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Open the Door to Foreign Health Professionals

Susan Nowakowski, for HealthLeaders News, February 14, 2008
When the Congressional debate over immigration reform collapsed last year it was a blow for national policy in general and for healthcare in particular.

The debate, as it played out in Congress and in the media, focused almost exclusively on what the United States should do about illegal immigration. Healthcare was brought into the discussion because of the increasing burden illegal immigrants are putting on hospitals and other government supported facilities and resources.

What received less attention was the link between healthcare delivery and legal immigration. While illegal immigrants may be eroding resources, legal immigrants are providing skills and services that are vital to the daily delivery of healthcare in the U.S.

Consider that the number of physicians being trained in the United States has remained static since 1980, though we have added 70 million people to the population in that time. We have been more proactive about training additional nurses, but our ability to do so has been stymied by an understaffed educational system. Over 147,000 qualified applicants to nursing programs were turned away last year, mostly because we do not have the faculty or the facilities to train them.

Given the current posture of physician and nurse training there is only one way to immediately increase the supply of needed clinical professionals, and that is through legal immigration. While most people agree that the goal should be to train more U.S. physicians and nurses, in practice it is not that simple. Physician training is a time consuming and expensive process. A concerted effort to train more U.S. physicians by building new medical schools and expanding residency programs would not bear fruit for 10 years, even if we began today. Nurse training offers faster turnaround times, but the nurse shortage is so severe that it too will take years to address.

Immigration offers the benefit of a qualified talent pool that could be readily available given a more practical and enlightened U.S. immigration policy. That is why the collapse of the Congressional immigration debate is likely to have serious if poorly understood consequences for healthcare. It left us with a legal immigration system that is completely out of touch with current realities.

Foreign medical graduates make up over 20 percent of physicians engaged in patient care in the United States and about the same percentage of doctors in training. Without them, access to medical services would be drastically curtailed and any hope of expanding healthcare coverage would be untenable. Foreign-born nurses compose only about 3.5 percent of the total nurse workforce, but they represented 15 percent of newly licensed nurses in the U.S. in the last two years, and they too are a vital resource on whom many hospitals depend.

Unfortunately, U.S. immigration policy is extremely restrictive when it comes to foreign born physicians and nurses. The Department of Labor has designated nursing as the number one shortage occupation in the country, yet foreign nurses are virtually excluded from accepting offers of employment here as they are unable to obtain permanent immigrant visas due to the limited supply.

Foreign physicians are restricted in their ability to work in the United States due to an annual cap on "H-1B" visas. The federal government received over 125,000 applications for such visas on April 3, 2007, the very first day that applications could be filed, even though only 65,000 H-1Bs are available each year. Once the cap has been reached, backlogs begin to develop which can exclude healthcare professionals from working in the United States for years and may cause them to seek employment elsewhere. Due to backlogs, foreign trained nurses are precluded from entering the United States for the next five years.

When Congress declined to act on illegal immigration, it also walked away from a broken and dysfunctional system of legal immigration. The essential problem is that so far Congress has linked these two issues, when they really should be regarded separately. It would be relatively easy for Congress to exempt "designated shortage professions" such as nurses from annual visa caps, or at least increase the quota of visas available to high-need professionals such as nurses and physicians. Congress also could act to recapture unused visas from prior years without undertaking comprehensive immigration reform. The Senate took action in October of 2007 by passing legislation that would do just that, allowing hospitals to resume hiring foreign nurses. Unfortunately, this legislation was rejected in the House of Representatives.

Practical remedies to our current legal immigration system are available, but it will take the full and vocal support of the healthcare industry to implement them. Advocating changes that would increase the supply of legal, well trained foreign health professionals should be an industry priority for 2008.


Susan Nowakowski is president and CEO of AMN Healthcare, the largest healthcare staffing company in the United States.
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