Recent immigration and citizenship policies unveiled by the Trump administration may be exacerbating barriers to hospice among undeserved patient populations.

A trio of executive orders launched in 2025 have generated mounting concerns about equitable access.

“As the Trump administration cuts Medicaid and targets immigrants, it’s our patients who bear the brunt,” said California State Sen.María Elena Durazo, a Democrat, in a statement shared with Hospice News.

This article is the final installation in a three-part series examining this year’s regulatory changes and the significant effects on end-of-life care. The first installment discussed the Wasteful and Inappropriate Service Reduction (WISeR) Model, while the second piece explored the unknowns of Trump’s “One Big Beautiful Big Act” (OBBA), which contains Medicaid cuts totaling $1 trillion over the next decade. 

Immigration policy changes

Among the earliest White House executive orders to make waves in hospice came in January. The executive order stipulated that the U.S. Department Homeland Security (DHS) could take “all appropriate action” to enable the U.S. Immigration and Customs Enforcement (ICE), the U.S. Customs and Border Protection (CBP) and the U.S. Citizenship and Immigration Services (USCIS) to set priorities for their agencies that “protect the public safety and national security interests of the American people.”

The executive order allowed federal agencies to seek actions to identify and publicize information about undocumented immigrants, pursue expedited deportations and impose civil fines and penalties. Failure to comply with legal obligations can in some cases result in individuals being treated as a “civil and criminal enforcement priority,” according to the executive order’s language.

The changes in immigration policy, coupled with impending Medicaid cuts from the OBBA legislation, will result in worsening health disparities among many underserved patient populations nationwide, Durazo indicated. Hispanic communities have been at particular risk for significant health impacts.

The Trump administration policies have restricted access to care among low-income patients, who represent a large portion of Medicaid beneficiaries. The funding cuts could eliminate vital support for vulnerable and undeserved groups, Durazo said. Additionally, patients are delaying care out of fear of ICE raids or an inability to navigate decreased Medicaid coverage.

“Immigrant patients are avoiding care,” Durazo said. “Residents report that Latino patients, particularly those without documentation, are delaying treatment due to fear of ICE — leading to worse health outcomes. With the recent passage of federal Medicaid cuts and escalating fear among immigrant communities, physicians warned that eliminating the fund could deepen disparities for patients already facing systemic barriers. It’s a moral commitment to the health and dignity of all our communities.”

Recent immigration laws may negatively affect operations in several health care settings where terminally ill individuals are served, such as skilled nursing and assisted living facilities, adult day centers and in the home and community, according to a report from Justice in Aging.

Recent federal policies have adopted an “increasingly aggressive posture” on immigration and deportation, resulting in escalating fear, anxiety and challenging circumstances among providers and the patients they serve, the authors stated in the report.

“The essential services that older adults rely on at health care facilities and social services centers require an intricate network of staff,” the authors wrote in the report. “The threat of deportation is invoked particularly against non-citizen immigrants, but also to persons who have had protected legal status. Many of the staff in these settings may themselves be immigrants, have connections to immigrant communities, or otherwise be the subject of immigration enforcement.

Potential workforce impacts

Another significant regulatory move furrowing the brows of hospice leaders was a White House executive order that took effect on June 9 introducing restrictions on the entry of foreign nationals from certain countries into the United States.

Hospice and home health providers have raised concerns that the policy could have a chilling effect on the workforce.

More than roughly 1 million non-U.S. citizens are employed in health care, many of whom are undocumented and working in “essential, hard-to-fill” clinical occupations in hospitals, outpatient settings and nursing homes, a study found, which was recently published in Lancet Regional Health – Americas.

Immigrant workers can help hospices to better understand the unmet spiritual, social and cultural needs among their most diverse and underserved patient populations, according to Victor Couzens, owner, founder and CEO of Ohio-based Mahogany Home Health and Hospice.

Having stronger immigrant representation across a hospices’ interdisciplinary hospice team can make a significant difference in how patients and their families experience the end of life, Couzens said.

“[It’s] important to have providers that know about the needs of the spiritual, religious diversity among immigrant communities,” Couzens told Hospice News. “It’s about how they mourn, how they face end-of-life decisions, their specific rituals and the demographic of people actually in the community. We’re looking for people who can articulate that to us and who are deeply involved in the community.”

Staffing shortages have long plagued the hospice and home health care fields, and immigrants can be a valuable workforce resource amid rising demand among a swelling aging population with serious and terminal conditions, according to authors of a 2025 report from the National Immigration Forum.

“Immigrants, who already work in large numbers in the sector, could mitigate workforce shortages and be a major contributor to the long-term care of the elderly,” the author wrote. “To meet the demand, it will be indispensable to implement sound workforce development policies and immigration reforms to encourage and equip more native and foreign-born workers. Reforming our immigration system by creating both non-immigrant and immigrant visa categories to attract and retain foreign-born home health care workers, including home health aids, nursing assistants and personal care assistants, would assist numerous American families in caring for their elderly relatives.”

Recent immigration policies could limit the potential for stronger workforce development. Among the potential opportunities for deeper integration of immigrant workers is establishing more partnerships with other countries that bring greater volumes of nurses and certified nursing assistants and other health care workers into the United States.

This strategy has enabled some U.S. facilities to work towards increasing recruitment and retention while also trying to improve quality, including Illinois-based Plymouth Place Senior Living. The senior living provider formed a collaboration to bring more nurses from the Philippines, growing its clinical workforce in the process.

Despite the uncertain fallout from immigration policies in the United States, these collaborations could be an effective avenue toward improved clinical capacity and sustainability, Plymouth indicated in a recent article published in Caring for the Ages.

Citizenship policies in the mix

Among the policies under contentious debate is a White House executive order released in January that aims to remove birthright citizenship.

If enacted, the executive order would establish greater restrictions for citizenship eligibility among individuals born in the United States to immigrant parents. It directs the federal government to deny citizenship documents to children born in the country to undocumented or temporary immigrant parents.

Historically, birthright citizenship has been granted to any individual born in the country, regardless of their parents’ status.

The U.S. Department of Justice intends to ask the U.S. Supreme Court to rule on birthright citizenship, according to recent media reports.

Unknowns around the citizenship policies have deepened mistrust and misunderstandings among many underserved and immigrant communities, recent research has found.

Undocumented immigrants in the United States face significant barriers to hospice care, according to a 2025 case study published in the Journal of Pain and Symptom Management. Researchers included clinicians and social workers at Stony Brook University Hospital who examined issues related to culturally sensitive hospice care among undocumented immigrant patient populations.

Among the challenges related to the limited provision of hospice was fear of deportation, as well as interdisciplinary bias related to citizenship status, the study found. More hospice programs aimed at equitable care are needed, particularly amid the Medicaid cuts in the OBBA, the researchers stated.

More than 11 million immigrants in the United States do not have legal authorization to reside in the country, or are undocumented, the Pew Research Center recently reported.

Caring for immigrant and undocumented adult and pediatric patients at the end of life can come with complex situations for hospice providers to navigate, according to the Palliative Care Network of Wisconsin (PCNOW). These patient populations lack an understanding of the U.S. health care system, often have limited caregiving and social support and have heightened fears related to their safety and potential legal enforcement actions.

Hospice and palliative care clinicians should approach patient interactions with cultural humility and education about their end-of-life care options, the organization indicated in a recent statement.

“Fear of arrest and deportation leading to a hesitancy to seek medical care is prevalent in the undocumented patient population,” PCNOW stated. “Addressing and validating patient fears can promote the development of a trusting patient-clinician relationship. Provide education to the patient and family about the patient’s rights to seek medical care and to non-disclosure of their immigration status.”