickle cell anemia or other serious medical conditions without immigrant eligibility restrictions. A recent report indicates more than 4,600 children in Tennessee are enrolled in CSS.

Health care providers and advocates in the state have warned that this data sharing will likely lead families to stop participating in the program, which could lead to disruptions in care that have life threatening consequences. Reporting requirements could also have “chilling effects” that lead to disenrollment and forgone enrollment among a broader group of families than those subject to the new reporting requirements due to confusion and fear. 

A 2025 national KFF survey shows that the share of immigrant adults who said they avoided applying for a government program that helps pay for food, housing, or health care in the past 12 months because they did not want to draw attention to their or a family member’s immigration status rose from 8% to 12% between 2023 and 2025. Further, 11% of immigrant adults say they have stopped participating in such a program since January 2025 because of immigration-related worries, including about four in ten (42%) of those who are likely undocumented and about one in six (17%) parents. Moreover, about half (51%) of immigrant adults overall and about eight in ten (78%) of those who are likely undocumented said they are “somewhat” or “very” concerned about health officials or providers sharing patient information with immigration enforcement officials (Figure 1). These data were collected prior to recent state-level actions to share data on immigrant families with immigration enforcement officials.

Beyond the data sharing actions in Tennessee and several other states, in July 2025, the Centers for Medicare and Medicaid Services (CMS) and U.S. Immigration and Customs Enforcement (ICE) established an Information Exchange Agreement that enables immigration enforcement officials to access the personal data of millions of Medicaid enrollees to help identify and locate “aliens in the United States.” This data sharing represents a reversal in prior policy that asserted CMS would not share such information and ICE would not use such information for immigration enforcement purposes, with assurances made to the public, applicants and enrollees, health care providers, and states that information collected to determine eligibility for health coverage programs would not be used for immigration enforcement. The administration also has directed the Internal Revenue Service to share personal information of individuals for immigration enforcement purposes, although these actions are facing court challenges.

On July 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will roll out a new, temporary program covering GLP-1s for obesity for people with Medicare. The program, known as the Medicare GLP-1 Bridge, provides coverage of GLP-1s used for weight reduction and weight management to eligible beneficiaries enrolled in Medicare Part D, although the program will operate outside of the Part D benefit and payment system. Under the Medicare GLP-1 Bridge, eligible beneficiaries can get Medicare coverage of GLP-1s for obesity for a $50 monthly copayment, which will not count towards the Part D deductible or out-of-pocket spending cap and Part D Low-Income Subsidy cost-sharing assistance will not apply. The temporary program, running from July 2026 through December 2027, does not change the current statutory prohibition on Medicare coverage of drugs used for weight loss but instead is being established using the federal government’s Section 402 demonstration authority.

The Medicare GLP-1 Bridge will provide coverage of three GLP-1s (Wegovy, Zepbound, and Foundayo) that have been approved by the FDA for chronic weight management in adults with obesity (BMI of 30 or more) or adults with overweight (BMI of 27 or more) plus a weight-related comorbid condition. The clinical criteria for determining eligibility for the Medicare GLP-1 Bridge are somewhat more restrictive than the FDA approvals, however, and include Part D enrollees with a BMI of 35 or more; with a BMI of 30 or more and heart failure with preserved ejection fraction, uncontrolled hypertension, or chronic kidney disease stage 3a or above; or with a BMI of 27 or more and pre-diabetes, previous myocardial infarction, previous stroke, or symptomatic peripheral artery disease.

Eligibility for the Medicare GLP-1 Bridge will also be limited to Medicare beneficiaries who have not filled a prescription under their Part D plan for a GLP-1 in 2026, and who do not have a diagnosis with a condition that is a medically accepted indication for a GLP-1 drug that could be covered under Part D (specified by CMS as type 2 diabetes, obstructive sleep apnea (OSA), and noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)), even if they otherwise meet the clinical criteria. These limits are designed to prevent GLP-1 use that could be covered under Part D from shifting to the Medicare GLP-1 Bridge and will also help to limit the cost of the program to Medicare. As part of the prior authorization process for Bridge, prescribing clinicians will need to attest that the GLP-1 prescription is for weight reduction and weight management and that beneficiaries meet the clinical criteria and do not have a diagnosis of type 2 diabetes, OSA, or MASH that would make them eligible for GLP-1 coverage under Part D.

CMS has not released an estimate of how many beneficiaries could be eligible for the Medicare GLP-1 Bridge, although the director of Medicare at CMS, Chris Klomp, recently stated the agency anticipates the program will start with “single-digit millions” of beneficiaries. This analysis uses 2023 Medicare claims for traditional Medicare, Medicare Advantage encounter data, and Part D prescription drug event data to estimate the total number of Medicare beneficiaries with obesity or overweight, the number of Part D enrollees who met the Bridge eligibility criteria in 2023, and those who met the Bridge clinical criteria but who also had diagnoses recorded in claims or encounter data that would qualify for Part D coverage of GLP-1s (type 2 diabetes, OSA, or MASH) or who had a GLP-1 Part D-covered prescription during the year, either of which would make them ineligible for Bridge (see Methods).

More than 13 million Medicare beneficiaries met the BMI thresholds for obesity or overweight in 2023, but not all are potentially eligible for the Medicare GLP-1 Bridge. In 2023, an estimated 13.3 million Medicare beneficiaries enrolled in Parts A and B had obesity or overweight, based on having BMI of 27 or more recorded in claims or encounter data, or 24% of Medicare beneficiaries overall (Figure 1). (This estimate could be conservative to the extent that not all beneficiaries with obesity or overweight may have a claims-based diagnosis.) However, the potentially eligible population for the Medicare GLP-1 Bridge is not as broad as if the program were targeted to all people with Medicare with obesity or overweight. As detailed below, an estimated 3.8 million beneficiaries could be eligible for Bridge as of 2023, based on meeting all the eligibility criteria.

Among the 47.5 million Medicare Part D enrollees in 2023, 9.7 million enrollees met the clinical criteria for the Medicare GLP-1 Bridge in 2023, but less than half of this group—3.8 million (39%)—is estimated to be eligible for Bridge (Figure 2, Table 1). These 3.8 million Part D enrollees met the clinical criteria, did not have a diagnosis of type 2 diabetes, OSA, or MASH, or a GLP-1 Part D-covered prescription in 2023, and could be eligible for the Medicare GLP-1 Bridge, assuming no changes in diagnosis or GLP-1 use in Part D in 2026. This estimate, which includes Part D enrollees in traditional Medicare and Medicare Advantage, represents 8% of Medicare Part D enrollees and 7% of the total population enrolled in Medicare Part A and Part B for the entire year in 2023. The other 5.9 million Part D enrollees met the clinical criteria but also had claims or encounter data recording a diagnosis of type 2 diabetes, OSA, or MASH, and/or had a GLP-1 Part D-covered prescription, either of which would make them ineligible for Bridge.

The total cost to the federal government of the Medicare GLP-1 Bridge will depend in part on how many beneficiaries are eligible in 2026 and 2027, what share of them participate, how quickly they initiate use under the program after it begins, and how many prescriptions each participating beneficiary fills during the 18-month period. While take-up is uncertain, interest in the program among potentially eligible Medicare beneficiaries is likely to be strong. Based on the estimated 3.8 million Part D enrollees eligible for the Medicare GLP-1 Bridge as of 2023, if 10% to 25% participate in Bridge from when the program launches in July 2026 and fill a prescription each month for the 18-month duration of the program, the cost to Medicare would be $1.3 billion to $3.3 billion (at a net monthly cost of $245 minus the $50 beneficiary copay). Assuming higher participation rates ranging from 50% to 75%, the cost to Medicare would be between $6.7 billion and $10 billion. The ultimate cost to the federal government of the Medicare GLP-1 Bridge will depend on actual participation numbers and adherence during the 18-month program, as well as potential cost offsets from savings that might accrue over time due to beneficiary health improvements from GLP-1 use for weight reduction and weight management.

On June 9, 2026, the Medicare Trustees issued the annual report on the financial status of the Medicare program for 2026. The Trustees highlighted that the Medicare Part A trust fund is projected to be depleted in 2033, the same year but one quarter earlier than last year’s projection. In addition to discussing the status of the Part A trust fund, the report also provides substantial additional details on federal spending for Medicare Part B and Part D benefits, the distribution of spending for traditional Medicare and Medicare Advantage, and revenue sources for Medicare, along with updated spending and revenue projections and a detailed discussion of factors that have contributed to changes in the program’s financial outlook. This brief provides an overview of key trends in Medicare spending and spending growth, as well as the impact of these trends on out-of-pocket costs for Medicare beneficiaries and Medicare program solvency, as projected by the Medicare Trustees.

Physician Services and Other Outpatient Services Account for Roughly Half of Total Medicare Benefits Spending

In 2025, Medicare benefit payments totaled $1.2 trillion, up from $666 billion a decade earlier (Figure 1). Spending on Part B services (including physician services, outpatient services, and physician-administered drugs) accounts for the largest share of Medicare benefit spending (48% in 2025), as it has since 2015. In contrast, spending on Part A services (including inpatient hospital services, skilled nursing facility services, and hospice care) has declined as a share of Medicare benefit spending (from 43% in 2016 to 37% in 2025). Over time, this decline has been driven in part by a shift of some services from inpatient to outpatient settings reflecting changes in practice patterns, along with increases in spending on services covered under Part B, including high-cost physician-administered drugs. Spending on Part D prescription drugs has accounted for a relatively constant share of Medicare benefit spending for much of the past decade (12-13%) but rose to 15% in 2025 and is projected to continue growing in the coming years.

Spending on Part A and Part B Benefits in Traditional Medicare Was $481 Billion in 2025

Looking at spending by type of service in traditional Medicare, the single largest category of benefit spending in 2025 was for inpatient hospital services covered under Part A (spending by type of service for Medicare Advantage enrollees is unavailable). Although a relatively small share of beneficiaries use inpatient hospital services, these services accounted for roughly one-third of total benefit spending in traditional Medicare ($159 billion or 33%), followed by outpatient hospital services covered under Part B ($76 billion or 16%) (Figure 2). This means that combined spending on hospital services (both inpatient and outpatient) accounted for nearly half of spending on Part A and Part B benefits in traditional Medicare in 2025. Services covered under the Medicare Part B physician fee schedule accounted for $71 billion (15%), and the remaining $174 billion (36%) consisted of payments for all other Part A and Part B services, including physician-administered drugs (8%), skilled nursing facility services (6%), and hospice care (6%), among others.

Spending on the Medicare Part D Prescription Drug Benefit is Projected to be Significantly Higher Over the Coming Decade Compared to Last Year’s Projections

The Medicare Trustees currently project that Medicare Part D spending will nearly double from 2025 ($181 billion) to 2035 ($346 billion), representing an average annual growth rate of 6.7% compared to the 4.8% that was projected for a similar period last year (Figure 3). The Trustees indicate that higher spending projections for Part D in the 2026 report are due to increased use of GLP-1s and other high-cost specialty drugs. The Trustees also point to other factors that have contributed to changes in Part D spending in recent years, including the pharmacy price concessions policy that lowers point-of-sale prices for beneficiaries but reduces rebate revenue to Part D plans, which leads to higher federal Part D spending; the exemption of more orphan drugs from drug price negotiation in the 2025 budget reconciliation bill (H.R. 1), which will lower federal savings from negotiation; and the redesigned Part D benefit that improved the generosity of coverage while shifting more liability onto plans and increased the level of federal subsidies for coverage. These higher spending trends are offset somewhat by the effect of drug price negotiations and inflation rebates established by the Inflation Reduction Act.

Spending on Medicare Advantage was $534 Billion in 2025, Over Half (53%) of Total Medicare Program Spending

Payments to Medicare Advantage plans under Medicare Part A and Part B nearly tripled as a share of total Part A and Part B spending between 2016 and 2025 (from $189 billion to $534 billion), including payments for the cost of Part A and Part B services, as well as rebates, which must be used to reduce cost sharing, pay for extra benefits, or buy down the Part B and/or Part D premium (Figure 4). This growth is partly due to increased enrollment in Medicare Advantage plans, which rose from 33% to 54% of all eligible beneficiaries over this same period. At the same time, Medicare pays an estimated 14% more per enrollee in Medicare Advantage than it would if the same beneficiary were covered by traditional Medicare, resulting in $76 billion in additional Medicare spending in 2026. Those higher payments largely reflect the impact of higher coding intensity and favorable selection into Medicare Advantage. Growth in Medicare Advantage spending is projected to continue into the next decade, with payments to Medicare Advantage plans under for Part A and B benefits projected to increase to $1.3 trillion in 2035, or 59% of total Part A and Part B spending.

The Medicare Part A Trust Fund is Projected to be Depleted in 2033, Seven Years from Now

The depletion of the reserves in the Medicare Hospital Insurance (Part A) trust fund, which pays for inpatient hospital, skilled nursing facility, home health, and other Part A services, is projected to occur in the second quarter of 2033, based on the latest projections from the Medicare Trustees (Figure 5). This is one quarter earlier than the projection in last year’s report. According to the Medicare Trustees, the earlier depletion date is primarily the result of updated estimates of Social Security tax revenue (one source of Part A funding) that are lower than previously projected due to changes in the 2025 budget reconciliation bill (H.R. 1). If the reserves in the Part A trust fund are fully depleted, Medicare would not have sufficient funds to cover Part A benefit spending for the full year without additional revenues or reductions in spending on benefits or payments to providers.

Projected Increases in Medicare Spending Will Lead to Higher Medicare Premiums and Cost-Sharing Requirements

Medicare’s premium and cost-sharing requirements are determined annually based on expected growth in Medicare benefit costs for the coming year (though the exact approach to determining these amounts is different in each part). For 2027, the Trustees project that the monthly Part B premium will increase from $203 to $210 (3.3%), after increasing from $185 to $203 between 2025 and 2026 (9.7%). Likewise, the Part A hospital deductible is projected to increase from $1,736 to $1,788, and the Part D deductible from $283 to $292 in 2027. Further increases are estimated for the duration of the 10-year projection period in the 2026 Trustees report (Figure 6). These amounts may not reflect the costs that all beneficiaries face, particularly enrollees in Medicare Advantage plans, where cost sharing is generally different from the standard cost-sharing requirements for traditional Medicare beneficiaries. In 2024, seven million Medicare beneficiaries spent more than 10% of their income on the Part B premium alone. Increases in Medicare premiums and other out-of-pocket costs may represent a growing burden for many beneficiaries if income growth does not keep pace.

On June 1, 2026, the Centers for Medicare and Medicaid Services (CMS) issued a long-anticipated interim final rule that will guide state implementation of Medicaid work requirements. The 2025 reconciliation law requires 44 states to condition Medicaid eligibility for adults in the Affordable Care Act (ACA) Medicaid expansion group and enrollees in certain waiver programs, including in non-expansion states (Georgia, Tennessee, and Wisconsin), on meeting work requirements starting January 1, 2027, or sooner at state option. The law specifies mandatory exemptions, including individuals who are “medically frail.” Given the abbreviated implementation timeline, states had tentatively moved forward with key decisions over how to implement the medical frailty exemption even as they waited for formal guidance from CMS.

Significantly, the rule adopts a restrictive definition of medical frailty that differs from states’ early expectations and ties medical frailty to an individual’s ability to meet the community engagement requirements, including work or volunteer activities. The 2025 law specifies the medically frail exemption includes five categories of individuals who: are blind or disabled; have a physical, intellectual, or developmental disability that limits their ability to perform one or more activities of daily living (ADL); have a substance use disorder; have a “disabling” mental disorder; or have a “serious or complex” medical condition. The new rule requires states to consider not just whether the individual falls into one of the five categories described in the statute, but also whether the individual’s condition impairs their ability to engage in community engagement activities (including but not limited to work). States will likely need to pivot from earlier implementation plans and approaches to accommodate the new guidance.

States were already facing challenges in preparing to implement complex new requirements by January 1, 2027 and the provisions in the rule will amplify operational challenges, with added risks for states due to the potential for audits and financial penalties. The rule also may increase barriers for individuals to obtaining and maintaining coverage, leading to more people falling through the cracks and becoming uninsured. In addition, more complicated definitions of medical frailty may be difficult for states to explain as they conduct outreach with enrollees and potential applicants. This brief describes the new guidance and potential challenges states will face in operationalizing this exemption.

How Does the Interim Final Rule Define Medical Frailty?

For all categories of medical frailty, states are expected to develop a list of diagnosis and other codes to identify people who could potentially qualify for the exemption. States will be required to create lists of conditions that could potentially qualify someone as medically frail (generally in the form of health care code sets), which they must revise on a regular basis to reflect implementation experiences. CMS notes that the lists states use will be auditable, and if states are found to have determined an individual to be medically frail with little to no support for the conclusion that their physical, mental, or other behavioral health condition significantly impairs their ability to comply with the community engagement requirement, states would not be in compliance with the regulation and could be subject to financial penalties.

The rule relies heavily on existing definitions for the five medically frail categories and generally provides little additional clarification to help states develop the list of conditions for each category. In the rule, CMS said it did not believe it would be appropriate to include an exhaustive list of conditions in regulation, although they did provide examples of conditions across the various categories that could reasonably be expected to cause an individual to be medically frail. The rule acknowledges multiple existing definitions for several categories and ultimately defers to states the exact process of capturing individuals in these groups, explaining it “would be incredibly difficult to set one standard.” Notable details in the new rule include:

• In the case of individuals with an SUD, the rule clarifies that the medical frailty category applies regardless of whether they are in an active treatment program but does not include individuals who have been in active recovery for 5 or more years.
• For those with a serious or complex medical condition, the rule provides a new definition that requires a severe level of acuity for a condition to be considered serious or complex, which stands in contrast to other conceptions of “serious or complex” medical conditions that include individuals for whom maintaining access to health coverage is necessary to protect against serious health consequences if treatment is interrupted.

For all five categories, the rule makes clear that states must consider both if an individual’s condition meets the medical frailty definition and also if it significantly impairs their ability to work or engage in qualifying activities (Figure 1).

How Does the CMS Guidance Direct States to Verify Medical Frailty?

States are required to use claims and encounter data from the preceding 12 months to verify medical frailty status before requesting information from the individual; however, it will be difficult to use claims data alone to verify an individual’s ability to work. To ease the burden on individuals, the law directs states to use available information “where possible” to verify compliance with Medicaid work activities or exemption status, without requiring additional documentation from individuals. States are required to use claims or encounter data from the preceding 12 months as a data source. States are told they cannot consider information older than 12 months as this information “may not reflect the individual’s current condition.” The rule also encourages states to incorporate concise, plain language screening questions for use at application and renewal to identify individuals who may be medically frail. The rule is explicit that diagnosis alone cannot be used to verify medical frailty (because states must also consider whether an individual is sufficiently impaired from being able to work), limiting the ability of states to verify medical frailty on an ex parte (i.e., automatic) basis.

The rule does not provide details on criteria states should use for measuring severity of conditions or ability to meet new requirements. The rule only provides high-level examples of processes states may adopt to verify that an individual’s condition impairs their ability to work, such as algorithms that use administrative claims data to assign acuity scores, or using lists of qualifying diagnosis codes combined with utilization and other data. States may need to use combinations of data such as utilization data (e.g., hospitalizations), prescription drug data, and durable medical equipment (DME) prescription data. These approaches require states to implement even more complicated systems changes within the next six months that they were not anticipating based on earlier informal guidance. In addition, while these examples suggest states may be able to use acuity as a proxy for an individual’s ability to work, the rule is not clear on how states are expected to make these determinations. With the potential for audit, states may struggle to operationalize the medical frailty exemption in a way that protects them from financial penalty and minimizes administrative burden, without denying coverage to individuals who should qualify for the exemption.

Data limitations make it likely that medical frailty determinations will not be automated for many individuals. Examples of limitations include lack of data on file for new applicants and recent enrollees, or providers not consistently coding conditions or not using codes identified by the state. Certain individuals, such as those with functional limitations or behavioral health conditions, may also be more difficult to identify using claims data. States are also not provided with clear guidance on how to assess whether an individual is able to work or engage in community engagement activities, including what type of work activities states must consider. The more individualized the required assessment is, the more difficult it will be for states to auto-exempt individuals using data.

While states may need to rely on confirmation from treating providers to verify medical frailty conditions and ability to participate in community engagement activities, the rule offers little information on what information states need to collect from providers. States choosing to accept provider documentation are told that lists of who they choose to be allowable practitioner types must be shared with CMS if requested as part of oversight and data monitoring activities. Relying on provider confirmation could increase administrative burden (on the clinical workforce, individuals, and states), particularly for providers that treat large shares of Medicaid patients. Relying on providers or eligibility workers to determine whether an individual is able to work will likely require a subjective decision and could raise ethical concerns among providers. New Hampshire had previously implemented work requirements with a requirement that individuals needed to be deemed unable to work by providers to qualify for an exemption; enrollees with physical and behavioral health problems struggled when applying for exemptions, often because primary care providers resisted signing forms declaring that their patients were unable to work. Research also shows that physician attitudes to assisting patients who request exemptions from work requirements can vary substantially. In addition, because providers receive Medicaid payments and, therefore, have an interest in their patients maintaining health coverage, requesting information from them to confirm a medical frailty exemption could raise conflict of interest issues.

While states are permitted to use self-attestation to verify medical frailty, the rule limits reliance on self-attestation starting in January 2028. Given the limitations of existing data sources and the difficulty of identifying whether an individual is medically frail, accepting self-attestation of medical status or ability to work could relieve the administrative burden for states as well as applicants and enrollees. Acknowledging data limitations states face particularly for new applicants, the rule allows states to accept self-attestation throughout 2027 in cases where there is no reliable information available to the state. However, starting January 1, 2028, states may only accept self-attestation of medical frailty status one time during an individual’s enrollment period. States would then be expected to verify individuals using available data or require documentation or other information from individuals for future renewals.

The rule requires states to verify medically frail exemption status at least every 12 months. States must reverify medical frailty even for people whose health condition or disability status is unlikely to change every 12 months; however, the rule gives states the option to reverify medical frailty more frequently (such as at each 6-month renewal period). For states that elect to verify compliance between regular renewals (e.g., quarterly), the rule specifies that individuals identified as specified excluded individuals during their most recent verification, including those who meet medical frailty exemptions, are not subject to more frequent verifications.

Introduction

The Trump administration has made policy changes to restrict immigration into the U.S., including efforts to end Temporary Protected Status (TPS) designations for many countries, pauses and restrictions on the issuance of new visas, and significantly increased immigration enforcement. These actions could have negative implications for the U.S. workforce, which includes significant shares of immigrant workers, particularly in certain industries including health care. Immigrant workers include naturalized citizens as well as noncitizens, including lawfully present and undocumented immigrants.

This issue brief provides data on immigrants’ role in the U.S. workforce, including in health care and other key industries, based on KFF analysis of Current Population Survey (CPS) basic monthly data and American Community Survey (ACS) one-year data for U.S. workers 18 years and older by citizenship status. Key takeaways from this analysis include:

While the total number of immigrant workers in the U.S. held largely steady between January 2025 and April 2026, the number of noncitizen immigrant workers declined by about 600,000, or 4%, from 15.4 million to 14.8 million. This was offset by an increase in the number of naturalized citizen workers of over 800,000, or about 6%, from about 15.2 to 16.0 million. The number of U.S.-born workers increased by about 1% between January 2025 and April 2026 (125.6 to 126.7 million). Within the health care industry, there was an overall increase of 1% or about 130,000 workers from 19.4 to 19.6 million, which reflected increases among U.S-born (16.0 to 16.1 million) and noncitizen immigrant workers (961,000 to 1.2 million) that offset a decline among naturalized citizen workers (2.5 million to 2.3 million).

Immigrants accounted for about one in five (19%) or close to 31 million of the total U.S. workforce as of 2024. Within health care, immigrants accounted for 17% of the workforce, including 28% of physicians and surgeons and 30% of direct care workers in long-term settings. In hospitals, immigrants accounted for similar shares of clinical staff and non-clinical staff and played a particularly large role as physicians and surgeons (30%). Top countries of origin for immigrant health care industry workers include Philippines (12%), Mexico (11%) and India (7%). In hospitals, immigrants also play an outsized role in certain non-clinical occupations, including building cleaning and maintenance workers (29%). Immigrants, particularly noncitizen immigrants, also accounted for disproportionate shares of agriculture (33%); construction (26%); and food services, maintenance, and personal care service workers (23%).

Continued reductions in the number of immigrants could impact the U.S. economy and key industries, especially as the 65 and older population in the U.S. grows and there are fewer replacement workers available. Reduced immigrant participation in the health care workforce, including the long-term care workforce, could exacerbate existing worker shortages and negatively impact the health and well-being of Americans.

Recent Trends in the Immigrant Workforce

While the total number of immigrant workers in the U.S. held largely steady between January 2025 and April 2026, the number of noncitizen immigrant workers declined by about 600,000 or 4% from 15.4 million to 14.8 million. This was offset by an increase in the number of naturalized citizen workers of over 800,000, or about 6%, from about 15.2 to 16.0 million. The number of U.S.-born workers increased by about 1% between January 2025 and April 2026 (125.6 to 126.7 million). Within the health care industry, there was an overall increase of 1% or about 130,000 workers from 19.4 to 19.6 million, which reflected increases among U.S-born (16.0 to 16.1 million) and noncitizen immigrant workers (961,000 to 1.2 million) that offset a decline among naturalized citizen workers (2.5 million to 2.3 million).

Immigrants’ Role in the U.S. Health Care Workforce

Changes in the immigrant workforce may have important implications given the role that immigrants play, particularly in certain industries including health care.

Immigrants account for about one in five workers in the U.S. As of 2024, immigrants accounted for about 19%, or close to 31 million, of the total U.S. workforce over age 18 based on KFF analysis of ACS data. Naturalized citizens accounted for roughly 10% of workers and noncitizen immigrants accounted for another 9% of total workers.

Within health care, immigrants make up about one in six workers overall and account for even larger shares of physicians and surgeons and direct care workers in long-term settings. Immigrants accounted for 17%, or about 3.3 million, of the health care workforce overall and about three in ten physicians and surgeons (28%) and direct care workers in long-term care settings (30%) (Figure 2). Among physicians and surgeons, 22% were naturalized citizens and 7% were noncitizen immigrants. Among direct long-term care workers, 18% were naturalized citizens and 12% were noncitizen immigrants.

Three in ten immigrant health care workers are from Philippines (12%), Mexico (11%) or India (7%) (Figure 3).  China, Jamaica, Cuba, and Haiti contribute another 4% each of immigrant health care workers. Among immigrant physicians and surgeons, one in five (21%) are from India, 6% from China, 5% each from Canada and Pakistan, and 4% are from Philippines. Among immigrant direct long-term care workers, one in seven (14%) are from Mexico, 7% each are from Dominican Republic and Philippines, and 6% each are from Jamaica, China, and Haiti.

In hospitals, immigrants accounted for one in six (17%), or about 1.4 million, workers as of 2024. This includes 12% of hospital workers who are naturalized citizens and 5% who are noncitizen immigrants (Figure 4). Immigrants made up similar shares of clinical (17%) and non-clinical (15%) workers in U.S. hospitals. Clinical workers include physicians, surgeons, nurses, etc., and non-clinical workers include office workers, food service workers, cleaning and maintenance workers, and other non-clinical workers. Among immigrant hospital workers, 16% are from Philippines, 9% are from Mexico, 8% are from India, and 4% each are from China and Jamaica.

Within hospitals, immigrants made up three in ten (30%) physicians (Figure 5). This includes over one in five (21%) who are naturalized citizens and another 9% who are noncitizen immigrants. Immigrants also made up over one in five (22%) nursing assistants, about one in six registered nurses (17%), and about one in seven technicians (15%) and nurse practitioners and midwives (14%) at U.S. hospitals. Immigrants also play an outsized role in certain non-clinical occupations in hospitals, such as building cleaning and maintenance workers.

Immigrants, particularly noncitizen immigrants, also play an outsized role in other key industries including agriculture, construction, and service. As of 2024, immigrants made up one in three (33%) agricultural workers, of whom 26% were noncitizen immigrants and 7% were naturalized citizens; about a quarter of (26%) construction workers, of whom 18% were noncitizen immigrants and 8% were naturalized citizens; and about a quarter (23%) of food services, maintenance, and personal care service workers, of whom 14% were noncitizen immigrants and 9% were naturalized citizens (Figure 6).

Methods

Data sources: This brief is based on KFF analysis of federal survey data, namely the Basic Monthly Current Population Survey (CPS) and the American Community Survey 1-year Public Use Microdata Sample. These surveys are nationally representative household surveys conducted by the U.S. Census Bureau. While Basic Monthly CPS data are available on a monthly basis, ACS PUMS data are available on a yearly basis. Basic Monthly CPS data have a significantly smaller sample size than yearly ACS and yearly CPS data. Due to the smaller sample size, results may be more sensitive to potential decreases in survey participation among immigrants due to immigration-related fears.

Identifying citizenship status: Naturalized citizens are those who indicate becoming a U.S. citizen by naturalization; and noncitizen immigrants are those who say that they are not a U.S. citizen. Noncitizen immigrants include lawfully present and undocumented immigrants.

Identifying workers across different industries: Health care, agriculture, construction, and service workers are identified as individuals 18 years of age or older who report working either full-time or part-time in one of the aforementioned industries and who earned at least $1,000 during the year. Industries are classified based on Census codes that correspond with the North American Industry Classification System (NAICS). Codes 0170 through 0290 correspond to the agriculture industry; 0770 corresponds to the construction industry; 7970 through 8290 correspond to the health care industry; and 8680 through 9070 correspond to the food services, maintenance, and personal care services industries.

Identifying hospital and direct long-term care workers: Hospital workers are individuals 18 years or older who report working either full-time or part-time and indicate that their job was at a general medical or surgical hospital or a psychiatric or substance use hospital and who earned at least $1,000 during the year. Direct long-term care workers are individuals 18 years or older who report working either full-time or part-time, earned at least $1,000 during the year, and whose occupation is home health aide, personal care aide, or nursing assistant and who indicate working in home health care, nursing care facilities, residential care facilities, or individual and family services.