Foreign doctors loom large in rural healthcare

Rural America is starved for professionals. A rural lawyer shortage is the norm across much of the land, and doctors in rural places have nearly twice as many potential patients to serve as do their urban counterparts. A recent story in the “Struggling For Care” series from Valley Public Radio highlighted another dimension to the scarcity of doctors in California’s Central Valley:

Throughout California, roughly 27 percent of all doctors are international medical graduates (IMGs)…In the San Joaquin Valley, that number is nearly 50 percent. 

When IMGs come to the U.S., no matter how much experience they have, they’re required to complete a residency before they can legally practice. To do this, most get a J-1, or foreign exchange visa. When it expires, they’re required to return home—unless they spend three years working in an underserved area. 

After the J-1, foreign doctors commonly move on to an H-1B visa. That program brings in specialty workers ostensibly for jobs that Americans can’t fill. After a certain number of years on the H-1B, doctors can then apply for permanent residency and a path to citizenship. 

But since taking office, President Trump has made some changes to this pathway and hinted at others.

In a previous post, I questioned whether media accounts were overstating Trump’s potential to affect sectors heavily reliant on immigrant labor. In particular, I challenged reports that Trump’s efforts to enact a “travel ban” would bar potential IMGs or chill them from pursuing work in the United States. If I have been proven right, it has been for the wrong reasons – Trump has been simultaneously impotent in the legislative arena and impressive in the executive realm. Despite unified control of Congress and the White House, Republicans failed to deliver their fabled “repeal and replace” healthcare bill and may yet fail to ram through a tax plan, potentially leaving Trump without a significant legislative accomplishment in his first year.

But in the Executive Branch, a different story unfolds. Although the travel ban has faced repeated setbacks in litigation, most of Trump’s immigration moves have gone unchecked. The mass immigration raids of a decade ago have returned, and so has an environment where chance encounters with ICE are likely to end in removal. Impervious to public outcry, Trump’s deportation force has hunted domestic violence victims in courthouses and tracked parents to their children’s hospital beds. Weeks after taking office, Trump cut off expedited processing of H-1B visas, which allow IMGs to obtain "green cards" and potentially remain in rural clinics and hospitals permanently. As the consequences of this brash move became clear, the administration reversed course. More recently, Trump has imposed a kind of "extreme vetting" to H-1B renewals. .

The Valley Public Radio story also mentions unspecified plans to manipulate the J-1 visa process. Here, again, the president has substantial latitude. While it has been common over the last two decades to waive the return-home requirement for J-1 visa holders who agree to serve in healthcare shortage areas, the policy is more complicated. Federal law states that an application must receive a “favorable recommendation” based on a finding that a waiver is “in the public interest.” As is generally the case, regulations add substance to these vague standards; as always, those rules can be changed in a matter of months by the Executive Branch. Given the Trump Administration’s outsized success in the immigration realm, it is not hard to imagine how it might disrupt the pipeline for IMGs in under-served rural communities.

Although the Valley Public Radio piece alludes to the “San Joaquin Valley’s complicated relationship with international doctors,” it does not specify what the complication is. It may be – as has been explored repeatedly in this blog in contexts such as domestic spending, farm workers, and opioid abuse – that the weight of Trump’s policies falls most heavily in the places most eager to elect him:

CALIFORNIA COUNTY	IMGs AMONG DOCTORS	TRUMP VOTE SHARE
Kern	53%	53%
Kings	48%	53%
Madera	50%	54%
Merced	49%	41%
San Joaquin	49%	40%
Tulare	51%	52%
California (statewide)	27%	32%

A popular analysis of Trump's moves is that he is more constrained by the limits of what he can achieve than by the breadth of what he will attempt. If true, rural communities that depend heavily on IMGs have reason for concern: Trump's antagonism toward foreign workers is no secret, and he enjoys significant power to reshape their pathway to enter and remain in the United States. People in rural places already suffer from high healthcare costs, limited access to care, and current trends suggest that young people (potential doctors) will continue to leave rural places in droves. Under these conditions, IMGs' role in closing the doctor-patient gap is a matter of life and death.