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Table 1.  
Percentage of US Health Care Professionals Who Were Non–US-Born or Noncitizens, by Health Care Occupation, 2016a
Percentage of US Health Care Professionals Who Were Non–US-Born or Noncitizens, by Health Care Occupation, 2016a
Table 2.  
Distribution of Select US Health Care Professionals by Region of Birth, 2016a
Distribution of Select US Health Care Professionals by Region of Birth, 2016a
1.
Khullar  D, Blumenthal  DM, Olenski  AR, Jena  AB.  US immigration policy and American medical research: the scientific contributions of foreign medical graduates.  Ann Intern Med. 2017;167(8):584-586. doi:10.7326/M17-1304PubMedGoogle ScholarCrossref
2.
Pinsky  WW.  The importance of international medical graduates in the United States.  Ann Intern Med. 2017;166(11):840-841. doi:10.7326/M17-0505PubMedGoogle ScholarCrossref
3.
Educational Commission for Foreign Medical Graduates. ECFMG fact card: summary data related to ECFMG certification. https://www.ecfmg.org/forms/factcard.pdf. Accessed July 24, 2018.
4.
US Census Bureau. American Community Survey (ACS): methodology. https://www.census.gov/programs-surveys/acs/methodology.html. Accessed October 23, 2018.
5.
Van Hook  J, Bachmeier  JD.  How well does the American Community Survey count naturalized citizens?  Demogr Res. 2013;29(1):1-32. doi:10.4054/DemRes.2013.29.1PubMedGoogle ScholarCrossref
Research Letter
December 4, 2018

Proportion of Non–US-Born and Noncitizen Health Care Professionals in the United States in 2016

Author Affiliations
  • 1Princeton University, Princeton, New Jersey
  • 2now with the US Congressional Budget Office, Washington, DC
  • 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
JAMA. 2018;320(21):2265-2267. doi:10.1001/jama.2018.14270

National estimates of the proportion of current health care professionals, including physicians, who are non–US-born or noncitizens are unknown. These proportions may be significant. For example, non–US-born medical graduates comprise approximately one-fifth of practicing US physicians,1,2 and among non–US-born medical graduates who match into residency positions in the United States, approximately 60% are not US citizens.3 Using data from the US Census, this study estimated the proportion of non–US-born and noncitizen health care professionals in the United States in 2016.

Methods

The Harvard institutional review board waived review for this study. Analyses used data from the American Community Survey (ACS), an annual, nationally representative, US Census Bureau–administered survey of US households. The survey, which had a 94.7% response rate in 2016, is collected by mail, telephone, and personal-visit interviews and includes information on all household members.4

Individuals in self-reported health care occupations were included (for list of occupations, see Table 1) based on the US census classification scheme. Non–US-born individuals were defined as those who reported not being born in the United States or US territories and noncitizens were defined as those who were non–US-born who reported not being a US citizen (noncitizens were therefore a subset of non–US-born). First, the proportions of individuals in each health care occupation category who were non–US-born or noncitizens were calculated. Then the proportion of all and selected health care professionals by region of birth was calculated. ACS-provided replicate weights and the complex survey modules in Stata (StataCorp), version 14.2, were used to account for the complex survey design of the ACS.

Results

Our sample included 164 122 health care professionals (which represented 5.2% of the 3 156 487 household members surveyed in the ACS in 2016). Of all US health care professionals, 16.6% (95% CI, 16.4%-16.8%) were non–US-born and 4.6% (95% CI, 4.4%-4.7%) were noncitizens. Non–US-born health care professionals comprised a substantial proportion of several professions: dentists (23.7%; 95% CI, 21.1%-26.2%); pharmacists (20.3%; 95% CI, 18.8%-21.7%); physicians (29.1%; 95% CI, 28.0%-30.3%); registered nurses (16.0%; 95% CI, 15.5%-16.6%); and nursing, psychiatric, and home health aides (23.1%; 95% CI, 22.4%-23.7%) (Table 1). Noncitizens were also represented considerably among dietitians and nutritionists (7.7%; 95% CI, 5.7%-9.6%); physicians (6.9%; 95% CI, 6.3%-7.5%); nursing, psychiatric, and home health aides (8.7%; 95% CI, 8.2%-9.2%); medical assistants (5.6%; 95% CI, 4.8%-6.3%); and dental assistants (5.5%; 95% CI, 4.6%-6.4%) (Table 1). The majority of health care professionals not born in the United States emigrated from Asia (6.4%; 95% CI, 6.2%-6.5%) or Central America or the Caribbean (4.7%; 95% CI, 4.6%-4.8%) (Table 2). Nursing, psychiatric, and home health aides emigrated predominantly from Central America or the Caribbean (11.7%; 95% CI, 11.2%-12.2%).

Discussion

In a nationally representative sample, non–US-born individuals and noncitizens comprised a significant proportion of many health care professions in 2016. These proportions were notable not only among physicians, on which previously conducted studies have focused,1 but also among the majority of other health care occupations that are important for patient care. As the US population ages, there will be an increased need for many health care professionals, particularly those who provide personal care like home health care aides, a large proportion of whom are currently non–US-born. Limitations of this study include reliance on survey-reported occupation, the possibility of underreporting of non-citizenship by certain subgroups, which has been documented previously with the ACS, and lack of detailed physician specialty information.5

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: August 31, 2018.

Corresponding Author: Anupam B. Jena, MD, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (jena@hcp.med.harvard.edu).

Author Contributions: Mr Patel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ly, Hicks, Jena.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Patel, Ly, Jena.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Ly, Jena.

Administrative, technical, or material support: Hicks, Jena.

Supervision: Ly, Hicks, Jena.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Jena reports receiving consulting fees unrelated to this work from Pfizer, Hill Rom Services, Bristol-Myers Squibb, Novartis, Amgen, Eli Lilly, Vertex Pharmaceuticals, AstraZeneca, Celgene, Tesaro, Sanofi-Aventis, Biogen, Precision Health Economics, and Analysis Group. No other disclosures were reported.

Funding/Support: This work was supported by grant 1DP5OD017897 from the National Institutes of Health (Dr Jena), grant T32AG000186 from the National Institute on Aging (Dr Ly), and grant 1L60MD01200201 from the National Institute on Minority Health and Health Disparities (Dr Ly).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This article has not been subject to the Congressional Budget Office’s (CBO’s) regular review and editing process. The views expressed here should not be interpreted as CBO’s.

References
1.
Khullar  D, Blumenthal  DM, Olenski  AR, Jena  AB.  US immigration policy and American medical research: the scientific contributions of foreign medical graduates.  Ann Intern Med. 2017;167(8):584-586. doi:10.7326/M17-1304PubMedGoogle ScholarCrossref
2.
Pinsky  WW.  The importance of international medical graduates in the United States.  Ann Intern Med. 2017;166(11):840-841. doi:10.7326/M17-0505PubMedGoogle ScholarCrossref
3.
Educational Commission for Foreign Medical Graduates. ECFMG fact card: summary data related to ECFMG certification. https://www.ecfmg.org/forms/factcard.pdf. Accessed July 24, 2018.
4.
US Census Bureau. American Community Survey (ACS): methodology. https://www.census.gov/programs-surveys/acs/methodology.html. Accessed October 23, 2018.
5.
Van Hook  J, Bachmeier  JD.  How well does the American Community Survey count naturalized citizens?  Demogr Res. 2013;29(1):1-32. doi:10.4054/DemRes.2013.29.1PubMedGoogle ScholarCrossref
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