Doctors Battling Borders: How U.S. Immigration Policies Are Exacerbating the Nation's Physician Shortage.

• Author: Cornelio, Vania

"Non-U.S. [International Medical Graduates] play a critical role in providing healthcare to many Americans because they tend to choose primary-care specialties and work in areas of the country with higher rates of poverty; they are providing important medical services to communities in need.... [A]bout 20.8 million Americans live in areas where at least half of the physicians are foreign-trained." (1)

1. INTRODUCTION

   According to data published by the Association of American Medical Colleges, the United States could see an increased shortage of up to 121,300 physicians by the year 2030--a shortage that would more dramatically affect the promise of healthcare throughout the nation. (2) The current shortage is exacerbated by an increasing demand for physicians, stemming from both a growing and aging population, as well as the prevalence of chronic disease, expanded insurance coverage, and a recovering economy. (3) To combat the shortage, hospitals and residency programs must compete on the world stage to attract international medical graduates (IMGs)--foreign students who graduated from medical schools outside of the United States and Canada--in order to meet the demand. (4) Unfortunately, U.S. immigration policies have narrowed the doorway for the talent the U.S. healthcare system desperately needs, as IMGs, as well as foreign-born physicians--foreign doctors who graduated from either U.S. or non-U.S. medical schools--meet a complex immigration barrier at every turn. (5) An IMG must first complete residency training in the United States as a J-1 Exchange Visitor, then return home to fulfill a two-year foreign residency requirement for his or her J-1 visa or seek a waiver of the requirement. (6) Finally, IMGs must usually attain an H-1B nonimmigrant visa before they can practice medicine in the United States. (7)

   The United States' underserved urban and rural areas are those most negatively affected by the physician shortage. (8) Studies have shown though, that when compared with medical graduates who are U.S. citizens, IMGs are more likely to practice in both inner cities and rural communities, and are more likely to enter essential practice areas such as primary care and family medicine. (9) The Conrad Waiver Program (Conrad Program), a state-based program Congress implemented to provide physician resources, was implemented to assist underserved areas by granting waivers of the home residency requirement for IMGs if they were committed to work for three years in a designated "medically underserved area." (10) Launched in 1994, the Conrad Program originally allowed each state's Department of Health to sponsor up to twenty IMGs each year for a waiver of the two-year home residency requirement of the physician's J-1 visa. (11) Congress has reauthorized and extended the Conrad Program multiple times with reforms, allowing for an increase to thirty spots per state, and allotting ten waivers or "flex slots" per year for locations not designated as underserved, but that serve patients from underserved areas. (12)

   Nevertheless, the Conrad Program needs to undergo reform in order to address the acute physician shortage, and the Conrad Program's supporters seek to have it extended until 2021. (13) Legislation to reform the Conrad Program, the most recent introduced in March 2019, has been stalled, and discussion around reform is more contentious than ever due to the current national debate surrounding immigration. (14) If a bill is not passed to extend the Conrad Program, the entire waiver system could break down. (15)

   In the meantime, IMGs face formidable barriers to attaining necessary visas due to rigid immigration policies under the current administration. (16) Compre hensive immigration reform has been delayed at every pass, and changing attitudes and government policies have created an inhospitable landscape of uncertainty and hostility. (17) Specifically, President Donald Trump's executive orders, "Buy American and Hire American" (BAHA Order) and the so-called "Travel Ban" (Travel Ban), have created more barriers preventing IMGs from applying the skills that are essential to maintaining and growing the U.S. healthcare system. (18)

   This Note examines and analyzes prior and current immigration policies that have hindered IMGs from filling U.S. hospital positions and benefitting the U.S. healthcare system. (19) Part II maps out the various immigration processes that IMGs must complete in order to enter the U.S. medical field, and reviews the history of the Conrad Program. (20) Part II also details previously proposed legislation for reform and discusses the current administration's policies that have blocked reform. (21) Part III analyzes reform bills under consideration and evaluates their strengths and weaknesses, as well as outlines the negative effects of the current U.S. immigration landscape on the healthcare sector. (22) Finally, Part IV advocates for policy changes that should be made in order to combat the physician shortage that the nation faces. (23)

2. HISTORY

   1. Becoming a U.S. Physician: The Residency Training Program

      For an IMG, the path to obtaining medical licensure in the United States is long, costly, and confusing. (24) An IMG is a "physician who received a basic medical degree or qualification from a medical school located outside the United States and Canada." (25) Although these IMGs may be qualified as physicians in the country from which they graduated, they must still pursue U.S. programs of Graduate Medical Education (GME), which aim to prepare physicians for practicing in the United States. (26) Most GME programs are overseen by accreditation boards, and include training under the direct supervision of attending physicians. (27) In order to enter a training program to become a clinical physician, however, the IMG must be sponsored and certified by the Educational Commission for Foreign Medical Graduates (ECFMG). (28)

      1. ECFMG Certification

         The ECFMG is the sole institution that assures eligibility of training programs for IMGs in the United States and exclusively manages the J-1 Exchange Visitor Program for Alien Physicians. (29) The medical community created the ECFMG in 1956 to evaluate IMGs' qualifications before they enter U.S. GME programs. (30) In addition, the ECFMG verifies each IMG's medical graduation status, administers certain prerequisite exams before IMGs may enter residency training programs, and certifies requirements of non-Canadian-educated IMGs to train to practice medicine in the United States. (31)

         To satisfy eligibility standards for ECFMG certification, an IMG must meet several requirements, the first being the medical school requirement. (32) The IMG's medical school must meet certain qualifications as defined by the ECFMG and listed in the World Directory of Medical Schools. (33) Additionally, the IMG must submit an online application for ECFMG certification attesting to his or her identity and degree. (34) Finally, most IMGs must pass Step (1) and Step (2) of the United States Medical Licensing Examination (USMLE), which can take years to prepare for and pass. (35) Once the IMG completes each of these steps, the ECFMG will issue a certificate to the IMG, allowing the IMG to begin the mandatory U.S. residency training program. (36)

      2. The Residency Training Program

         After receiving ECFMG certification, any IMG who wants to practice medicine in the United States must complete an accredited residency training program in the United States or Canada, regardless of whether he or she previously received similar training overseas. (37) Depending on the area of medical specialty, these training programs take between three to eight years, and involve long hours and low pay. (38) In order to qualify for and enter these programs, however, the American Medical Association advises IMGs to submit a minimum of twenty five comprehensive applications to have the chance to "match" with a desired residency program. (39) The National Resident Matching Program (NRMP) annually administers The Match process to link applicants and hospital residency programs--a process all U.S. and non-U.S. medical students must undergo. (40) Congress funds these residency programs, which have a limited number of slots available each year. (41)

         IMGs face many challenges in order to be matched with a residency program, while also competing with U.S.-trained medical students as part of the overall matching process. (42) As of 2018, the overall position "fill rate" for residencies was 96.2%, with 94.3% of graduating U.S. medical students matching compared to only 56.1% of non-U.S. IMGs matching to a residency position. (43) The discrepancy in figures can be attributed to IMGs demonstrating lower USMLE test scores and not ranking enough residency programs necessary for The Match process. (44) Most importantly, however, in order to be eligible for and engage in these clinical training programs, the IMG must obtain a visa. (45)

   2. Entering the United States: The J-1 Exchange Visitor Program

      1. History of the J-1 Visa

         The most common visa path for IMGs is the J-1 nonimmigrant visa, also known as the Exchange Visitor Program. (46) The earliest roots of the Exchange Visitor Program date back to 1948, when Congress enacted the Smith-Mundt Act. (47) The purpose of the Exchange Visitor Program within the Smith-Mundt Act was to "promote mutual understanding" between the American people and people of other countries. (48) Four years later, the Immigration and Nationality Act (INA) replaced the Smith-Mundt Act, incorporating and amending the Exchange Visitor language. (49) It was not until 1961, however, when Congress passed the Fulbright-Hays Act, that the J-1 visa was created as a distinct category under the INA. (50)

         Significantly, foreign physicians were not specifically mentioned in the J-1 visa provision of the INA until Congress enacted the Health Professions Educational Assistance Act of 1976...