Shifts in immigration policy in the wake of the war on terrorism have diminished the flow of foreign physicians into U.S. practice venues, particularly medically underserved areas, according to a recent report by an Washington, D.C.-based immigration policy group.
But immigration policy changes that occurred even prior to the terrorist attacks of Sept. 11, 2001, have halved the supply of foreign-born nurses in the United States, the report says.
As a result, despite a national shortage of about 126,000 nurses, the average number of nurses granted legal residence status in the United States each year fell to about 4,800 in the late 1990s, compared with 8,600 at the start of the decade.
The report points out that the U.S. healthcare system heavily relies on foreign workers. It employs 1.1 million immigrants, or 13% of all healthcare providers.
The foreign-born account for 25.2% of all U.S. physicians, 17% of nursing, psychiatric and home health aides, 15.8% of clinical laboratory technicians, 14.8% of pharmacists and 11.5% of registered nurses, according to "Health Worker Shortages and the Potential of Immigration Policy."
The report was written by Rob Paral, adjunct faculty member in the Department of Sociology at DePaul University in Chicago, for the American Immigration Law Foundation, a research arm of the American Immigration Lawyers Association trade group.
The U.S. Department of Agriculture in February 2002 withdrew as the primary sponsor of foreign-born physicians who were allowed to remain in the country after taking their residency training here under the J-1 visa program.
The program required the newly trained physicians to return to their home countries and stay for at least two years before they could apply for permission to work in the United States or be granted permanent residence here. They could remain, however, if they obtained a waiver from a sponsoring agency, including the USDA, in return for a pledge to work in medically underserved rural areas of the United States.
An estimated 35 million Americans live in designated health professional shortage areas where 16,000 more physicians would be needed to alleviate the shortfall today, and as many as 50,000 by 2010, according to the report.
Yet, after the USDA withdrawal, no federal program replaced it for 18 months, and when HHS launched a successor program in July 2003, it suspended the program a few months later, re-opening it again only after tightening eligibility rules, the report said.
Under these new restrictions, HHS would only approve waivers from the most underserved areas and only for work in community health centers and rural clinics. In Texas, for example, according to the report, 231 counties qualified as underserved under the old HHS guidelines, but just 46 counties did under the tighter restrictions, and only about two dozen of those have qualifying clinics. These restrictions eliminate about 86% of previously qualifying areas, according to the report.
In 2001, HHS and other federal agencies sponsored 525 waivers of medical school graduates. That number dropped to 386 by 2002.
Another waiver program, the 1994 Conrad 20 program -- named for its sponsor, Sen. Kent Conrad (D-N.D.) -- which provided 20 waivers per state, has picked up some of the slack. The number of waivers under the program has been upped to 30, but overall "it's still a net decrease from in the past," said Paral.
In addition, the program, perhaps reflecting its senatorial roots, apportions waivers not by need or population, but equally among the states.
"Texas gets as many as Vermont, which doesn't make sense," Paral says.
His report concludes that HHS? administration of the physician waiver program and the increased restrictions "raise concerns about whether the program will ever process significant numbers of waivers."
A similar bottleneck restricting the supply of foreign born nurses came with the Immigration Act of 1990, which provided H-1B visas for certain high-skilled workers, including computer programmers and nurses. The act required all nursing applicants for a waiver be graduates of a four-year college degree program, even though only one of the 50 states requires a college degree as a condition for nursing licensure, the report said.
The H-1C visa program specifically for nurses, created in 1999, makes available only 500 visas a year for hospitals in health profession shortage areas, but with caps on individual states.
"The shortage of 126,000 nurses nationally and the high wages that many hospitals are paying to fill those shortages lay to rest any concern about native-born nurses being frozen out of positions by the presence of foreign-trained professionals," the report said.
The foundation does not take a policy position favoring relaxing immigration standards, Paral says. For example, the report suggests the shortage of medical professionals could be met by increasing the number of positions for native-born candidates in U.S. medical training programs and by providing additional financial incentives to draw their graduates to underserved areas. But it also points out that adding slots in medical schools and residency programs would take years, if not decades, to eliminate current shortages; and even doubling the current admission rates to U.S. nursing schools beyond the current 7,000 per year would have little impact on the 126,000-nurse shortfall.
Dealing with the nursing shortage, the report concludes, "clearly requires a rethinking of immigration policy."