Carroll A. Immigration Reform’s Potential Effects on US Health Care. JAMA Forum Archive. Published online March 8, 2017. doi:10.1001/jamahealthforum.2017.0013
Immigration reform is a topic about which many people in the United States are passionate. It involves not only concerns about economic interests, but national security as well. Our health care system is especially sensitive to alterations in immigration policy. Recent events have highlighted the ways in which potentially small changes even to the ways we screen and admit refugees could affect the practice of medicine.
Aaron Carroll, MD, MS
The US health care system is very dependent on immigration. At the start of this decade, about 16% of all health care workers in the United States had been born in other countries. More than 25% of physicians were foreign-born. More recent data show that these percentages have only increased in the last few years.
Part of the reason for this is our system for training physicians. Compared with other countries, the United States produces many fewer doctors out of medical schools. In 2013, the United States was ranked 31st of 35 countries in the Organisation for Economic Co-operation and Development with respect to the number of medical graduates per 100 000 population.
With too few graduates and a widespread recognition of a shortage of medical services in the United States, allowing international medical graduates (IMGs) is the only way to fill all of the training slots at US residency programs. In the 2013-2014 academic year, IMGs comprised about 24% of specialty program residents and 36% of subspecialty program residents. Nearly two-thirds of nuclear medicine residents and more than 40% of internal medicine residents were IMGs. About 70% of IMGs aren’t US citizens, and even more were born outside the country.
States vary widely by their need for IMGs as well. While they comprise less than 10% of the physicians in Montana, Idaho, Alaska, Colorado, and Utah, IMGs make up more than a third of the physicians practicing in New Jersey, New York, and Florida. More than half of states have at least one-fifth of their physicians born and trained outside of the country.
They make up a huge percentage of our primary care workforce. More than half of the geriatricians in this country are IMGs. Almost 40% of internal medicine physicians, more than a quarter of pediatricians, and more than a fifth of family physicians are immigrants. More than 40% of all IMGs practice in 1 of these 4 specialties.
However, primary care isn’t the only area that is affected. Some of our most highly trained physicians are also IMGs. Of the 345 surgeons who work at 28 transplant centers, 30% of thoracic and 29% of abdominal surgeons are IMGs.
Most foreign-born physicians moving to work in the United States do not come from high-income countries, or even middle-income countries. A 2012 study found that almost half of IMG physicians came from countries with a gross national income per capita of $3855 or less.
Of these, more than 85% come from just 8 countries. More than 40% of IMGs come from India, and a fifth of those practice in New York and California. About 16% come from the Philippines and practice disproportionately in New York and California as well. About 10% of IMGs are from Middle Eastern countries. One in ten IMGs comes from Pakistan, and they practice disproportionately in Texas, New York, and Illinois.
Studies show that IMG physicians in the United States provide care that is at least comparable with that of provided by physicians educated at US medical schools. A recently published analysis of Medicare data showed that although patients treated by IMGs had slightly more chronic conditions, they also had lower mortality. Previous research has found similar results or no differences, but no studies have shown care by IMG physicians to be less than equal.
While a robust debate may be had as to whether the United States will have, or currently has, a physician shortage, it certainly has a shortage of physician services. That debate would end without IMGs, however. We would have an undisputed, massive physician shortage without them. Because IMGs are more likely to be generalists, more likely to practice in primary care shortage (nonurban) areas, and more likely to treat Medicaid patients, their absence would exacerbate already strained areas of health care.
Even the executive order “travel ban” signed by President Trump in January that temporarily prevented people from 7 Muslim-majority nations from entering the United States had an immediate effect on the US health care system. More than 8000 physicians currently practicing in the United States are from of those countries. Those who were overseas at the time the ban was signed were therefore prevented from entering the United States (how many were in this situation is unclear); those who wanted to travel to their home countries for a visit faced the prospect of not being allowed to reenter the United States. Even the revised travel ban issued on March 6, which focuses on preventing new visas from being issued from 6 of the 7 countries named in the original executive order (Iraq being excluded in the revised policy), will likely interfere with new residents, fellows, and physicians from those 6 countries from working in the United States.
Clearly the recent news-making bans aren’t the same thing as more protracted changes that might come from new immigration policy, but any talk of limiting immigration must take into account our dependence on it to keep the health care system, especially the primary care system, functioning properly. We already have an undisputed shortage of health care services, especially in some of the poorer areas of the country. Those shortages would only be worsened by reductions in immigrant physicians.
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