This evening Congress passed historic legislation extending health coverage to more than 30 million more Americans. That’s the equivalent of adding the population of the entire country of Canada to the insurance rolls. This is going to be a monumental challenge for many reasons one of which is the fact that the country already has a severe physician shortage. According to Reuters:

A growing shortage of primary care doctors could place a major burden on the U.S. healthcare system if President Barack Obama succeeds in extending medical insurance to millions of Americans who currently lack it.

As healthcare legislation works its way through the U.S. Congress, most of the focus has turned to how to finance a reform that could cost $1 trillion in the next 10 years and aims to cover most of the 46 million uninsured Americans.

Less attention has been paid to what might happen if millions of new patients join a healthcare system that is unprepared and unequipped to handle the load.

The United States already has a shortage of between 5,000 and 13,000 primary care doctors, according to the Robert Graham Center. Add millions of previously uninsured people and the shortfall will balloon to as many as 50,000 doctors.

So why in the world is US Citizenship and Immigration Services enacting  a series of policy changes to make it more difficult for foreign-born, American-trained doctors to get visas to remain in the US after receiving the US taxpayer-subsidized graduate medical education at teaching hospitals around the US.

More than 25% of the doctors in training in the US are international medical graduates.  Immigration policies that tend to drive these doctors out of the country rather than encouraging them to remain can have a dramatic impact on Americans access to health care.

What are those policies? Here’s an incomplete list that gives you and idea:

1.       The January 2010 Neufeld memorandum that essentially bars the use of H-1Bs by doctors who are not directly employed by hospitals and health care facilities. Most doctors have traditionally been employed by groups or self-employed and many states actually mandate this.

2.       USCIS is taking draconian interpretations of H-1B cap exemption requests by physicians working at non-profit institutions affiliated with universities and research institutions. USCIS has a great deal of discretion here but chooses to take a restrictive view that drastically limits employment opportunities for many doctors.

3.       More than a quarter of international medical graduates are Indian nationals who face green card backlogs of 5 to 10 years longer than almost every other nationality. As I blogged yesterday, USCIS has the ability to enact policies to alleviate the backlogs including changing the way “filing” is interpreted and not counting spouses and kids in the green card tally.

4.       USCIS routinely excludes physician graduate medical education from benefits it extends to those pursuing graduate degrees in the US. For example, the bonus cap of 20,000 H-1B visas is interpreted in such a way that US-educated doctors are excluded. And USCIS has not created a “cap gap” bridge provision to keep doctors waiting on October 1^st H-1B start dates even though it has created a similar one for other job categories.

5.       Until the AAO stepped in, USCIS recently took the position that the MBBS medical degree – the degree used in more than 40 countries including India and the United Kingdom – was not an advanced degree and all such doctors should be relegated to a low employment-based green card preference level with waits of nearly ten years.

There are many other issues I could include in the list. USCIS should see itself as playing a critical role in helping to implement this momentous legislation. It needs to identify every policy that serves to curb the supply of doctors (and other health professionals) and embrace the “yes we can” philosophy of this Administration to reverse course and be a part of the solution.

The situation for other health care professionals is also severe and will only get worse as a result of the new legislation. Despite the economic downturn, the nursing shortage in the US persists with a gap of 50,000. That number was expected to increase significantly in years to come even before the new legislation was passed. And the shortage of other health care professionals - physical therapists, pharmacists, medical technologists, etc. The problems noted for doctors apply here as well, but can be even more severe. For example, USCIS takes extremely conservative views on which jobs qualify for H-1Bs and has generally rejected most nurse positions as being below H-1B caliber and ignored its own memorandum from 2002 on the subject.

Congress, of course, could do a lot to improve the situation as well.  North Dakota Democratic Senator Kent Conrad’s S.682 bill which would make a number of improvements to physician immigration rules. The bill creates H-1B cap exemption opportunities for doctors going to the worst shortage areas and also creates green card cap exemptions to reward such service.

On the nurse front, HR 2536, the Emergency Nursing Supply Relief Act, introduced by Congressman Robert Wexler (D-FL) would immediately help relieve the bottleneck that has caused a five to ten year wait to bring in nurses to the US. That legislation is sorely needed and needs to be strengthened to include a broad exemption from green card caps for nurses and other allied health professionals until we have a domestic pipeline of workers that can meet our needs. 

Many on both sides of the immigration debate will be tempted to say we should roll these bills in to a comprehensive immigration reform bill. That's fine, but these bills need to be put on a separate track independent of broader immigration legislation. They are health care bills more than immigration bills and we can no longer afford to wait for these crucial issues to be addressed. The time to act is now.