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Greg Siskind on Immigration Law and Policy

Will uscis sabotage the new health care bill?

Rating: 4 votes, 4.00 average.

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
to Reuters:

growing shortage of primary care doctors could place a major burden on the U.S.
healthcare system if President Barack Obama succeeds 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
health care.

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.

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  1. guest's Avatar
    How about the new legislation for Nurses. There is a big backglog in this visa cathegory too.
  2. Jim's Avatar
    If people think there is a physician shortage then that 40-50,000 shortage is nothing to the 250-260,000 nursing shortage by 2015. And remember, by 2014 32 million more people are expected to be insured by then. And just like Greg mentioned, that is roughly the size of some countries. That's no big joke.

    What's more scary is all those physician and nursing shortage projections does not account yet HCR but just the status quo.

    California is even expected to need 80,000 nursing in just 5 years.

    The 60,000 visas for nurses (20k a year for 3 years) mentioned from all those previous nursing bills floated the last 3 years will not even be enough just for one State in California.
  3. George Chell's Avatar
    USCIS wants to kill our seniors! Perhaps AARP should run a commercial suggesting as such!
  4. George Chell's Avatar
    And my mother wonders why I go to Singapore to get my Primary Care..medical check up. I use an American brain drain doctor there. He is a Primary physicians from Minnesota and now lives and practices and Singapore.
  5. Gary's Avatar;jsessionid=7F261432B365861DCDA409D5B456B02B.w5?a=565917&single=1&f=28

    Thomas L. Friedman

    Indeed, if you need any more convincing about the virtues of immigration, just come to the Intel science finals. I am a pro-immigration fanatic. I think keeping a constant flow of legal immigrants into our country - whether they wear blue collars or lab coats - is the key to keeping us ahead of China. Because when you mix all of these energetic, high-aspiring people with a democratic system and free markets, magic happens. If we hope to keep that magic, we need immigration reform that guarantees that we will always attract and retain, in an orderly fashion, the world's first-round aspirational and intellectual draft choices.
  6. Jim's Avatar
    Friedman is absolutely correct.

    And with the passage of HCR, immigrants will have renewed interests to be entrepreneurs. There might be a small business boom in America and then they will be able to buy the excess homes and so on and so forth. Win-win
  7. Greg Siskind's Avatar
    I've expanded my original post to include more on the other professions as well as actions needed by Congress.
  8. Adi's Avatar
    More deportations, more h1b raids, weird memos intrepreting laws, disregard to previous memos, disregard to humane way of dealing with immigration, characterization of immigrants as unwanted garbage in the country......good going Mr. President. Sometimes it makes me miss Bush era.
  9. Dan's Avatar
    The very next question should be asked is, what will Graham do now since the HC bill is passed?
  10. My 2 cents's Avatar
    Janet Napolitano needs to be fired, she is incompetent (obvious from her handling of the x'mas day bomber & all the memos coming from USCIS). Put someone like Arnie Duncan in charge for radical, bold & thorough shakeup of USCIS.
  11. trend06's Avatar
    Greg blogged about point # 3 earlier this weekend:

    The impact of this "Mehta-Endelman" plan, if enacted, cannot be understated. If dependents are not counted off the quota, and you assume that on AVERAGE there is 1 dependent per primary applicant, then it will have the effect of doubling the quota overnight, thus speeding the green card process by 50% -- just by virtue of a simple administrative policy change. No CIR needed!

    Now the question is will they do it and will AILA get behind this Metha-Endelman plan.
  12. trend06's Avatar
    I meant it cannot be overstated! Got too keyboard happy there
  13. Jim's Avatar
    The Senate should really strongly consider adding the Emergency Nursing Relief act to the Reconciliation package this week.

    If the student loan bill can be part of it, I do not see why not an Emergency Nursing relief act cannot be included in the Reconciliation package specially since it is more HC related and w/c HCR directly affects.

    And I do not see the nursing unions making a fuss about it anymore specially after HCR just passed. They must be crazy if they think they can handle everything on their own. The nursing turn-over ratio would not last 3-5 years anymore with all those projections. New grad nurses will be quitting in 1-1.5 yrs. Maybe 2.5 yrs at most if they are masochists.

    And of all States, California would be the hardest hit. The State where the largest nursing union is located and where the first HC system would collapse because of a shortage of 80k ++ nurses in 5 yrs. Getting other domestic nurses from other States into California would be a hard sell as well because CA is bankrupt and has high taxes.
  14. George Chell's Avatar
    "The Senate should really strongly consider adding the Emergency Nursing Relief act to the Reconciliation package this week."

    It is time to do something dramatic..either the President forces USCIS to interpret the law broadly regarding the medical visas, or the AARP should run commercials saying that the USCIS and the Nursing Union wants to kill grandma!

  15. Jim's Avatar
    The GOP succeed in opening up the Reconciliation package and it would have to be returned to the House for another vote.

    Since the reconciliation package is now open, could both parties agree on adding an amendment to fix the physician and nursing shortage. Can someone point them to that suggestion.

    Instead of trying to add silly amendments like no Viagra for sex offenders and other silly amendments that are really just their just to slow things down why not add real meaningful amendments to fix the healthcare worker shortages.

  16. Nikki King's Avatar
    There are several american trained nurses that have gone thru highschool, college, worked using the OPT for a year and are still waiting for visa? Yet there are many job openings in nursing homes, rural areas, online, travel but they can't work...remain in school and continue waiting. BUT FOR HOW LONG?
  17. Belinda's Avatar
    Why go overseas, when we have nurses out of school in the Us that can't get jobs? Something is wrong here.
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