Several immigration moves and executive orders by the current White House administration could affect healthcare and care giving in the U.S. in years to come. While no sweeping policy has happened, proposed policy changes could affect healthcare staffing. Current immigration efforts include limiting the number of work visas issued yearly, limiting citizenship opportunities in family-based immigration, and revoking temporary protected status for migrants in the wake of humanitarian disasters.
Some providers believe policy changes could cause the U.S. to lose its competitive edge in attracting talent to an industry that’s already facing major workforce shortages. But some point out that more demand for workforce will result in higher wages for native born citizens. Higher wages may just push more native citizens into the healthcare field, and if not, targeted federal policies allowing foreign-born health professionals will probably happen to keep up with demand. One thing for certain is national immigration actions will ripple into the biggest sector of the national economy. How could federal immigration issues effect healthcare, and especially nursing?
Home Health Aides will be in high demand; Senior Care/Long-Term Care will be looking for answers
As aging Baby Boomers will increase the demand for direct care workers, senior care will find itself at the center of the nation’s debate over immigration. The long-term care industry is already facing a worker shortage, and if tens of thousands of immigrants leave the U.S., the country’s growing elderly population will be left with fewer caregivers. The ending of the TPS (temporary protected status) of immigrants from El Salvador, Haiti, Honduras and Nicaragua by September 9, 2019 is one example of a policy that will affect supply workers for elderly care facilities. The Trump administration is proposing plans to bring in skilled immigrants while limiting overall arrivals, so watch for how elderly or long-term care workers fit into these plans. The Bureau of Labor Statistics shows that personal care aides and home health aides are among the fastest growing jobs in the country.
Losing the pipeline of foreign born elderly care workers would obviously drive up demand/wages for U.S. born workers in this category. But because Medicaid and Medicare is the largest payer for this type of care, wages cannot easily adjust when reimbursements stay stagnant.
International physicians, scrutiny could push them elsewhere
Some healthcare industry stakeholders believe various immigration executive orders have slowed the number of international medical graduates applying to enter physician residency programs. In 2017, the number of international medical graduates who applied to be matched into a residency program dropped 3% to 7,067 students. That number fluctuates yearly, but the timing is notable after some immigration policy changes. It doesn’t look like scrutiny of the H-1B visas is going to stop any time soon, and most foreign physicians obtain work visas through the H-1B Temporary Visitor or the J-1 Exchange Visitor programs to participate in residency training. Some estimates state that up to 30% of transplant physicians in the U.S. began their medical careers in other countries. We may see foreign medical graduates seeking opportunities in the United Kingdom, Ireland or Australia in years to come, the 3 countries which are generally competitors for international physicians.
It’s not just doctors
Dentists, occupational therapists, pharmacists, and physical therapists from other countries are important to American healthcare and talent supply. 15,000 international professionals in these job categories receive H-1B visas annually. Large health systems are citing a shortage of occupational therapists and physical therapists already.
Impact on scientific research, teaching, care, and health IT
Much of the science and research community relies on foreign students and professors. In fact there are reportedly 16,000 medical students in the U.S. who are from the 7 countries named in the recent travel ban. (Iran, Venezuela, Sudan, Somalia, Libya, Somalia, Yemen) Altering this pipeline of international talent could affect everything from bedside care to teaching and research. Bans could even affect admissions to scientific conferences and training seminars, which are vital in keeping the U.S. the hub of scientific progress.
Tech isn’t shielded from immigration policies either. Finding the best talent for healthcare IT positions is crucial as the U.S. leads this sector. The Census Bureau reports that 24% of the overall U.S. IT workforce is foreign-born. While a U.S. nursing and physician shortage is old news, a shortage of healthcare IT workers is also an ongoing concern. IT professionals in needed job categories could be earmarked in the fast-tracked skilled immigrant worker category, but administrative burdens could push these workers other places.
Insurance coverage – Better percentages of insured populations, but less unauthorized non-citizens will attain subsidized care or social programs
Since 2016 there has been increased focus on immigration enforcement and scrutiny of undocumented immigrants. Recent focus groups with immigrant families show that fears are leading to some decreased participation in Medicaid, CHIP, and other programs. In addition, fewer eligible immigrants may enroll in health coverage options due to recent cuts in federal funding for consumer outreach and enrollment assistance, particularly since direct one-on-one outreach and assistance is often key for overcoming the enrollment barriers faced by many immigrants. Lastly, there remains uncertainty around continued federal grant funding for community health centers, which are an important source of care for immigrants, particularly those who are uninsured.
While immigration scrutiny could lead to unauthorized immigrants attaining less subsidized health coverage, the overall rate of insured U.S. residents could increase. Of the estimated 23 million non-citizens residing in the United States (about 7% of the total resident population), nearly 40% are uninsured compared to less than 9% for U.S. born and naturalized citizens. This could increase hospital reimbursement metrics.
How could it affect nursing?
Foreign-born nurses make up about 15% of RNs in the U.S., according to a June 2016 report by the Institute for Immigration Research at George Mason University and the Immigration Learning Center. California, New York, Florida, Texas and New Jersey employ more than half of these nurses, but they are needed in other parts of the country too, particularly in rural pockets. The states of California, Oregon, Washington, Nevada, Montana, New Mexico, Georgia, South Carolina, and Maine are expected to have noticeable nursing shortages by 2025. Colorado and North Carolina are going to have an even higher nurse shortage. Arizona is expected to have the worst U.S. nursing shortage by 2025, with 28,000 fewer RNs than necessary. This could even result in less retirees and snowbirds flocking to this warm weather haven.
Nurse wages could go up…. even more
Demand for nurses, especially in a few high need metro areas, has already pushed nursing wages up. Perks like signing bonuses, student loan repayments, and housing programs to attract new talent is becoming the norm. But a study by the Institute of Government and Public Affairs points to even higher wages if nurse immigration were to slow down. Evidence shows that immigration by foreign-trained nurses increases the supply of nurses and this increase in supply is associated with a decrease in annual earnings. Estimates suggest that a 10% increase in supply due to immigration is associated with a 1-4% decrease in annual earnings. So it is reasonable to think that a decrease of foreign trained nurses will increase nurse wages and recruitment efforts.
Nurse immigration to the United States is critical; a shortage of 200,000 nurses is expected by the year 2020. A disruption of international nurses coming to the U.S. would be a very big deal. Whoever is in the White House in the next 5-10 years will probably exempt and streamline applications for international nurses, especially in some high-need areas with the worst nurse shortages. The government has eased immigration restrictions on foreign trained nurses in the past, such as the Immigration Nursing Relief Act of 1989 which established five-year H-1A visas. Many of these immigrant nurses adjusted to lawful permanent resident status.
- “What do U.S. immigration policies mean for the healthcare workforce?” Modern Healthcare, May 19, 2018, Steven Ross Johnson
- “Will New Immigration Laws Prevent International Nurse Recruitment,” May 9, 2018, Ronald Shapiro
- “Effect of Immigration Nurses on Labor Market Outcomes of U.S. Nurses,” U.S. National Library of Medicine, National Institutes of Health/HHS Public Access Report, Robert Kaestner and Neeraj Kaushal
- “5 ways Trumps Travel Ban Affects Nurses,” Nurse.org, Keith Carlson, BSN, RN, NC-BC
- “Immigrant Nurses: Filling the Next U.S. Shortage,” Lisa Esposito, U.S. News & World Report
- “What President Trump’s New Immigration Law Means for Our Nurses,” SWHealth, Nathan King
- “How Trump’s Immigration Polices Could Affect Senior Care,” Time Magazine, Abigail Adams, May 10 2018
- June 2016 report by the Institute for Immigration Research at George Mason University and the Immigrant Learning Center
- The Bureau of Labor Statistics 2018
- “Health Coverage for Immigrants,” Henry J. Kaiser Family Foundation December 13, 2017