The Somali refugee population in Minnesota has received a lot of national attention recently because of a daycare fraud scandal. The twin cities of Minneapolis/St. Paul have the largest Somali population in the United States at approximately 80,000. Central Ohio has the second largest Somali refugee population at about 70,000. Most of these refugees came to the United States in the late 1990’s, fleeing Somalia’s Civil War. Approximately 82% of Central Ohio’s Somali population are either naturalized citizens or legal permanent residents (green card holders). However, some Somalis in Ohio are under federal temporary protected status, allowing them to live and work in the United States as refugees when return to their home country is unsafe due to war or environmental disaster. Last month, the Trump administration canceled temporary protected status for Somalis, requiring them to leave the country by March 17, 2026.
Twenty years ago Somali refugees accounted for a large percentage of our hospital’s housekeeping and janitorial staff. These are largely unskilled workers who often had limited education. Today, the children of those refugees now occupy skilled positions in our hospital as nurses, respiratory therapists, and physicians. From my own experience as our hospital’s medical director, it is difficult to fill unskilled positions, such as hospital housekeeping staff. U.S.-born citizens with U.S. educations are largely uninterested in cleaning soiled hospital bed linens, moping floors, or washing dishes in the hospital kitchen. We rely heavily on immigrants and especially refugees who are willing to take on any job as long as that job allows them to stay in America. Immigrants do the hospital jobs that no one else will do.
Our hospital is not unique. A study from the Kaiser Family Foundation found that 1 out of 6 hospital workers (16%) in the U.S. are immigrants. But there are significant geographic variations. For example, only 0.5% of hospital employees are immigrants in Wyoming but in California, 32.4% of hospital employees are immigrants.
For low-paying hospital jobs requiring less education, such as cleaning and maintenance jobs, nationwide, fully 29% are immigrants. More specifically, 17% are naturalized citizen immigrants and 12% are non-citizen immigrants. A recent study in JAMA found that 9% of hospital housekeeping and janitor workers are undocumented immigrants. These jobs are essential for our nation’s hospitals to function and we cannot fill all of these jobs with American-born workers.
Immigration pathways
The United States allowed approximately 1.2 million immigrants to enter the country in 2023 as lawful permanent residents. Of these, the largest percentage, 756,000, entered by being sponsored by an immediate family member, for example, a spouse, child, or parent of a U.S. citizen. Approximately 197,000 entered the U.S. as employment-based immigrants – mainly skilled workers on work visas. The annual diversity visa lottery accounts for about 55,000 immigrants each year – these visas are allotted to people from countries that have low rates of immigration to the U.S. such as Ghana, Nepal, and Armenia. Refugee status accounted for 125,000 immigrants.
Immigrants tend to be young and of working age. Data from the U.S. Citizenship and Immigration Services indicate that in 2024, 88.1% of all individuals becoming naturalized citizens that year were under age 65. Data from the U.S. Department of Homeland Security indicates that 88% of undocumented immigrants are under age 55 and 79% are between ages 18 – 55, indicating that the vast majority of undocumented immigrants are in prime working age.
In 2023, there was a total of 51.8 million immigrants living in the U.S. Of these, 23.8 million (46%) were naturalized U.S. citizens, 11.9 million (23%) were green card holders, 2.1 million (4%) were temporary lawful residents, and 14.0 million (27%) were unauthorized.
Of those 14 million unauthorized immigrants, 2.6 million were asylum applicants, 700,000 entered the U.S. legally after receiving parole (“parole” from an immigration definition is a person who has been granted legal authorization to remain in the U.S. because of humanitarian reasons or significant public benefit), 700,000 were authorized to be in the U.S. because of being victims of crime or violence, 650,000 had temporary protected status, 650,00 were brought to the U.S. illegally as children (DACA). Another 1 million had been apprehended by U.S. Border Patrol agents and released into the country with an order to appear in immigration court. Finally, 8 million of the unauthorized immigrants were undocumented; this is the group that the government has targeted for deportation. 50% of undocumented immigrants live in just three states: Texas, California, and Florida. The most common country of origin is Mexico:
When it comes to employment, 64% of immigrants in the U.S. are in the workforce. The majority of the rest are homemakers, children, or the elderly. Of the unauthorized immigrants, fully 71% are in the U.S. workforce. In contrast, only 44% of U.S. born citizens are currently in the U.S. workforce. In other words, a much higher percentage of immigrants are in the workforce than U.S. born citizens, reflecting the younger average age of immigrants compared to U.S. born citizens. In addition, undocumented immigrants have to work as they are not eligible for federal programs such as SNAP, ACA insurance, Social Security, Pell grants, Medicare, or Medicaid.
Hospital-based immigrant physicians and nurses
The United States is heavily dependent on immigrant physicians who account for 27% of all physicians in American hospitals. Of these 19% are naturalized U.S. citizens and 8% are noncitizen immigrants. Because of the rigorous training and licensure requirements for doctors, essentially no practicing physicians are unauthorized/undocumented immigrants. In other words, they are all here legally.
16% of U.S. hospital nurses are immigrants of which 13% are naturalized citizens and 3% are noncitizens. 22% of nursing assistants are immigrants of which 15% are naturalized citizens and 7% are non-citizens. Similar to physicians, nurses require training and licensure; as a result, essentially no practicing nurses are unauthorized/undocumented immigrants.
For home-based services, the U.S. relies even more on immigrants with 41% of home health aides being foreign born. As our nation’s population ages, home health will be increasingly important and without these immigrant workers, home health delivery would be unable to meet the country’s needs. Although many home health aides are employed through home health companies that require their employees to have documentation of legal immigrant status, many other home health aides are employed directly by families and often paid in cash. As a result, undocumented immigrants account for 3.8% of home health workers.
We need more immigrants
We have healthcare employment needs that cannot be fully met by U.S. born citizens. Currently, nearly half of U.S. nursing homes have limited admissions due to staffing shortages and only 19% meet the minimum staffing numbers required by 2029 as mandated by Medicare. Data from 2023 indicated that two-thirds of hospitals had to reduce inpatient capacity due to staffing shortages, a number that will be of no surprise to anyone who has had to wait in the emergency department for hours or days for an inpatient bed because no open beds were available.
Immigrants in the United States have always taken the jobs that no-one else wanted to do. Forced immigrants (the enslaved) were brought to America in the 1600’s and 1700’s to do farm labor that free Americans would not do. Following the Great Famine of 1845, Irish immigrants took unskilled jobs in American, such as building canals, working in textile mills, and working in mines. Chinese immigrants came to the U.S. in the 1860’s to work building railroads, a dangerous and low-paying job that railroad owners could not fill with American born workers. After the railroads were built, the Chinese went on to work in laundries, another job that could not be filled with American born workers. In the 1900’s, it was migrant farmworkers who were essential for much of the U.S. agricultural output. These also were physically demanding and low paying jobs that few U.S. citizens would take. Today, immigrants continue to do the jobs that cannot be completely filled with U.S. born workers: kitchen staff, farmworkers, day laborers, roofers, daycare workers, drywall installers, painters, etc.
In the U.S. healthcare system, immigrants perform many of the so-called entry-level jobs that require minimal skills and little training. While it is true that these jobs can frequently be filled by U.S. born citizens entering the workforce with only high school or less education, these least educated U.S. born citizens are often less motivated to work than immigrants and are more likely to move on to some other job after a short period of time. Quite simply, immigrants often make the best employees for unskilled jobs in healthcare – they are glad to have a job, work hard, and are less likely to quit after just a few weeks or months on the job.
The U.S. citizenry is aging and the U.S. birthrate is falling. As a result, we will have a large population of elderly Americans needing home healthcare, nursing home care, and hospital care over the next several decades. And at the same time, the low birth rate will result in fewer young Americans available and willing to take unskilled hospital jobs like home health aides, hospital kitchen workers, nursing aides, and hospital housekeeping staff.
So, what is the solution?
As with all too many things in life, politics gets in the way of pragmatism. The pragmatic solution to our current and soon to be worsening shortage of unskilled hospital workers is to bring in more legal immigrants who are of working age. The politics is that too many Americans feel threatened by immigrants – either because of fear that the immigrants are criminals, fear that the immigrants are going to take their jobs, or simply fear of people from a different culture.
The best way to reduce unauthorized/undocumented immigration is to allow more young immigrants who are motivated to come to the U.S. for jobs to enter legally. We need to allow hospitals and other healthcare employers to sponsor immigrants who agree to take those jobs that cannot be filled with U.S. born citizens. They can then do the work that is needed by our healthcare system, pay into the Social Security system (which is needed to prevent Social Security from running out of money), and avoid wasting money being spent to round up, detain, and deport those who can contribute to society.
Our nation’s hospitals’ immigration problem is that we need more immigrants.
February 6, 2026
