In a surprise turn of events this month, Sen. Lindsey Graham (R-S.C.) derailed a Judiciary Committee hearing on banned books to talk about immigration. His calls were promptly echoed by Sens. Dick Durbin (D-Ill.), John Cornyn (R-Texas), Amy Klobuchar (D-Minn.), and Sheldon Whitehouse (D-R.I.). Despite this bipartisan signaling, the Senate Judiciary hasn’t marked up a single immigration bill in years. With border issues, parole and DACA firmly in the hands of the judiciary, passing a bipartisan health care focused immigration bill could profoundly impact the ability of hospitals and nursing homes to meet their workforce needs.
The forecast for health care workers in the U.S. is dire. A physician shortage of 124,000 is estimated for 2033, and 200,000 new nurses yearly will be needed to replace the retiring workforce. For rural America, the impacts are especially dire. Even without substantial increases in annual immigration, a narrow bill could establish near and long-term solutions to these troubling demographic trends while restoring public faith in Congress’s ability and willingness to play an active role in immigration policy.
First, we must increase investments into programs that train Americans to meet our labor needs without burdening American taxpayers. The American Competitiveness and Workforce Improvement Act (ACWIA) requires employers hiring foreign specialized workers on the H-1B visa to pay a fee ranging from $750 to $1500 per petition to fund the upskilling of Americans. This fee should also be mandatory for employers sponsoring foreign workers for the L-1 intracompany transferee visa.
So far, $78 million in H-1B fees has shored up programs to train, recruit and retain nurses, and an additional $40 million was dedicated to rural health care workforce investments. In FY2019, USCIS approved over 30,000 L-1 petitions, so requiring the fee for L-1 petitions could generate up to $45 million to fund additional workforce training programs for Americans.
Retaining the talent we train in the U.S. is critical to our health care system. We must ensure that individuals educated in our medical schools can finish their training and practice in the U.S. by adding M.D. and D.O. programs to programs designated for STEM-OPT. Optional practical training (OPT), is an optional extension of the student visa that allows international students to continue their education through practical application in the workplace. Graduates of STEM-OPT eligible programs are permitted an additional two years of training work authorization beyond graduates of other non-STEM programs.
Veterinary preventive medicine, pharmaceutical sciences, and molecular medicine graduates are all eligible to take advantage of the STEM-OPT extension, but medical school graduates are not. As a result, many struggle to secure work authorization and have no choice but to complete their residency outside the U.S. Residency is an essential part of a doctor’s medical training, with resident physicians working over 60 hours per week on average and treating 80 percent of level 1 trauma care cases in the U.S. Retaining the physicians that provide such high levels of specialized patient care is critical.
Similarly, DACA recipients who have completed a medical degree in the U.S. or have been working in the health care field for at least three years should be given a permanent pathway to live and work in the U.S. An estimated 29,000 DACA recipients work in health care, and since 2018, over 240 have enrolled in U.S. medical school to begin their physician training.
Keeping these workers in limbo will only accelerate the workforce shortage. Critically, it will also make it easier for the many other wealthy countries also experiencing a health care worker shortage to poach U.S.-educated medical graduates. Though meaningful protection for Dreamers is unlikely to precede a Supreme Court decision, we should act in the interim to protect this crucial subset.
States should also have a say in filling their health care needs. The Conrad State 30 and Physician Access Reauthorization Act has attracted bipartisan interest. Conrad 30 incentivizes international medical graduates studying in the U.S. on a J-1 visa to practice in medically underserved areas or with medically underserved populations. Each state manages the program based on local needs and can host up to 30 graduates annually in unfilled medical roles. Although this program has benefited more than 44 million patients in the U.S., it will expire on Oct. 1. It should be reauthorized to ensure continuity of care, and states with the greatest needs should be permitted to petition the federal government for additional slots left unused by other states.
Finally, rural hospitals and nursing homes should be exempt from the annual H-1B cap for the next five years. The H-1B visa is a temporary visa for specialized workers, requiring most employers to enter a randomized lottery. This year, a mere 25 percent of lottery registrants were invited to apply for a visa. Non-profit hospitals affiliated with universities already benefit from a lottery exemption. Rural hospitals, typically located far from prominent universities, lack similar access to necessary talent. Exempting them from the cap would ensure they can meet their needs in the short-term while investments made through the aforementioned fees establish a domestic pipeline of workers that can continue to meet their needs in the long-term.
Together, these provisions have the potential to significantly improve hospital capacity, patient care, and workforce readiness in the United States. If Graham is looking for a bipartisan immigration bill that can pass, this should be the first.
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