The Role of Immigrant Health-Care Professionals in the United States during the Pandemic
The harsh, unyielding storm that is COVID-19 returned with full force in mid-fall, and the latest projections offer no foreseeable respite. Like other pandemics, such as AIDS in the early 1980s, and disasters such as Hurricane Katrina in 2005, the coronavirus outbreak has exposed the systemic failures of the U.S. health system and the disparities to which it gives rise. In this, as in so many cases, these disparities have fallen hardest on racial and ethnic minorities, immigrants, people who do not speak English well, and rural communities.
One particularly alarming result has been dire shortages of health-care professionals seen first and vividly at the pandemic’s start in New York, New Jersey, and Washington State and now in places ranging from El Paso, Texas to Bismarck, North Dakota, and Hutchinson, Kansas.
Pandemics and disasters yield both tragedies and innovations. One promising experiment that emerged in the spring was the introduction by eight states of policies that would create new pathways for international health professionals already resident in the United States to be licensed and practice so they could join the fight against COVID-19. It was hoped that these policies might cut through existing regulatory thickets, leading to credentialing and rapid employment of international health professionals currently either sitting on the sidelines or employed in much lower-skilled work. Several countries also experimented with expanding temporary access to immigrant and refugee health professionals. Taken together, these policies can be seen as a loosening of hardened regulatory arteries that afflict national health systems worldwide—not just in the United States.
As the spring and the COVID-19 wars lengthened, three lessons emerged. One is that there is a large pool of highly educated immigrant health professionals in the United States who are underemployed or unemployed and, as a result, sitting on the sidelines during the public-health crisis. The Migration Policy Institute (MPI) estimates 263,000 such health professionals are enduring what is sometimes referred to as brain waste. These include doctors, nurses, and therapists. Many are multilingual; almost all are legally present.
A second lesson is that the language and cultural skills that these immigrant health professionals bring cannot be replicated among the current health workforce. In the short term, the value of these immigrants may be especially high in the field of mental health and public health. Stress levels across the U.S. population have been high, with symptoms of depression tripling since the pandemic began. In addition, early evidence shows that the success of contact-tracing programs—a time-tested public health tool to limit the spread of infection in communities—often depends on language and cultural parity of the workers and the population being served. The value of these immigrants may be especially high when it comes to staffing the rapidly expanded contact-tracing initiatives now being carried out at federal and state levels. Those skills are needed now to build trust in communities that have become fearful of punitive immigration enforcement policies and rhetoric as well as complex new restrictions flowing from the Trump administration’s public-charge policies on immigrants’ access to health care and other benefits. That trust will be even more essential in convincing skeptical populations of the safety and effectiveness of a vaccine.
A third lesson is that the launch of the state credential-speeding initiatives in March and April did not lead to large numbers of internationally trained health professionals obtaining licenses and entering the field. Some roadblocks were consistent with prior experience, including the fact that international licenses are often insufficient to get hired and the costs of licensing are prohibitive for many. Other barriers had to do with rigid requirements set by emergency orders that could not be met in a short period. Developed in a moment of crisis, there was little time to think through these roadblocks. This is where one state—Idaho—offers a valuable lesson: The state already had an existing law (the Idaho Medical Practice Act) allowing physicians with valid licenses from other countries or other U.S. states to practice during emergencies.
The state initiatives to license and place these immigrant medical professionals also take place against the backdrop of powerful macro trends within society. These include the aging of the nation’s population and the increased demand for health services that flows from it, as well as the aging of the health-care workforce itself, which is facing accelerating retirements and departures in the wake of the crushing coronavirus caseload.
Efforts to enable skilled, underemployed international health-care professionals to practice and contribute represent just one immigration-related step towards making the health system more resilient and flexible—especially in times of crisis. Others make sense as well. For example, one change in federal policy that the incoming Biden administration might consider would be to allow doctors and other health professionals on high-skilled (H-1B) visas to work outside the significant limits imposed by their visas on what and where they can practice. By adjusting visa requirements, the government could regulate the number and geographic distribution of temporary workers already in the United States, freeing them to play a larger role during emergencies.
While expanding licensing for the 263,000 immigrant health-care professionals who are underemployed or allowing H-1B visa holders to move to states with greater needs will not solve the deeper issues of limited supply and unequal access and outcomes, they are tools that could be used more broadly and effectively. The goal would be to create a more flexible, resilient workforce that can respond to both short- and long-term needs. The experiments that have taken place to date make it clear that better, more intelligent decisions can be made—decisions that are rooted in an understanding not just of the supply of underemployed immigrant health-care professionals but the demand for workers in the large and evolving health and public-health sectors.