Just as President Donald Trump's tariffs are wreaking havoc with American farmers and many manufacturers, his misguided immigration policies will inevitably impose a large and unnecessary burden on the nation's healthcare system.
Rural communities, where support for the president has been strongest, will feel the pain first. But it will also ripple through major cities, where the healthcare workforce has become highly dependent on a steady stream of physicians, nurses and support staff born in other countries.
The partial government shutdown over funding for Trump's border wall, the longest in U.S. history and still going strong as of this writing, sends an unmistakable signal to foreign-born healthcare workers that they're not welcome here.
The administration's anti-immigration stance fails to recognize the extent to which providers now depend on foreign-born workers. A JAMA study in early December found nearly 30% of the physician workforce is foreign-born. Nearly a quarter of those doctors are not citizens. In many rural and impoverished communities, 1 in 3 doctors are foreign-trained and likely visa-holding immigrants, according to the American Immigration Council.
On the other end of the wage spectrum, 24% of nursing, home health and psychiatric aides are foreign-born, according to a 2017 analysis by the Migration Policy Institute. In California, New Jersey and New York, the number is more than half. Some are working here without legal documentation.
It's important to remember that over the past decade, the healthcare industry served as America's last-resort hiring hall. During the 2008-09 recession, the sector added over 5 million jobs, offsetting about a third of the devastating job losses in the rest of the economy.
In the years since 2010, when the recovery began, the pace of healthcare job growth fell off significantly. Yet hospitals, physician offices and other providers still added over 2.5 million jobs. The Bureau of Labor Statistics projects healthcare support staff occupations will remain among the fastest-growing job categories in the decade ahead.
Will native-born Americans take those jobs if immigrants fail to show up? If history is any guide, it will require a substantial hike in pay and benefits for those positions to attract workers, especially given the current job market with its growing number of higher-paying alternatives.
As I've argued in this space before, the bottom half of the healthcare workforce deserves an increase in wages and benefits. They also should be given better training and more responsibilities as part of the sector's overall effort to improve quality and raise efficiency.
But taking that high road has major implications. In the short run, it will raise costs for healthcare payers, whether it's the government or private insurers. Are they prepared to step up to the plate and lift reimbursement rates for services like home health and behavioral health, which now employ large numbers of the foreign-born?
In the long run, the high-road wage strategy will reduce spending since it will hasten the ongoing shift away from high-cost, acute-care settings. Even with higher wages, treatment at home or within assisted-living and skilled-nursing facilities still costs less.
But it will also slow the pace of hiring and change the composition of the healthcare workforce. An America with better-trained aides and technicians capable of delivering more efficient outpatient care won't end the need for more doctors. We're still an aging society. But it will change the required skill mix.
It will raise the demand for primary-care physicians capable of coordinating care and preventing chronic disease. It will reduce demand for specialists who earn outsized incomes from their fee-for-service procedures delivered in hospitals.
Primary-care slots are precisely what foreign-born doctors have trained for and are willing to take. Those are precisely the people Trump is scaring away with his cruel and counter-productive immigration policies.