Greg Siskind on Immigration Law and Policy
Will uscis sabotage the new health care bill?
This evening Congress passed historic legislation extending
health coverage to more than 30 million more Americans. That's the equivalent
of adding the population of the entire country of Canada to the insurance
rolls. This is going to be a monumental challenge for many reasons one of which
is the fact that the country already has a severe physician shortage. According
growing shortage of primary care doctors could place a major burden on the U.S.
healthcare system if President
Barack Obamasucceeds in extending medical
insurance to millions of Americans who currently lack it.
healthcare legislation works its way through the U.S. Congress, most of the
focus has turned to how to finance a reform that could cost $1 trillion in the
next 10 years and aims to cover most of the 46 million uninsured Americans.
attention has been paid to what might happen if millions of new patients join a
healthcare system that is unprepared and unequipped to handle the load.
United States already has a shortage of between 5,000 and 13,000 primary care
doctors, according to the Robert Graham Center. Add millions of previously
uninsured people and the shortfall will balloon to as many as 50,000 doctors.
So why in the world is US Citizenship and Immigration
Services enacting *a series of policy
changes to make it more difficult for foreign-born, American-trained doctors to
get visas to remain in the US after receiving the US taxpayer-subsidized graduate
medical education at teaching hospitals around the US.
More than 25% of the doctors in training in the US are
international medical graduates. *Immigration
policies that tend to drive these doctors out of the country rather than
encouraging them to remain can have a dramatic impact on Americans access to
What are those policies? Here's an incomplete list that
gives you and idea:
The January 2010 Neufeld memorandum that
essentially bars the use of H-1Bs by doctors who are not directly employed by
hospitals and health care facilities. Most doctors have traditionally been
employed by groups or self-employed and many states actually mandate this.
USCIS is taking draconian interpretations of
H-1B cap exemption requests by physicians working at non-profit institutions
affiliated with universities and research institutions. USCIS has a great deal
of discretion here but chooses to take a restrictive view that drastically
limits employment opportunities for many doctors.
More than a quarter of international medical
graduates are Indian nationals who face green card backlogs of 5 to 10 years
longer than almost every other nationality. As I blogged yesterday, USCIS has
the ability to enact policies to alleviate the backlogs including changing the
way "filing" is interpreted and not counting spouses and kids in the green card
USCIS routinely excludes physician graduate
medical education from benefits it extends to those pursuing graduate degrees
in the US. For example, the bonus cap of 20,000 H-1B visas is interpreted in
such a way that US-educated doctors are excluded. And USCIS has not created a "cap
gap" bridge provision to keep doctors waiting on October 1st H-1B
start dates even though it has created a similar one for other job categories.
Until the AAO stepped in, USCIS recently took
the position that the MBBS medical degree - the degree used in more than 40
countries including India and the United Kingdom - was not an advanced degree
and all such doctors should be relegated to a low employment-based green card
preference level with waits of nearly ten years.
There are many other issues I could include in the list.
USCIS should see itself as playing a critical role in helping to implement this
momentous legislation. It needs to identify every policy that serves to curb
the supply of doctors (and other health professionals) and embrace the "yes we
can" philosophy of this Administration to reverse course and be a part of the
The situation for other health care professionals is also severe and will only get worse as a result of the new legislation. Despite the economic downturn, the nursing shortage in the US persists with a gap of 50,000. That number was expected to increase significantly in years to come even before the new legislation was passed. And the shortage of other health care professionals - physical therapists, pharmacists, medical technologists, etc. The problems noted for doctors apply here as well, but can be even more severe. For example, USCIS takes extremely conservative views on which jobs qualify for H-1Bs and has generally rejected most nurse positions as being below H-1B caliber and ignored its own memorandum from 2002 on the subject.
Congress, of course, could do a lot to improve the situation
as well.* North Dakota Democratic Senator Kent Conrad's S.682 bill
which would make a number of improvements to physician immigration rules. The bill creates H-1B cap exemption opportunities for doctors going to the worst shortage areas and also creates green card cap exemptions to reward such service.
On the nurse front, HR 2536, the Emergency Nursing Supply Relief Act, introduced by Congressman Robert Wexler (D-FL) would immediately help relieve the bottleneck that has caused a five to ten year wait to bring in nurses to the US. That legislation is sorely needed and needs to be strengthened to include a broad exemption from green card caps for nurses and other allied health professionals until we have a domestic pipeline of workers that can meet our needs.*
Many on both sides of the immigration debate will be tempted to say we should roll these bills in to a comprehensive immigration reform bill. That's fine, but these bills need to be put on a separate track independent of broader immigration legislation. They are health care bills more than immigration bills and we can no longer afford to wait for these crucial issues to be addressed. The time to act is now.