What do U.S. immigration policies mean for the healthcare workforce?

At Providence St. Joseph Health, eight staffers have been forced to take a leave of absence because they lost their ability to work in the U.S. under the Deferred Action for Childhood Arrivals program. And nearly 300 of the system's 110,000 employees are either nationals or dual-nationals from the seven countries targeted in President Donald Trump's travel ban.

"Even though that's a small number, it's pretty palpable that people who have been great employees are no longer working," said Dr. Rod Hochman, the system's CEO. "That's very problematic for us." Trump's various executive orders to implement the travel ban have been blocked in court several times, but the administration still believes it will prevail in banning travel from Iran, Libya, North Korea, Somalia, Syria, Venezuela and Yemen. The U.S. Supreme Court is currently deciding the fate of challenges to the executive order and is expected to rule in the coming weeks. Observers expect the high court's ruling to fall along party lines and ultimately uphold the travel ban. "Overall, I would say it's just cast a sense of doom over folks in terms of the way they want to interact and think about their work and their research," Hochman said. Some healthcare industry stakeholders also believe it's had a chilling effect on the number of international medical graduates applying to enter physician residency programs. Last year, the number of international medical graduates who applied to be matched into a residency program dropped 3% to 7,067 students. That number has fluctuated in the past, but the timing of the most recent decline raises eyebrows, especially since it comes after the proposed travel ban and several other policy changes. They include ending DACA, a program that gave immigrants a chance to live and work in the U.S. without threat of deportation if they were brought here illegally by their parents as children. Source: Immigrant Doctors Project Approximately 7,800 doctors working in the U.S. come from the countries on Trump's executive order. They provide up to 15.6 million appointments a year, according to the latest figures from the Immigrant Doctors Project, which is run by Harvard and MIT researchers. Other proposed policy changes potentially affecting healthcare staffing include limiting the number of work visas issued each year; limiting citizenship opportunities related to family-based immigration, which critics call "chain migration"; and revoking temporary protected status for migrants in the wake of humanitarian disasters. Many providers believe that these policy changes could cause the U.S. to lose its competitive edge in attracting talent to an industry that's already facing major workforce shortages. Even before the travel ban controversy arose, the Association of American Medical Colleges had projected the total physician shortage could grow to as many as 94,700 doctors by 2025. "A lot of people who come to my office say they feel that they are not welcomed here, and that they are from the wrong country or the wrong religion," said Carl Shusterman, a former trial attorney for the U.S. Immigration and Naturalization Service and now an immigration attorney who helps healthcare recruiting firm Merritt Hawkins procure work visas for international medical graduates. "I think people are going to more-welcoming countries." Shusterman is also concerned about the federal government's recent proposed limits on the number of work visas that are issued every year to highly specialized professions. Foreign physicians obtain work visas primarily through either the U.S. State Department's H-1B Temporary Visitor or J-1 Exchange Visitor programs in order to participate in their medical residency training. Both permit foreign healthcare professionals to work in the country and then return to the U.S. after going back to their home country for two years. Many doctors on a J-1 visa get a waiver that allows them to forgo the two-year requirement and remain in the country to work in a medically underserved area. An estimated 75% remain in the U.S. after completing their residencies, according to a 2016 report conducted by George Mason University's Institute for Immigration Research and nearly 80% of international medical graduates are involved in direct patient care during their training. In 2016, about 10,500 physicians received an H-1B visa, according to a 2017 study in JAMA. But the Trump administration has increased scrutiny of H-1B visa holders, which Shusterman and others believe has partly contributed to a two-year decline in H-1B applications. In the past year they fell 4.5%, from 199,000 to 190,098. Some believe the increased difficulty in procuring a visa has likely caused some prospective medical graduates to seek job opportunities in other countries such as Canada, the United Kingdom, Ireland and Australia, all of which had a share of foreign-trained physicians that was comparable to or higher than the U.S. in 2015, according to the most recent figures from the Organisation for Economic Co-Operation and Development. "I think that's a real risk, especially if things get more restrictive than they have already been," said Leon Rodriguez, a partner at the law firm of Seyfarth Shaw in Washington D.C., and former director of the Department of Homeland Security's U.S. Citizenship and Immigration Services. That could mean not only fewer staffers, but also obstacles to meeting the needs of an increasingly diverse patient population. For example, AAMC Executive Vice President Dr. Atul Grover said that in communities with patients of Somali, Afghani or Syrian descent, "it may make the most sense to recruit physicians who are both culturally sensitive for patients but also culturally aligned so that their non-Syrian and non-Somali colleagues can also have the benefit of learning what's culturally appropriate. This may affect patients in a number of different ways." At Providence St. Joseph, based in Washington state, that kind of diversity could make a difference. Roughly 1 in 7 residents in the state is an immigrant, while 1 in 8 residents is a native-born U.S. citizen with at least one immigrant parent, according to the Census Bureau. While only eight Providence staffers were affected by the end of the DACA program, about 800,000 people throughout the country are in danger being deported. It is unclear how many DACA participants are in the healthcare field. But in a letter sent to lawmakers in September, American Medical Association CEO Dr. James Madara said that in 2016, 108 students with DACA status applied to medical school. He estimated that the program could introduce as many as 5,400 previously ineligible physicians into the U.S. healthcare system over the next few decades. The letter also predicted that rural and underserved areas might be most affected since most DACA doctors are likely to work in high-need areas. The home health industry could also be particularly hard-hit since the number of immigrant healthcare workers in that field has risen from 520,000 in 2005 to 1 million in 2015, according to a 2017 report by PHI, a national research and consulting organization based in New York. That report found immigrants made up 25% of all home health workers in the country. The demand for skilled-nursing care will only increase as the estimated number of Americans age 65 and older is expected to double to more than 83 million by 2050. Home healthcare has become an increasingly successful strategy for redirecting patients out of costly hospital and nursing home visits for less serious issues. In fact, between 2016 and 2026, home health employment is expected to rise by nearly 500,000 jobs, according to a February article in Health Affairs. Supporters of the Trump administration's policies say any jobs rejected by foreign workers should go to qualified, U.S.-born candidates. "When you depend on an outside source for needed workers, it discourages the training institutions from expanding their capacity to train new healthcare professionals," said Ira Mehlman, media director for the Federation for American Immigration Reform, a D.C.-based organization that seeks to reduce both legal and illegal immigration. "There has to be some effort on the part of these institutions to say if we're going to need a million new doctors in the next 10 years then maybe we should start training people here in this country," he said. The AAMC's Grover says these efforts have been underway since 2006. He expects a 30% increase in the number of students enrolled in allopathic physician programs by year-end compared with 2002, and a 170% increase in the number of students enrolled in osteopathic programs during the same period. "To say that we just need to expand domestic enrollment of U.S. physicians—we've done that," Grover said. "But we need to be expanding our training to a point where we're training all those new grads plus a couple of thousand extra that right now need to come from foreign countries. We want to bring in the best and brightest from all over the world because that helps us with our own advancement of healthcare."