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: https://datawarehouse.hrsa.gov/tools/quickmaps.aspx|
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.