Sunday, March 12, 2017

Immigration policy adds a bitter taste to Trump's healthcare gumbo

Last week Republicans in the House of Representatives introduced their latest attempt to dismantle the Affordable Care Act (ACA). Appropriate for the hydra-headed problem of healthcare coverage, the American Health Care Act is currently proceeding in two bills and will likely have to merge with a divergent Senate proposal if it passes the House.

The healthcare system is not a new topic for this blog, as previous posts have unpacked various dimensions of the ACA's effects in rural areas. 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. As the opioid epidemic has seized many rural Americans, including newborns, the ACA's role in facilitating rural treatment programs has garnered new attention. Nonetheless, the health insurance exchanges have had a mixed record in rural America: both in the early years of the ACA as well as more recently.

For seven years, a popular item on the political menu has been the "repeal and replace" special. Now 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, so-called "Conrad 30" waivers are available for FMGs who 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.

As the map below indicates, HPSAs are widespread throughout the country.
Green areas indicate a designated primary-care HPSA. Source:
However, the distribution of HPSAs does not track the distribution of metropolitan and non-metropolitan counties (see below).
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.

Furthermore, the share of FMGs coming from the affected countries is small. The Educational Commission for Foreign Medical Graduates, a leading certifying body, processed 10,000 FMGs in 2015. Some 3,100 of these were U.S. citizens -- some aspiring doctors complete their studies abroad for academic, financial, and other reasons. Of the 6,900 foreign nationals, four countries subject to the travel ban contributed 571 FMGs. This does not include possible ban-affected individuals among the 1,100 doctors from countries with fewer than 50 FMGs, but it does include Iraq (118), which is not subject to the ban's second iteration. The Scientific American piece (above) notes that 8,400 FMGs from Iran and Syria are currently working in the United States, but this figure is eclipsed by the 50,000 Indian nationals who practice in this country as FMGs.

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 also 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.


ofilbrandt said...

It would be interesting to see the factors that these doctors consider in deciding to practice in the United States and if the other countries that the author predicts they will turn to offer similar benefits. US Citizens that choose to attended foreign schools usually have more students debt and the United States health care pays physicians more than other countries, is that a major factor for FGMs who choose to practice in one of the HPSA areas? The United States has cutting edge research centers within an airplane or helicopter's ride to rural places. Americans have mutations and make poor health choices necessitating care at the same rate as other areas.

A follow up to this article may also encompass a study on the shortage of medical training programs in contrast to the demand for health care professionals. Essentially, is it that trained health professionals are choosing to practice in urban areas or is it that there just are not enough to cover rural areas, even if they wanted to?

RGL said...

It would also be interesting to see what other sectors of the economy are most affected by the travel restrictions being implemented by this Administration. The core to Washington state's standing claim against the government in the first proceedings against the government for the travel ban was that the state universities were directly impacted. The professors and students from the 7 original countries would have no way to return if they went home, or if they already happened to be in their home country when the EO was put into effect. The new EO is not as restrictive in terms of LPRs and people who already have visas, but as is shown by this post, there will be at least some effect on US health care, and other sectors where immigrants contribute. The conversation between Bannon and Trump about Silicon Valley CEOs is illustrative. California's economy is essential to this country, and immigrants make up a large portion of it. The immigration policies coming down from the White house are bombshells to the American economy, beyond just a few thousand doctors.