One week after taking office, President Donald Trump delivered on a high-profile campaign promise and issued an antiterrorism order that has reverberated around the world. The president banned nationals of seven Muslim-majority countries (Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen) from traveling to the US for the next three months, suspended admission of all refugees for four months, and indefinitely blocked admission of Syrian refugees to the US. Up to 100,000 people were affected, with many detained, some deported, and thousands overseas forced to change their travel plans to the US.
Some physicians employed in the United States were caught up in the executive order. The episode has not only provoked a showdown over the federal courts' authority to block the president's order, it has alerted health care organizations that they may be unable to keep their staffing at full strength. In California, hundreds — possibly thousands — of doctors could be affected by immigration bans.
How Many Noncitizen Physicians Are in California?
At CHCF's request, Janet Coffman, a health services researcher and associate professor at the UCSF School of Medicine's Institute for Health Policy Studies, and research associate Igor Geyn mined the American Community Survey Public Use Microdata Sample from 2011 through 2015 to provide estimates. The data suggest that 5,040 physicians employed in California in 2015 were not US citizens — fully 5% of the 97,436 physicians working in the state. Of the non-US-citizen doctors in California's physician workforce, 204 are from countries covered by President Trump's travel ban; Iran had the most, at 169, with Syria representing 22, and Iraq 13.
Here are the nations with the most nationals employed as physicians in California:
Another 30,541 employed physicians in California, or 31% of the total, are naturalized US citizens, Coffman said, noting that many of them were likely practicing medicine in the state at some point as non-US citizens.
The extent to which health care organizations rely on immigrant health care professionals may not be fully appreciated by policymakers in Washington. More than one in four physicians in the US was born overseas, and foreign-born professionals account for 16% of all civilians employed in health care occupations.
Available data about the trainee pipeline (PDF) suggest that significant reliance on immigrant physicians will continue in California. Last year, 78 non-US-citizen graduates of non-US medical schools were placed in first-year residency positions in California, according to Coffman. This group included 75 graduates of medical schools outside the US (other than Canada). That's about 3% of total matches for first-year residency positions in California.
Nationally, more than half of the 7,024 internal medicine positions in the 2016 US residency match were filled by graduates of medical schools outside the US, according to a February 1 article in the New England Journal of Medicine (NEJM). Residencies last up to seven years, so the affected population is many times larger than the one-year match figures indicate.
In addition to trainees, thousands of full-fledged young physicians from overseas are required to obtain a so-called J-1 immigration waiver in order to remain in the US after training. Among the 9,206 J-1 doctors in the US in 2015, the NEJM article reported that 1,879 of them were from Muslim-majority nations, including Syria.
Immigrant Docs Serve Needy Communities
Health care employers nationwide disproportionately rely on immigrant doctors to deliver hospital and primary care, especially in medically underserved communities in rural, urban, and tribal areas. If the ban or a variant of the executive order survives the legal challenges, we can expect adverse effects on international medical students applying for positions at hospitals and on medical residents from the seven Muslim-majority nations already working in the US.
By working in underserved areas, noncitizens can obtain waivers from US immigration rules requiring them to return home for at least two years after training before resuming work in the US. As a result, noncitizen physicians in the US are more likely to work in rural areas and in hospitals in underserved areas.
This map shows areas with shortages of primary care physicians.
Source: Health Resources and Services Administration (HRSA), Division of Data and Information Services, Office of Information Technology. HRSA Data Warehouse, Map Gallery: Health Professional Shortage Area Facilities – Primary Care.
"Many immigrants take the toughest jobs in medicine, work in the most undesirable places, and take care of the most difficult-to-treat patients," Bruce Y. Lee, associate professor of international health at the Johns Hopkins Bloomberg School of Public Health, wrote in a recent article. "Many immigrants work in clinics and hospitals that serve rural America."
And immigrant doctors are delivering high-quality care, Lee said. For Medicare beneficiaries admitted to hospitals, 30-day adjusted mortality rates were lower for patients treated by international medical graduates than for those treated by US medical graduates, despite international graduates caring for patients with higher rates of chronic conditions, according to a Harvard study published last month in The BMJ. The research focused on 1.2 million hospitalizations under the care of 44,000 general internists.
Physician Pipeline Narrows at a Time of Shortage
The Association of American Medical Colleges anticipates that by 2025 the US physician supply will be 94,700 short. AAMC Executive Vice President Atul Grover said he worries about the potential for immigration restrictions to disrupt the lives of medical trainees and their patients.
"These are doctors," Grover said. "They could be exceptional practitioners, and I don't know if you want to stop them from coming here and serving their patients."
Volatile legal and political dynamics make the situation fluid and unpredictable. The health care industry will need to remain vigilant about changes in immigration policies that could worsen the access problems facing millions of medically underserved Americans, including those here in California.