Introduction

Immigrants, including those on H-1B visas, make significant contributions to the U.S. health care workforce and help to increase its capacity. H-1B workers are foreign workers with temporary approval to work in the U.S. in jobs that require specialized skills or knowledge. The Trump administration has implemented policies that will likely reduce the supply of H-1B workers, including a $100,000 entry fee for new H-1B visas as well as enhanced vetting and “online presence” reviews for all H-1B and H-4 (dependent) visa applications that have led to significant delays in visa processing.

This issue brief provides an overview of the H-1B visa program, analyzes trends in H-1B visa approvals for the health care and social assistance industries using data from the U.S. Citizenship and Immigration Services (USCIS) H-1B Employer Data Hub for fiscal years (FY) 2022-2025, and discusses potential implications of recent policies impacting the H-1B program on the U.S. health care workforce.

The analysis shows that H-1B workers have comprised an increasing role in the health care and social assistance industries in recent years with new and continuing H-1B visa approvals for the health care and social assistance industries rising by 8% between FY 2022 and 2025. As such, reductions in the H-1B workforce would likely lead to gaps in the industries and exacerbate existing health care worker shortages, including in the rural physician workforce.

Background

The H-1B visa program helps supply high-skilled workers to the U.S. workforce, including the U.S. physician workforce, particularly in lower income areas as well as within research universities and university-affiliated medical centers. The H-1B program allows U.S. employers to temporarily employ foreign workers for jobs that require specialized skills or knowledge. According to the American Hospital Association, physicians account for almost half of approved H-1B visas for medical and health occupations. Research further finds counties with the highest poverty levels had a higher percentage of H-1B-sponsored physicians and other health care workers compared to those with the lowest poverty levels (2.0% vs. 0.5%) and that rural counties similarly had a higher share of H-1B physicians and other health care workers than urban counties (1.6% vs. 1.0%). Research universities and university-affiliated medical centers are some of the largest employers of H-1B health care and social assistance workers. In FY 2025, the top three employers of workers with H-1B health care and social assistance visa approvals included Cleveland Clinic in Ohio, St. Jude Children’s Research Hospital in Tennessee, and Memorial Sloan Kettering Cancer Center in New York.

The number of new H-1B visas is capped at 65,000 each year with an additional 20,000 visas for those with a U.S. master’s degree or higher, although the cap is typically exceeded via exemptions. The H-1B visa cap of 65,000 was first established in 1990 under the Immigration Act of 1990, although it was temporarily increased from FY 1990-2000 as well as FY 2001-2003 by Congress. In FY 2004, the cap reverted to 65,000, with an additional 20,000 new visas reserved for those with a U.S. master’s degree or higher and has stayed the same since. However, the number of new H-1B visas granted each year generally exceeds the annual cap of 85,000 because of cap exemptions. For example, institutions of higher education, government research organizations, and certain nonprofits are exempt from the annual cap.

The Trump administration has implemented changes that are expected to reduce the number of H-1B workers in the U.S. These changes include a Proclamation issued on September 19, 2025, under which new H-1B visa petitions by employers must be accompanied by a $100,000 entry fee, a move that is being legally challenged by 20 states on the basis that it violates the Administrative Procedure Act. The Department of Labor launched Project Firewall in September 2025, which has led to an increase in random site visits and stricter scrutiny of third-party worksites in an effort to root out H-1B “fraud and abuse.” Additionally, the U.S. Department of State began enhanced vetting and “online presence” reviews of all H-1B and H-4 (dependent) visa applications starting December 15, 2025, which has led to significant delays and cancellations of visa interviews, leading to many H-1B workers getting stuck abroad.

Recent Trends in H-1B Visa Approvals

Based on KFF analysis of data from USCIS, new and continuing H-1B visas for the health care and social assistance industries increased by over 8% from just under 18,000 in FY 2022 to over 19,000 in FY 2025 (Figure 1). The Bureau of Labor Statistics defines the health care and social assistance industries as establishments that provide health and medical care, as well as those that provide social assistance. Examples of such establishments include but are not limited to hospitals, clinics, nursing homes, medical laboratories, home health agencies, and social service centers. In contrast, the total number of new and continuing H-1B visas across other industries fell by 9% from over 420,000 in FY 2022 to about 390,000 in FY 2025.

H-1B workers play a particularly significant role in the health care and social assistance industries in certain states. NY (14%), MA (9%), CA (8%), PA (6%), and OH, TN, and FL (5% each) accounted for over half (52%) of new and continuing H1-B visas for the health care and social assistance industries approved in FY 2025 (Figure 2). These states are home to large research universities and medical centers, which, as noted, are some of the biggest employers of H-1B workers in the health care and social assistance industries.

Implications

These data suggest that H-1B workers have played an increasingly large role in the health care and social assistance industries in recent years, suggesting that reductions in the supply of H-1B workers could leave gaps that exacerbate health care worker shortages. Recent actions by the Trump administration are anticipated to reduce the number of H-1B workers in the U.S., including the new $100,000 entry fee as well as “online presence” reviews for H-1B visa applications. A decline in the supply of H-1B workers in the health care and social assistance industries could disproportionately impact states that employ the largest numbers of H-1B workers, lower income and rural areas where H-1B health care workers often are employed, and smaller employers who would face greater challenges paying the new $100,000 fee. Research universities and university-affiliated medical centers, which are some of the largest employers of H-1B health care workers, also are likely to be disproportionately impacted at a time when they are already facing broader funding cuts. The resulting shortages in the health care workforce are likely to increase barriers to accessing health care, potentially affecting the health and well-being of the population over the long term.

These actions to reduce the number of H-1B workers come against a backdrop of increased immigration enforcement as well as other restrictions on lawful immigration into the U.S. These efforts have reduced the flow of immigrants into the country and have increased fears among immigrants already here. Researchers project that restrictive policies undertaken by the Trump administration could reduce legal immigration into the U.S. by 33% to 50% over four years as compared to FY 2023 levels. Broad reductions in immigrants could particularly affect the health care workforce given the significant role they play as hospital physicians, nurses, as well as direct long-term care workers. These reductions may be compounded by a projected decline in the U.S.-born labor force over the next few decades due to an increase in the share of the U.S.-born population that is over 65 years of age and therefore less likely to participate in the workforce.

2026 marks the first year since 2020 that enrollees in the Affordable Care Act Marketplaces do not have access to enhanced premium tax credits. The effect of the expiration on how many people will use ACA Marketplace coverage remains unclear.

New data released by CMS on plan selections show that ACA sign-ups for 2026 are down by over 1 million people compared to the same time last year, marking the first year since 2020 that sign-ups appear to have declined. A more detailed Health Insurance Exchanges Open Enrollment Report is expected in March or April that will detail demographics, income, and metal levels for people who select or are automatically renewed into a plan. Plan selection data is unable to fully capture the effects of the enhanced tax credits expiring on the number of people with coverage. As some people end up not making their premium payments, actual enrollment—known as “effectuated” enrollment—will inevitably decline. With the expiration of enhanced premium tax credits, premium payments are estimated to have increased 114%, on average, for subsidized enrollees who stay in the same plan. With such steep increases, it is not yet clear how many people who have selected a plan during Open Enrollment will make a payment. 

This brief explains the limitations of early data in understanding the impact of the expiration of enhanced premiums tax credit on ACA enrollment. It also provides a timeline of when more complete data will become available. The bottom line is that it will be quite a while before we get a complete picture of how much enrollment has dropped following expiration of the enhanced premium tax credits.

What are the limitations of plan selection data?

Plan selection (or “sign-up”) data does not accurately reflect the number of people who ultimately have ACA Marketplace coverage because it does not account for premium payments. In other words, it shows how many people have selected a plan or been automatically renewed into ACA coverage, but it does not show how many people actually gain or maintain coverage.

New enrollees are generally required to submit their first premium payment (“binder” payment) within 30 days of the coverage effective date, thus “effectuating,” or beginning, their coverage. Returning subsidized customers, however, are generally given a 3-month grace period for nonpayment of premiums. This means that these returning consumers would then have until March 31, 2026, to catch up on premium payments before their coverage is retroactively terminated. The impact of enhanced subsidies expiring will therefore not be evident (even to insurers) until all applicable grace periods have been exhausted.

For 2026, nearly 20 million of the plan selections are returning customers. Plan selection data from 2025 shows that more than four in ten people in the ACA Marketplaces were automatically renewed into their coverage that year, meaning they did not actively sign up for their plan. As consumers automatically renewed for 2026 received their first premium bills for January, some may have disenrolled or stopped making a payment. Depending on what action they take and the timing, many people could be counted in preliminary plan selection data (in the “Final Snapshot” just released and the “Open Enrollment Report” in the spring) even though they may not truly have coverage.

When will we know more about ACA enrollment?

Below is a timeline of key ACA Marketplace deadlines and data releases. The data timing listed below is based on recent years’ release dates and there could be different dates in 2026. The section following the timeline explains each of these data sources in detail.

*Note: Timing is based on recent years and may change for plan year 2026.

Effectuated Enrollment

The effectuation rate is the share of people who have a plan selection during Open Enrollment who effectuate (or start) their coverage. While it is possible that some states or insurers may provide information about effectuation rates earlier, the first national data on ACA enrollments will likely come out in July 2026 with the Effectuated Enrollment Report, if the timing of past years is followed.

As shown in the chart below, the effectuation (or premium payment) rate has been quite high since 2022, meaning the vast majority of consumers who selected a plan ended up with coverage. For that reason, in recent years, plan selections and effectuated enrollment have often been discussed synonymously. However, the expiration of enhanced premium tax credits in 2026 will mark the first time that most ACA Marketplace enrollees experience a significant increase in their premium payments, making past years’ effectuation rates unreliable indicators of this year’s rate.

CMS typically releases an Effectuated Enrollment: Early Snapshot each summer. This data will provide a better picture of the impact of the expiration of enhanced tax credits on enrollment than plan selection data alone.

Based on past years, the Effectuated Enrollment: Early Snapshot report will likely be released in July 2026, and will report February 2026 effectuated enrollment, as measured on March 15, 2026. In other words, the July data release will likely show how many people had effectuated enrollment in February, based on what insurers know about premium payments by mid-March. However, as mentioned above, returning customers have until the end of March to make premium payments under the grace period. So even the data released in July of 2026 may still overstate the number of enrollees.

The effectuated enrollment data released in July of 2026 will likely not count new consumers who missed their binder payment for January or February, nor would it count consumers who were automatically renewed in December but then actively disenrolled in January. However, it wouldstill count people who were automatically renewed for January coverage and did not make a payment during the grace period—even if they eventually had their coverage retroactively terminated as of January 31.

The Effectuated Enrollment: Full Year 2026 data, likely to be released in the summer of 2027, would show the number of effectuated enrollees after all grace periods have elapsed. As a share of plan selections made during Open Enrollment, the chart below shows the final February effectuation rate from the Full Year (green) data has historically been a few percentage points lower than the Early Snapshot (blue).

Another reason the Effectuated Enrollment: Early Snapshot (expected to be released in July 2026) may not give a complete picture of the effect of expiring enhanced tax credits is that there could still be additional coverage loss later in the year. If an enrollee makes an initial premium payment but then decides their premium is unaffordable and drops their coverage mid-year, they may still be counted in the Effectuated Enrollment: Early Snapshot data even though they will not have coverage after their termination.

CMS may release additional effectuated enrollment counts before the Effectuated Enrollment: Full Year report; since this additional reporting may be after the run-out of grace periods, they would reflect finalized enrollment. In 2025, effectuated enrollment counts for the first five and seven months were released. Additionally, these releases may include information on the contribution of premium tax credits to the gross premium.

While effectuated enrollment data will tell us the number of people who are covered by ACA plans, it will not provide information about who paid their premium. The Open Enrollment Report and concurrent public use files, based on plan selections, will be the earliest source of information about income and other demographics of ACA enrollees. It is likely that the demographics and income distribution of ACA enrollees could shift from between the measurement of plan selections and effectuated enrollment. Additionally, the effectuated enrollment data from the Full Year report does not typically include metal level selection. There could be differences in payment rates for people who stay in their previous plan and face large premium increases and those who switch to lower-cost plans.

What other sources can be used to understand 2026 enrollment trends?

Quarterly Earnings Reports: April and May 2026

Prior to the publication of the effectuated enrollment data, some data on enrollment trends may be available from the insurers that enroll large shares of the individual market, during investor earnings calls. Insurers will host their fourth-quarter and year-end 2025 earnings calls in late January or February of 2026: Centene and Oscar will host their Q4 earnings calls on February 6 and February 10, respectively.

Insurers may start releasing membership counts for 2026 during their first-quarter 2026 earnings calls, expected to happen in April or May. Centene has announced their first-quarter earnings call for April 28. Elevance and UnitedHealthcare typically have first-quarter calls in April, while Oscar and Cigna typically report earnings in May. First-quarter calls that include enrollment information may not be fully adjusted for retroactive terminations due to nonpayment grace periods.

Insurer Rate Filings: Summer 2026

Every spring and summer, individual market insurers, including those offering ACA Marketplace plans, publicly file proposed premium rate changes to state regulators. These filings offer insight into what insurers believe is driving health cost growth and changes in enrollment. These rate filings will show insight into what insurers are planning in 2027 and may provide early counts of 2026 enrollment.

National Health Interview Survey Quarterly Releases: Likely January 2027

The National Health Interview Survey (NHIS) early release data will provide early indications of changes in the uninsured rate without the enhanced tax credits. From 2021-2024, first-quarter data came out in the summer of the same year, and data for the second quarter of the year came out closer to the end of the year. The Centers for Disease Control and Prevention has transitioned to biannual releases of data and released data for the first half of 2025 at the end of January 2026. If this release schedule remains consistent, data for the first half of 2026 may become available in early 2027.

Risk Adjustment Data: July 2027

Based on past years, the CMS Risk Adjustment Program State-Specific Data for 2026 is expected to come out in July 2027. The risk adjustment data will provide a state-by-state look at how many billable member months were reported for the ACA-compliant individual market. Because it will include on- and off-Marketplace enrollment, it will capture all people in ACA compliant coverage, even if they chose to purchase it off-exchange.

Issuer Level Enrollment Data: July 2027

The issuer-level enrollment data is split between HealthCare.gov and state-based exchanges. Data for HealthCare.gov states includes more information, including average monthly effectuated enrollment and average months of enrollment for those who have disenrolled. Additionally, issuer-level enrollment across all states will be made available through the Medical Loss Ratio Data and System Resources Public Use File, released late in the following year.

Enrollee-Level External Data Gathering Environment (EDGE): 2028

Enrollment by metal tier can be determined using the Enrollee-Level External Data Gathering Environment (EDGE) dataset, but this is subject to its own limitations: sparse enrollee demographic information, incomplete longitudinal data, and no information on terminated/non-effectuated coverage prevent fine-grained analysis on how the expiration of enhanced premium tax credits affected enrollee decisions. EDGE data for 2026 will likely not be available until 2028.

Update: On February 3, 2026, the President signed the “Consolidated Appropriations Act, 2026” which includes funding provided in the FY 2026 National Security, Department of State and Related Programs (NSRP) appropriations bill and accompanying explanatory statement detailed below. This resource was originally published on January 14, 2026.

On January 11, 2026, the Appropriations Committee released the FY 2026 National Security, Department of State and Related Programs (NSRP) (formerly State, Foreign Operations, and Related Programs [SFOPs]) appropriations bill and accompanying explanatory statement. The bill and explanatory statement include funding for U.S. global health programs at the State Department. Funding for global health programs at the State Department through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totals $9.4 billion, which is a decrease of $615 million (-6%) compared to the FY25 level ($10 billion). All program areas either decreased or remained flat as follows:

• Decreased: Funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), bilateral HIV, tuberculosis (TB), global health security, neglected tropical diseases (NTDs), and vulnerable children declined; while the Global Fund accounted for the largest decrease (-$400 million or -24%), this funding supports the administration’s pledge of $4.6 billion for the eighth replenishment and serves as the first installment of that pledge. In addition, the explanatory statement accompanying the bill states that there are also “sufficient unobligated balances” from prior Acts “to fulfill the United States pledge for the seventh replenishment.”
• Remained Flat: Funding for malaria, maternal and child health (MCH), nutrition, and family planning and reproductive health (FP/RH) remained flat.

In addition, the bill included provisions that either impact or provide direction on global health funding including:

• Program Area Amounts: Funding for many of the global health program areas is specified in the explanatory statement (rather than the bill). Unlike prior years, this bill specifically states that funding “shall be made available at not less than the amounts specifically designated in the respective tables included in the explanatory statement” ensuring that the administration is required to provide the amounts for the areas specified. The bill also prohibits the administration from deviating from the global health amounts in the bill and explanatory statement.
• Funding Availability Timeframe: PEPFAR funding (bilateral HIV and the contribution to the Global Fund) is available for five years. Funding for most other program areas is provided for two years, with the exception of funding for Gavi, the Vaccine Alliance and the Coalition for Epidemic Preparedness Innovations (CEPI), which is provided for one year.
• Reports/Briefings: The bill requires the administration to provide updates (via reports or briefings) on numerous global health areas including (but not limited to) the PEPFAR Transition Strategy, Market Access Strategy, bilateral health agreements, multilateral health engagement, the development of an Innovation Fund, and the status of available funding (i.e. apportionment, allocations, obligations, and disbursements).
• Additional Requirements: The bill requires coordination with the Centers for Disease Control and Prevention (CDC) on global health activities and establishes the Prevention, Treatment, and Response Initiative, which supports “research, development, and delivery of vaccines and other prevention technologies”.

See the table below for additional detail on global health funding. See other budget summaries (including the summary on FY 2026 Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) global health funding) and the KFF budget tracker for details on historical annual appropriations for global health programs.

Update: On February 3, 2026, the President signed the “Consolidated Appropriations Act, 2026” which includes funding provided in the FY 2026 Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) conference bill and accompanying report detailed below. This resource was originally published on January 22, 2026.

The Committee on Appropriations released its FY 2026 Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) conference bill and accompanying report on January 20, 2026.

While most U.S. global health funding is provided to the State Department through a separate appropriations bill (see the KFF budget summary on this funding here), the Labor HHS appropriations bill includes funding for global health programs at the Centers for Disease Control and Prevention (CDC) as well as funding for global health research activities at the National Institutes of Health (NIH). Total global health funding at CDC and NIH through the Labor HHS bill is not yet known, as funding for some programs (i.e. global HIV/AIDS and malaria research) at NIH is determined at the agency level rather than specified by Congress in annual appropriations bills. Funding for global health in the Labor HHS bill remained flat compared to the FY 2025¹ level as follows:

• CDC: Funding for global health programs at CDC totals $693 million, the same level as the FY 2025 enacted amount.² Within CDC, funding for each specific global health program area was also maintained at the FY 2025 level.
• NIH: Funding for global health research activities at the Fogarty International Center (FIC) at NIH totals $95 million, the same level as the FY 2025 enacted amount.

In addition, Section 236 under the Labor HHS section of the bill specifically states that funding “shall be for the budget activities, and in the amounts specified in the table under each such heading in the explanatory statement” instructing the administration to provide the amounts for the areas specified.

See the table below for additional details on global health funding. See other budget summaries and the KFF budget tracker for details on historical annual appropriations for global health programs.

1. Funding for FY25 was provided in a full-year Continuing Resolution (CR), which maintained FY24 levels. All FY25 amounts and associated notes are based on those specified in relevant FY24 appropriations bills. ↩︎
2. The FY26 Request eliminates CDC's Global Health Center and most of its bilateral programs, except funding for "Global Disease Detection & Emergency Response", which is transferred to "Crosscutting Activities and Program Support", and "Parasitic Diseases and Malaria", which is transferred to "Emerging and Zoonotic Infectious Diseases". ↩︎

Ahead of the Trump administration’s planned expansion of Medicare coverage for GLP-1s to treat obesity through temporary models and the availability of Medicare’s negotiated price for certain GLP-1 products beginning in 2027, new data from the Centers for Medicare & Medicaid Services (CMS) shows that use and spending for these drugs under Medicare has grown substantially in recent years, reflecting their demonstrated effectiveness at treating type 2 diabetes and other conditions. Medicare currently covers GLP-1s for type 2 diabetes, cardiovascular disease, and sleep apnea, but coverage for weight loss drugs is prohibited by law, even as GLP-1s have proved to be highly effective for this purpose (and even cost-effective, according to a recent analysis).

To address this gap in coverage for GLP-1s to treat obesity, CMS is launching a model called BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) under which CMS will negotiate pricing and coverage rules for GLP-1s, with the aim of expanding access to these medications and lifestyle interventions to support weight loss. The model, beginning in 2026 for Medicaid and 2027 for Medicare, is voluntary for drug manufacturers, state Medicaid programs, and Medicare Part D plans.

This analysis examines CMS’s Medicare Part D claims data from 2019 to 2024 to document the increase in the number of beneficiaries being treated with GLP-1 drugs and the growth in Medicare spending and claims for GLP-1s. Expansion of coverage under Medicare of GLP-1s to treat obesity under the BALANCE model is likely to increase utilization above current levels, as Medicare begins to meet the demand for obesity drugs among beneficiaries who have been unable to access or afford these medications to date. At the same time, the availability of Medicare’s lower negotiated price for certain GLP-1 products under the Medicare Drug Price Negotiation Program (semaglutide beginning in 2027 and dulaglutide beginning in 2028) could mitigate the increase in Medicare spending that could come about from ongoing and expanded use of these medications.

Ozempic Was Used by Two Million Medicare Part D Enrollees in 2024, Up from Fewer Than 150,000 in 2019

Semaglutide, the GLP-1 drug branded as Ozempic, Rybelsus, and Wegovy, was the most used GLP-1 in 2024. Two million Part D enrollees took Ozempic, which was approved by the FDA in 2017 to treat type 2 diabetes, up from fewer than 150,000 in 2019 (Figure 1). Nearly 1 million Part D enrollees took Mounjaro, approved in 2022 for type 2 diabetes, up from 54,000 in 2022. This increase reflects a pattern of growing use of newer GLP-1s, such as Ozempic and Mounjaro, while use of older products, such as Byetta (approved in 2005), Victoza (approved in 2010), and Trulicity (approved in 2014), has declined. While most GLP-1 drugs are currently available as injections, the introduction of new oral formulations, which could be easier for patients to take, could result in additional shifts in utilization among GLP-1s.

Medicare Part D Gross Spending on GLP-1s Increased Five-Fold Between 2019 and 2024, But Estimated Rebates of Around 50% Mean That Net Spending is Much Lower

Gross Medicare Part D spending on GLP-1s in 2024 (not accounting for rebates) totaled $27.5 billion, a five-fold increase from 2019, reflecting an expansion in use of GLP-1s with more recent FDA approvals for type 2 diabetes. (FDA approvals of Wegovy for cardiovascular disease and Zepbound for sleep apnea occurred in 2024 and therefore these uses are likely not reflected in Part D data through 2024.) More than half of gross spending in 2024 was on semaglutide products (Ozempic, 47%; Rybelsus, 7%; Wegovy, 1%) and nearly one fourth (23%) was for Mounjaro. Gross spending overstates the true cost of these products to the Medicare program, however. According to estimates from MedPAC, negotiated rebates for diabetic therapy were equal to or greater than 50% in 2023. Assuming rebates of 50% across all GLP-1 products in 2024 would mean net spending of around $14 billion in 2024.

Claims for GLP-1s Increased Four-Fold Between 2019 and 2024

In accordance with an increase in both the number of Medicare Part D enrollees using GLP-1s and spending on these products, the number of claims for GLP-1s increased four-fold between 2019 and 2024, from 4.8 million to 21.8 million, with claims doubling between 2022 and 2024 alone. More than 10 million claims for Ozempic were submitted in 2024, up from 524,000 in 2019 (an 82% average annual growth rate) and another 5.1 million for Mounjaro, up from 122,000 in 2022 (average annual growth of 549%).

In December, Nebraska was the first state to announce that it would be enforcing Medicaid work requirements early, starting May 1, 2026. The 2025 reconciliation law requires states to condition Medicaid eligibility for adults in the ACA Medicaid expansion group and enrollees in partial expansion waiver programs (Georgia and Wisconsin) on meeting work requirements starting January 1, 2027; however, states have the option to implement requirements sooner through a state plan amendment (as is the case for Nebraska) or through an approved 1115 waiver. Implementing work requirements will require complex changes to eligibility and enrollment systems, as well as enrollee outreach and education, staff training, and coordination with managed care plans, providers, and other stakeholders. Early reports from the state during its recent January Medicaid Advisory Committee (MAC) meeting and data from KFF’s Medicaid work requirements tracker provide initial insight into how Nebraska is preparing to implement Medicaid work requirements. Similar information from MAC meetings in other states and data on the KFF tracker can be helpful to assess how other states may implement new requirements as well. 

Most Medicaid adults in Nebraska under age 65 who will be subject to the new work requirements are working already or attending school. As of March 2025, there were about 72,000 expansion enrollees in Nebraska who could be affected by the new requirements. KFF analysis indicates that roughly 65% of Medicaid adults without dependent children in Nebraska who could be subject to work requirements work 80 or more hours per month or are attending school. In addition, many enrollees who are not working the required hours will likely qualify for exemptions from the new work requirements.

In a recent Medicaid Advisory Committee (MAC) meeting, Nebraska provided a first look into how the state is planning to implement work requirements. All states are required to have a Medicaid Advisory Committee to advise the State Medicaid agency about health and medical care services. These groups include Medicaid enrollees, advocates, and providers. In its January 15, 2026 meeting, Nebraska state officials provided early insight into key decisions related to work requirements and look-back periods, data matching, medically frail exemptions, enrollee verification, short-term hardship exceptions, and outreach (Table 1). State officials also confirmed that the state does not intend to hire or increase staffing levels to facilitate implementation of work requirements or other eligibility changes.

There remain multiple operational and implementation issues the state will need to resolve in the next four months. State officials emphasized that conversations with the federal government are ongoing, and that Centers for Medicare and Medicaid Services (CMS) staff had recently travelled to Nebraska to plan implementation with state officials. As part of the MAC meeting discussion, state officials noted areas where there is ongoing work to identify data sources to verify compliance or exemption status:

• Volunteer activities. Officials acknowledged they had not yet determined how volunteer activities will be defined or how volunteer activities could be identified through data matching. Current guidance from CMS does not clearly outline what types of volunteer activities count towards compliance with Medicaid work requirements.
• Education activities. Officials said the state is working on specifics for defining hours of educational activity using course credit hours. The state is also exploring data matching for educational activities, including higher education enrollment data.
• Work verification. Data matching for work hours was not discussed during the meeting, though officials confirmed that, as required by the reconciliation law, individuals can meet the work requirement if they are working and earn the equivalent of the federal minimum wage multiplied by 80 hours in a qualifying month.
• Number of enrollees affected. State officials could not yet provide internal estimates of how many enrollees could already be identified as in compliance with the new requirements using currently available data sources, but explained they are currently running models to see who they can identify as being in compliance or exempt from Medicaid work requirements.

KFF is tracking metrics related to Medicaid enrollment, renewal outcomes, and application processing times that can provide insight into a state’s potential readiness to implement data matching and other necessary system changes. As of September 2025, Nebraska was performing in line or better across several renewal metrics compared to the United States national average (Figure 1). Nearly nine in ten applications were processed within 30 days and eight in ten individuals going through a Medicaid eligibility redetermination had their coverage renewed. Of people who retained coverage, 88% were renewed via ex parte processes (meaning the state verifies ongoing eligibility through available data sources before sending a renewal form or requesting documentation from an enrollee), although this percentage in September 2025 was higher than the average of 69% across the prior 6 months. Among those who were disenrolled, 53% were terminated for procedural reasons (meaning an individual was disenrolled because they did not complete the renewal process). While these metrics provide insight into Nebraska’s Medicaid eligibility systems, they are not the only indicators or predictors of successful implementation of work requirements, which will also require enrollee outreach and education, staff training, and coordination with managed care plans, providers, and other stakeholders.

As states implement work requirements, ongoing monitoring can help assess how processes are working and identify areas of concern. Central to that oversight is timely data on renewal outcomes, including data on disenrollments related to work requirements. While available data (highlighted above) from CMS can be helpful, these data are not timely enough for real-time monitoring and they do not isolate outcomes for the expansion population. States can fill that gap by reporting more timely data on application and renewal outcomes that include breakouts for individuals subject to work requirements. During the MAC meeting, state officials in Nebraska communicated their intention to be transparent in reporting how many enrollees are disenrolled.

As part of broader efforts to reduce immigration, the U.S. Department of State (DOS) recently announced that it will pause issuance of all immigrant visas for individuals from 75 countries. This analysis shows that workers from 69 of the 75 countries affected by the pause for which data are available make up nearly one in ten (8%) of the U.S. health care workforce. The pause will likely reduce the supply of workers and particularly health care workers in the U.S., which could exacerbate existing health care worker shortages. Shortages are likely to be compounded by other policies limiting immigration into the U.S. as well as ongoing deportation efforts. Estimates suggest the Trump administration’s policies could reduce legal immigration to the U.S. by 33% to 50% over four years.

On January 14, 2026, the DOS announced that it will pause processing of immigrant visas for individuals from 75 countries who it identified as at, “high risk for use of public benefits” and becoming a public charge. (See Methods for full list of impacted countries). This policy is part of broader efforts to expand public charge policies.The DOS indicates that the pause is being implemented to ensure “immigrants must be financially self-sufficient and not be a financial burden to Americans”. However, the DOS has not provided details about the process used to identify countries subject to the pause. Moreover, few immigrants are eligible for federal benefits due to longstanding restrictions. For example, most lawfully present immigrants have to wait five years after obtaining a “qualified” immigration status to be eligible for federal programs including Medicaid and the Supplemental Nutrition Assistance Program (SNAP).  

The pause went into effect on January 21, 2026, for nationals from the 75 countries applying for immigrant visas. Immigrant visas allow an individual to live and work in the U.S. on a permanent basis and can provide a pathway to citizenship. Examples of immigrant visas include family-based visas (when a U.S. citizen or lawful permanent resident (LPR or “green card” holder) sponsors a family member for permanent residency), certain types of employment-based  visas, as well as refugee visas (although entry of refugees to the U.S. has already largely been eliminated through executive action). Individuals applying for non-immigrant visas such as a student visa, tourist visa, or temporary work visa like H-1B are not impacted by the pause. The DOS states that, during this pause, applicants from impacted countries may submit visa applications and attend visa interviews, but that it will not issue any immigrant visas. The pause does not impact immigrants from the 75 countries who are already present in the U.S.

Foreign-born workers from 69 of the 75 countries impacted by the DOS visa pause for which data are available make up nearly one in ten (8%) of health care workers in the U.S. Based on KFF analysis of 2025 Current Population Survey data, there were 7.8 million foreign-born workers (ages 19 to 64) from 69 of the 75 countries impacted by the visa pause as of 2025, including 1.2 million health care workers. A little over half (55%) of health care workers from these countries are employed in health care support occupations such as home health aides and nursing aides, and the remaining 45% are in health care practitioner and technical occupations such as physicians, surgeons, and nurses. These workers include individuals who may have arrived on immigrant or non-immigrant visas since the data do not include information on visa type. Separate data for the remaining six countries affected by the pause (The Gambia, Kosovo, Kyrgyz Republic, Rwanda, South Sudan, and Tunisia) were not available. Among foreign-born workers from the 69 countries, those from Haiti (13%), Jamaica (10%), and Nigeria (9%) made up about one in three (32%), or the highest shares, of health care workers. Workers from 69 of the 75 countries affected by the DOS visa pause accounted for 6% of the total U.S. adult workforce and 8% of health care workers under age 65 (Figure 1). Immigrants from other countries not impacted by the pause accounted for 14% of the U.S. adult workforce and 11% of health care workers, and U.S.-born citizens accounted for the remaining eight in ten workers.