April 2010 Newsletter
Healthcare Reform + Immigration = “Healthigration”

April 5, 2010
By Robert D. Aronson

DEAR CLIENTS AND FRIENDS:

Throughout its whole tortured path to passage, immigration and healthcare reform became intertwined in the public’s mind on the issue of healthcare coverage eligibility for undocumented aliens. But there is another intersection point between healthcare reform and immigration, and that concerns the potential for foreign physicians to staff the startling and constantly growing shortage of physicians that just recently became even more exacerbated through the expansion of healthcare coverage to roughly 32 million additional Americans.

So, call it “HEALTHIGRATION” – that is, the positive and now even indispensible role of immigration in the successful implementation of healthcare reform. A robust, promotive immigration policy for foreign physicians can, if done correctly, accomplish simultaneously two important national goals: 1) tap into a readily available pool of foreign physicians to staff a grossly under populated domestic physician workforce that is facing staffing shortages of staggering and alarming proportions; and 2) through a carrot-and-stick approach, channel foreign physicians into the most socially beneficial practice settings specifically by making the issuance of various immigration benefits (the “green card”) contingent on the fulfillment of a mandatory period of service in positions deemed to serve the national benefit. Conversely, at this point in time, take away the immigration prospects for International Medical Graduates (IMGs) and healthcare reform has the same chance of success as logging onto the internet using a typewriter or eating a hot dog at a World Series baseball game in Wrigley Field in Chicago.

Now, help me out with math.

We have just witnessed the enactment of major healthcare reform legislation, which represents the most extensive reengineering of the U.S. healthcare system since the passage of Medicare in 1965. The challenge now becomes to successfully implement this initiative so as to avoid the fate described by the American poet T.S. Elliott of “Between the idea and the reality/Falls the shadow.”

Here’s a snapshot of current healthcare reality:

• According to multiple studies, there is already an alarming shortage of physician providers in both primary and specialty care disciplines that pervades all geographic areas of the United States;
• There will be an expected shortage of physicians by 2020 in the magnitude of 100,000-200,000;
• In addition to this macro physician shortage, there are growing inequalities in the healthcare delivery system owing to geographic maldistribution of physicians and an unbalanced compositional split between primary care practitioners and medical specialists;
• As a result of the passage of healthcare reform, there will shortly be an additional 32 million Americans – roughly the population of Canada – who will qualify for healthcare coverage, thereby adding additional pressures on an already overstretched physician workforce;
• We have a declared national commitment to avoid the rationing of healthcare;
• We have a moral imperative to preserve the quality of healthcare, as well as to enhance its availability to segments of the U.S. population that have traditionally been underserved.
  

My basic question is: where do we get the bodies to expand the physician workforce + maintain high professional standards + expand the safety net + rationalize the distribution of healthcare services + contain overall national expenditures on the provision of healthcare services?

Now, I do not mean to be cavalier or blithe, but the resolution of this conundrum reminds me of a recurrently made statement by my favorite law school professor, which is that such imponderable, insolvable questions can only be answered on the final examination. But these are issues that simply cannot be ignored as theoretical abstractions. They are real and critical issues that need to be addressed and solved – NOW.

Here is a quick synopsis of some of the moving parts that need in some form to come together in this new era of national healthcare reform:

• Numerical increase in the physician workforce;
• Alternative delivery of medical services (such as Nurse Practitioners, Physician’s Assistants, etc);
• Revisions in the physician compensation model;
• Better measurement (and reward) for medical outcomes;
• Recalibration of the physician workforce with a greater emphasis on primary care medicine;
• Expansion and enhancement of telemedicine;
• Enhanced efficiency of medical service (that is, electronic medical records, et. al.)
• Tort reform;
• Expansion of biomedical research leading to discoveries for both preventive and therapeutic purposes;
• Substantial commitment to public healthcare initiatives to move medical dollars from therapeutic to preventive objectives;
• Analysis of medical ethics in this era of the culture wars, particularly the competing considerations of end-of-life vs. quality-of-life;
• Enlistment of nontraditional sources of physicians, such as International Medical Graduates (IMGs).

The real need to look to the immigration of IMGs to address, in some measure, the current physician shortage situation rests on seven (7) main pillars:

1. There is an immediate need to increase the number of practicing physicians in the United States, as exemplified by current plans to create up to 15,000 new Graduate Medical Education (GME) Training slots;
2. IMGs represent the only trained, available source for staffing these new positions (which, incidentally, serves as the most cost-effective provider of “safety net” services to the indigent and medically underserved);
3. Until we see a major expansion in medical school enrollment – and at best, there is contemplated only a marginal, gradual increase in new medical schools given the prohibitive costs to such an endeavor – the number of GME slots will substantially exceed the number of U.S. Medical Graduates (USMGs), so this definitely is not a situation in which foreign physicians are taking jobs from their U.S. counterparts;
4. There is a great deal of cost efficiency in recruiting IMGs to these newly formed GME positions, given that the underlying costs of medical education have been absorbed with the home country;
5. Given the worldwide competition for physicians, it is no longer plausible or productive to regard IMG immigration as a brain drain to the home country, given that there are substantial employment opportunities and active recruitment efforts for physicians to work in the countries of the OECD and the Middle East;
6. It is counterproductive to waste the investment of public funds used in the training of IMGs to become fully licensed and credentialed physicians only to have them depart the United States to take up medical practice opportunities abroad.
7. But it is this final pillar that from a public policy/national benefit standpoint carries the most weight in this era of healthcare reform: Whereas U.S. physicians are influenced by market mechanisms to guide their choices of professional practice settings, immigration can be used as a social instrument to move IMGs into practice opportunities of maximum social benefit. In short, our immigration system should create a tradeoff between the conferral of immigration status and a required period in which an IMG needs to perform socially beneficial professional service. It is precisely because immigration policy can be an effective tool for promoting socially desirable behavior that IMGs disproportionately go into primary care disciplines, work in practice settings that traditionally have been understaffed by their U.S. counterparts, and provide critically needed gap-filling services to the benefit of minorities, the indigent, and the medically underserved. We can and should build upon this inherent ability of immigration law to channel IMGs into socially beneficial service of maximum national benefit.

We have now gone through a bruising battle on healthcare reform and in the near future, we may see the Congress turn its attention to Comprehensive Immigration Reform (CIR). In my own opinion, this will be a long-overdue initiative as we absolutely need to update a rickety, tottering system to meet modern-day realities (or, to paraphrase the New York Times editorial writer, Tom Friedman, to create a more receptive environment for high IQ entrepreneurial risk-takers and job creators).

But regardless of legislative passage of CIR, we absolutely need to redesign certain facets of our immigration system for IMGs and foreign allied healthcare professionals. Their positive contributions are substantial in this era of healthcare reform. Our immigration policies have gone begrudgingly from tacit acceptance of the role of IMGs to a more affirming embrace and acceptance of foreign physicians as a necessary component of the U.S. physician workforce. But we are now at a stage where we absolutely need to move to a different level by creating a unified, seamless pathway for foreign physicians to come to the United States initially to undertake programs of GME (as required for licensure purposes) and to then undertake stipulated, mandatory periods of medical service in socially desirable positions in return for the benefit of permanent resident status. This legislative reform measure would be neither purely an immigration nor a healthcare initiative; rather, it would stand at the cross-roads in its own definitional category of HEALTHIGRATION, which could well serve our Nation’s interests.

As always, please feel free to distribute this Newsletter to other interested recipients and by all means, please bring any questions or comments to our attention. It is always a pleasure to hear from those whom we serve.

Cordially,

ROBERT D. ARONSON

This memorandum is one of a series of communications prepared as a general public service to our clients and friends. The information herein presented is not intended nor should it be utilized as legal advice on any specific situation. Furthermore, given the rapid pace of change, the veracity of this information is constantly subject to modification and/or reversal. Rather, this piece represents a good faith attempt to orient clients and other interested parties served by Aronson & Associates to current immigration developments. This piece in no manner supercedes the need to seek competent legal advice when engaged in activities carrying possible immigration-related consequences.

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Minneapolis, MN 55403
Tel: 612-339-0517
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info@aronsonimmigration.com

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