Immigrants and the immigration system have made significant contributions to the U.S. healthcare system, making them an important part of the cadre of professionals addressing the COVID-19 pandemic. However, the effort to incorporate more of these professionals into the response faces obstacles such as extended wait times for green cards for doctors and nurses and state licensing requirements that prevent many non-citizens from practicing in the United States. However, other countries and some U.S. states have adopted strategies ranging from fast-tracked adjudications of permanent residence permits to adjusting state licensing requirements to eliminate these obstacles and incorporate non-citizens into their COVID-19 workforce. Using these ideas as a starting point, we outline immigration policy recommendations that can eliminate these obstacles and quickly integrate non-citizen healthcare professionals into the country’s COVID-19 response strategy.
Foreign-born health care professionals face a variety of obstacles to legally work in the United States. While the federal government dictates the conditions for immigrants to work in the country, state governments retain the authority for the system of licensing for medical professionals.1 Immigrant professionals generally face difficulty in obtaining employer recognition of their foreign educational or professional credentials. For graduates of foreign medical programs, this difficulty is exacerbated by the need to obtain a state-specific occupational license where they desire to work. In the case of individuals who cannot do so due to state credential recognition issues, extensive re-testing requirements, or lack of information about the licensing process, this “brain waste” can leave immigrant professionals underemployed or unemployed, including those with medical or health care backgrounds.
The geographic limitations on practicing physicians and nurses compounds these problems. Because H-1B visas and employment-based green cards are employer-specific, it limits physicians’ and nurses’ ability to easily move from state-to-state, based on where outbreaks are most prevalent. As Figure 2 shows, New York hosted the vast majority of foreign physicians in the J-1 exchange program in 2019. While New York currently has the most COVID-19 cases in the United States, epidemiologists have projected the virus will continue to infiltrate rural regions, meaning the United States will need to be prepared to quickly shift health care professionals to different parts of the country as the virus reaches different communities.
The limits on H-1B visas and employment-based green cards and backlogs in these programs create additional challenges. The H-1B specialty occupation visa is employer-specific, meaning that non-citizen health care workers with this status cannot change employers without submitting an extensive amount of paperwork to U.S. Citizenship and Immigration Services.2 Due to the annual cap of 85,000 visas, immigrants who may be eligible now will have to wait for the next application cycle in 2021, unless they are directly employed by a non-profit related to or affiliated with a higher educational institution. Physicians waiting for a green card face limitations on where they can practice until a green card becomes available.
Nurses face a separate set of challenges in the immigration system. In addition to long wait times for green cards, these professionals cannot come to the United States under temporary skilled worker visas, unless their position specifically requires a bachelor’s degree, which most nursing positions in the United States do not. However, nursing is considered a “shortage occupation” by the United States Department of Labor, meaning employers can avoid the lengthy labor certification process to sponsor foreign nurses for green cards. Nevertheless, the per-country limits on green cards can still mean lengthy waits. For example, Indian doctors can wait up to 20 years for a green card to become available while nurses from the Philippines can wait 3 to 5 years. As a result, the immigration system will not be a means to quickly fill immediate needs for health care workers in the short term.
In addition to the United States, other countries have struggled to find enough health care workers to tackle the COVID-19 pandemic. As a result, some countries have adopted measures to enable foreign medical professionals to support their efforts. These measures fall into two broad categories: fast-tracked adjudications and recruitment of non-citizens already in their populations.
In the case of fast-tracked adjudication of immigration benefits, countries such as Portugal and Spain have granted temporary or permanent residence to resident immigrants to immediately authorize them to work in the country. Portugal has granted approvals to non-citizens with pending applications for permanent status, allowing them to work in the country and access the Portuguese health care system. The Spanish government has also fast tracked the processing of work and residence permits for approximately 200 medical professionals to tackle the crisis, including rapidly completing the credential approval process to allow them to immediately work.
Recruitment of migrants within in countries’ populations tries to incorporate doctors and health care professionals, many of whom are refugees or asylum seekers, with foreign credentials into the workforce. Germany, the United Kingdom, and Argentina have followed this approach. In the German Bundesland of Saxony, the regional medical board is advertising for migrant doctors who already live in the region, but lack work authorization, to help fight the pandemic. The UK government announced that foreign doctors whose visas are set to expire before October 2020 will receive an automatic one-year extension to address shortages. Finally, Argentinean municipalities around Buenos Aires have begun recruiting Venezuelan health care professionals to tackle the pandemic, including doctors with valid and expired credentials.
In the United States, certain states are also adjusting licensing requirements to make it easier to integrate foreign health care professionals in the COVID-19 response. In New York, Gov. Andrew Cuomo (D), has issued a number of executive orders that will impact licensed professionals. For example, under Executive Order 202.5 nurse practitioners licensed in any state in the United States will be allowed to practice in New York without civil or criminal penalty related to lack of licensure. The order also allows physicians licensed in New York, but not registered in New York, to practice without civil or criminal penalty related to lack of registration. In New Jersey, Gov. Phil Murphy (D) signed an executive order authorizing the state’s Division of Consumer Affairs to grant temporary licenses to doctors licensed in foreign countries. The order also permits certain health care professionals to perform duties outside their normal scope of practice and grants civil immunity to professionals and facilities providing services in support of New Jersey’s COVID-19 response.
It is clear that foreign-born health care professionals are at the frontline of combatting the virus, meaning the United States needs to adopt policies that facilitate the integration of these individuals into the workforce to mitigate the pandemic. Legislators have three sets of policies that can address these challenges:
Fast track immigration benefits for health care professionals
With European countries already leading the way, this option is well within the realm of possibility. The Trump administration has urged medical professionals to contact a U.S. Embassy in order to move their application process forward.
- The Department of State posted a notice on how professionals with an approved immigrant or non-immigrant visa (e.g., Form I-140 or I-129) should make an appointment at their respective U.S. consulate and that J-1 foreign physicians should consult with their program sponsor, the Educational Commission for Foreign Medical Graduates, to extend their stay in the United States.
- ECFMG has worked with USCIS to make sure that 4,200 foreign-trained doctors who were approved for a J-1 visa could get their visas processed despite USCIS office closures. These doctors were on-track to begin their residencies in the United States by July 2020, but ECFMG should push for them to start earlier.
- In addition, the federal government needs to be flexible as to where foreign health care professionals can serve. H-1B visas are employer-specific and require extensive paperwork for individuals to switch employers. J-1 visa holders must complete their residencies at an accredited graduate medical school approved by ECFMG and the State Department. USCIS, ECFMG, and the State Department should relax these rules to allow professionals to easily move where the outbreaks are the worst.
- Achieving these recommendations, however, would require a significant lift on the part of the federal government. USCIS still processes most visa petitions by paper, contributing to lengthy processing times for applications. In addition, USCIS temporarily closed their offices from March 18 to May 3, although this date may be extended. With the offices closed, many immigrants have expressed fear that their status and work authorization may be put in jeopardy, as immigration appointments with USCIS often require immigrants to submit biometrics in person. With USCIS offices closed, it will need to relax rules requiring in-person biometric appointments, or partner with local agencies to share biometric data.
- With European countries already leading the way, this option is well within the realm of possibility. The Trump administration has urged medical professionals to contact a U.S. Embassy in order to move their application process forward.
Expand the number of visas available to health care professionals
Congress could, as part of its next coronavirus relief legislation, grant temporary cap exemptions for H-1B visas to foreign-born medical professionals
- Given that H-1B visas have already been allocated for the coming year, professionals who have recently graduated from their respective training programs now have to wait until next year in order to be eligible under the existing the cap.
- While President Trump faces political risk advocating for more foreign-born workers in a time of significant economic downturn, there is a clear immediate need for those workers now in the health care sector.
- Congress could, as part of its next coronavirus relief legislation, grant temporary cap exemptions for H-1B visas to foreign-born medical professionals
Encouraging more states to follow in New Jersey and New York’s footsteps
- As epicenters of the COVID-19 outbreak in the United States, the two states understand the need for increased health care providers and have taken dramatic measures to integrate foreign-born professionals into their workforce.
- The federal government should encourage other states to follow suit. As health care workers continue to test positive and are forced to self-isolate, foreign-born professionals who do not yet have valid work authorization or meet state licensing requirements can help fill that shortage.
While non-citizens are vital to the United States’ COVID-19 response, the pandemic has revealed the shortcomings of our immigration system to incorporate them into the workforce in times of crises. In the near-term, our recommendations would allow the country to meet very real labor shortages in our health care response to this public health emergency. However, we also need to reform and future-proof our immigration system to make it easier to incorporate non-citizens into future crisis responses. For instance, the United States must examine whether it should create mechanisms that allow the U.S. government to adjust the number of temporary and permanent migrants based on economic needs and other considerations such as public health emergencies. This measure is just one of many steps that United States can take to reform the system. Failure to do so means the United States have to deal with this problem again in future public health emergencies.
1 On March 18, the Trump administration announced that doctors would be allowed to practice across state lines for federal health programs. Physicians and nurses would have otherwise required a state license to practice in a particular state. https://www.phe.gov/emergency/news/healthactions/section1135/Pages/covid19-13March20.aspx.
2 For more information on recent USCIS policy changes regarding H-1B visas, see our previous blog post here.
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