Previous blog posts have unpacked various dimensions of the ACA's effects in rural areas. A few years into its tenure, the results in rural areas were mixed; this remains the case today. Seven years after its implementation, rural hospitals are bracing for its repeal. One of the ACA's wonkiest features is its push for data-driven healthcare, which can pay big dividends in rural communities by improving and standardizing outcomes. And as the opioid epidemic has seized many rural Americans, including newborns, the repeal effort seems ill-timed in light of rural needs. The Trump Administration, "establishment" Republicans like Paul Ryan, and the nihilistic Freedom Caucus are among the cooks in the Obamacare-abolishment kitchen, and if they find a way to coordinate their efforts the resulting gumbo is likely to leave a bad aftertaste in rural America.
This blog has documented the lack of rural doctors; in California, the people-to-doctor ratio in rural counties is more than twice that of urban ones. Many rural communities carry the government imprimatur of a "shortage designation," which permits special treatment of foreign medical graduates (FMGs). Doctors trained abroad often enter the United States on J-1 visas to complete additional training, but in most cases they are required to return to their home countries. (Section 212(e) of the Immigration and Nationality Act is meant to prevent brain-drain.) However, waivers are available for FMGs that commit to practicing in parts of the United States carrying the Health Professional Shortage Area (HPSA) designation. These practitioners comprise approximately one-quarter of all U.S. physicians.
When the current president imposed the first version of his travel ban affecting seven majority-Muslim countries, some observers (CNN, Forbes, NPR, and Scientific American among them) wondered what the implications for HPSAs would be. These reports overstated the impact, but they also predicted the trouble that the Trump Administration's immigration policy portends.
|Green areas indicate a designated primary-care HPSA. Source: https://datawarehouse.hrsa.gov/tools/quickmaps.aspx|
As a statistical matter, it overstates the case to draw a direct line from Trump's travel ban(s) to worsening rural doctor shortages. But there are many reasons to predict that the Trump Administration has more bad news in store for patients in rural places.
The travel ban is thought to be the brainchild of Trump advisors Stephen Bannon and Stephen Miller. Both men are key advisors to Trump, and Bannon espouses a "clash of civilizations" view toward the Muslim world. In a Bannon-Trump interview from November 2015, Bannon expressed alarm that "two-thirds or three-quarters" of Silicon Valley CEOs were from South Asia; the real figure is closer to one-seventh, but the trend is clearly troublesome in Bannon's view. To him, legal immigration is a scourge as bad as unauthorized immigration, and Trump appears to be coming around to that view. If "version 2.0" of the travel ban is upheld by the courts, the list of barred countries may expand and affect major FMG-sending countries like India or Pakistan. The "Conrad 30" program that permits FMGs to avoid returning home after their J-1 programs lapse is temporary. In 2012, President Obama signed a three-year extension; since then the program has been kept afloat through "Continuing Resolution" legislation and could expire as soon as April 2017. And while some have advocated for expanding the number of waivers beyond 30 per state (1,500 nationally per year), there's little reason to think that such proposals will become law under this administration.
Thus, the travel ban is not as grave a threat to FMGs as is the pervasive ring of anti-immigrant voices within the Trump Administration. Even if the legal status quo prevails, predictions that FMGs from will eschew the U.S. for friendlier climates (or in solidarity, or from fear) may be proved right. In these ways, Trump's immigration policies may affect the health of his rural supporters while up-ending the economies where they live. If these policies unfold as predicted, rural voters will decide if Trump's strongman saccharine is enough to mask the bitter taste of his cooking.