Op-ed: Hardline immigration policy hurts hospitals from the inside out

Immigration policy doesn’t have to specifically mention hospitals or health systems to become a major multilevel healthcare problem.

Plenty of reports focus on immigrant patients avoiding the health system and the sometimes devastating consequences that follow, but the fallout of harsh immigration rules and ramped-up enforcement go much wider and deeper, as immigrant workers have long been essential for healthcare operations in the US. They’re our doctors and custodial staff, our surgeons and maintenance techs, and our nurses, home health aides, hospice workers, and commercial drivers.

On Sept. 18, the US Department of Homeland Security’s latest public charge rule went into effect, rescinding a Biden-era policy. This latest iteration from the Trump administration gives immigration officers much more power to consider enrollment in programs like Medicaid and CHIP as indicators that certain immigrants, primarily green card applicants and their families, will be too dependent on the government (i.e., a “public charge”). The rule does not apply [1] to many immigrants, but the wide-reaching collateral anxiety will affect the entire industry, from the patient to the providers and hospital staff.

Patient health suffers

Experts say the new public charge rule will make it more difficult for people to get approved for a green card if they’re on any form of public assistance.

After a similar expansion to the public charge rule in 2018, the share of adults in immigrant families with at least one non-permanent-resident member who reported avoiding a public benefit out of fear jumped that year from 22% to 31%, a statistically significant increase, per a 2019 analysis. The rule wasn’t targeting medical care and also didn’t apply to most noncitizens, but people reacted based on how they believed it could detrimentally affect their families—a phenomenon known in the legal world as a “chilling effect.” In 2026, projections estimate the latest public charge rule could push up to 4.1 million eligible noncitizen adults and US citizen children to forgo Medicaid, CHIP, and food assistance.

In California, the consequences of this administration’s wider immigration agenda are already apparent. In the spring of 2025, a federal judge granted immigration authorities access to state Medicaid data, and California announced an immigration-status enrollment freeze that rolled back its unprecedented state-funded coverage for adults without legal status. Amid heightened immigration enforcement raids—even in hospitals—is an observable chilling effect in agricultural communities: UC San Francisco reported a 36% drop in visits to its rural mobile health clinics serving Central Valley farmworkers, and at Saint Agnes Medical Center, the other program Fresno County contracts to reach farmworkers, visits have reportedly dropped by nearly 20%. Research also suggests that emergency department utilization has risen 2.5–5 percentage points among certain immigrant communities in Los Angeles since the beginning of the 2025 enforcement efforts.

In the month after the freeze went into effect on Jan. 1, more than 86,000 immigrants without legal status left Medi-Cal or were denied coverage, and enrollment in the state’s immigrant expansion group fell to 1.4 million in March, an 18% decrease from June 2025 enrollment data. The state projects another 1.3 million adults with unstable immigration standing will lose comprehensive Medi-Cal coverage by 2030 as a result of state policy changes, and hospitals and clinics are projected to absorb at least several billion dollars in additional uncompensated care by 2030.

Disengagement with the health system also impacts long-term maintenance, like medication adherence. Studies of patients with asthma, diabetes, and heart disease link lower adherence to more emergency visits and hospital stays, and some researchers have linked nonadherence to at least 10% of US hospitalizations and about 125,000 preventable deaths a year, at a direct cost upwards of $100 billion annually. Noncitizens specifically report cost-related medication nonadherence at meaningfully higher rates than naturalized or birthright citizens—13.8% versus 9.5% and 11.0%, respectively—with the gap explained mainly by insurance coverage and food insecurity rather than citizenship status itself, according to a 2023 study. That same study found noncitizens, especially older noncitizens without Medicare, are more likely to cope by privately importing cheaper medications, [2] which the FDA warns could be counterfeit, contaminated, or subpotent.

Staffing troubles multiply

Nationally, immigrants make up nearly 14.8% of US residents and about 17% of the domestic healthcare workforce, or roughly 3.3 million workers. Inside hospitals, that includes about 30% of physicians and surgeons, 17% of registered nurses, and 22% of nursing assistants. A 2025 analysis also estimated that several hundred thousand undocumented immigrants work in healthcare, with tens of thousands inside hospitals directly. And while environmental services, food service, security, and transportation are frequently contracted out, the industry’s heavy dependency on these workers—essential custodial staff, kitchen staff, maintenance techs, and building engineers—stays the same, regardless of who pays their wages.

Florida is an example of how healthcare gets pinched when immigration rules get tighter. In 2023, Gov. Ron DeSantis signed SB 1718, a sweeping anti-immigration law that imposed strict penalties for undocumented people and those who interact with them. One provision states that any hospital receiving Medicaid or CHIP funding must ask patients about their immigration status. Though patients may decline to answer, many noncitizens and citizens have avoided medical care out of an abundance of caution. Also, reports have indicated that local businesses, namely food service, agriculture, and construction suffered immense losses of longtime workers and customers in the aftermath. [3] The governor touted SB 1718 as a success that saved millions of Medicaid dollars, [4] but this labor loss likely contributed to increased hospital operating costs, [5] which were also driven up by new administrative tracking infrastructure.

A separate federal action, a $100,000 H-1B petition fee, added another major hurdle for hospitals staffing noncitizen physicians last year. The American Hospital Association found that in response to the new petition fee, 64% of 1,000 hospitals using or planning to use H-1B visas expected to pause, defer, or limit recruitment last year, and more than 70% expected that to directly affect patient care. While federal judges have separately struck down this action, with the most recent ruling in October citing “a likelihood of irreparable harm” to employers of H-1B workers, the recruitment damage has already been done.

Clinicians are burdened

A July qualitative study, based on interviews with 38 primary care doctors in 13 states, found that over the past year, clinicians have been altering medical decisions for immigrant patients out of fear for their safety. They’ve delayed emergency referrals, prescribed three months of medication at a time instead of one, or rearranged surgery schedules around deportation timelines rather than by medical necessity. One doctor included in the study said she once moved up a critical abdominal surgery after learning the patient faced deportation. While she was able to perform the surgery in time, the doctor lost track of the patient afterward and never saw her again.

Researchers describe this psychological toll as “moral injury,” which is distinct from burnout. It is the sense that a clinician can’t provide the care they know a patient needs because of forces entirely outside the exam room, like immigration policy. The toll isn’t limited to clinicians treating immigrant patients either, as immigrant physicians in the July study also described feeling isolated and targeted, including one US-born doctor of Middle Eastern descent, who said he doesn’t do things alone out of fear of being profiled. That distress similarly runs through medical assistants, front-desk staff, community health workers, and interpreters, and the researchers found high turnover among frontline clinical staff as a result. While no study has yet tied immigration-related moral injury to physicians leaving the profession, a March survey mirrors a broader pattern of systemic attrition, finding that 34.5% of doctors experiencing high moral distress plan to leave their positions within two years, compared to just 18.2% of those who reported low distress.

Bottom line

A January study of nearly 400,000 adult emergency department encounters at Los Angeles County safety-net hospitals found that, after the September 2018 public charge announcement, the probability that an encounter involving a likely-undocumented patient would be classified as self-pay rose by about 2 percentage points, or an estimated 1,755 additional self-pay visits. This leaves a vulnerable workforce facing a steep penalty: Pay potentially thousands of dollars for a single emergency room visit on $35,890–$46,050 annual earnings for workers in agriculture and construction, the industries in the US with the highest concentrations of workers without work authorization.

For a hospital CFO or a payer actuary, the label of self-pay, uncompensated care, or disenrollment matters less than figuring out what happens to payer mix and utilization patterns when eligible people don’t enroll in or are afraid to seek care. Particularly in rural areas, an event like a local meatpacking plant losing a third of its workforce overnight has a ripple effect on the tax base the county hospital depends on, the insured patient volume it was counting on, and the emergency department that absorbs whatever care those families were getting through employer coverage before.

We’ve already seen that patients—including those who have valid authorization to live and work in the US—would rather disengage from the health system rather than risk potentially putting a target on their back. But healthcare avoidance and unpaid medical bills are the beginning of the consequences of harsher immigration rules and enforcement. From the other side of the bed, hospitals, already short of nurses, face having fewer critical noncitizen clinicians and support workers, and physicians with high moral distress are nearly 2x as likely to leave their jobs. We have documented answers on how these immigration policies impact the entire healthcare system (and beyond), so absent a change in federal policy or circumstances, there’s little reason to expect the current trajectory to change.

The author has contributed this piece in his personal capacity. The views expressed are his own and do not necessarily reflect those of his current or former employers.