Immigrants in the Health Care Workforce: An Explainer

Immigrants form a major part of the health care industry’s workforce. In 2018, foreign-born workers accounted for significant percentages of professions that are on the frontlines of battling COVID-19 today. It is estimated that 29% percent of physicians, 38% of home health aides, and 23% of retail-store pharmacists are foreign-born. Together, foreign-born employees make up 17% of the entire health care and social services industry, filling critical gaps in this part of the U.S. labor force.

Non-citizens in health care professions can work in the United States through several routes. Many immigrant doctors and some nurses can obtain work authorization through the United States’ temporary or permanent employment-based migration channels, depending on their educational credentials and licensure. Employers can sponsor doctors for an H-1B high-skilled visa that permits them to work in the country for three years with the possibility of renewing the visa for another three year period, if they can meet the required state licensure to practice. Employers also have the option of sponsoring non-citizens for an employment-based green card—including those with H-1B status—to work permanently in the United States. Although the H-1B application has education requirements and some labor market tests, the employment-based green card system has more rigorous requirements for a non-citizen’s credentials and tests to determine whether the non-citizen would displace native-born workers or harm their wages.

While employers can sponsor some nurses for an employment-based green card, U.S. Citizenship and Immigration Services has set limits on which types of nurses qualify for an H-1B visa. Specifically, USCIS has stated that Registered Nurses generally do not qualify because the position does not “normally require a U.S. bachelor’s or higher degree in nursing (or its equivalent) as the minimum for entry into these particular positions and thus are unable to qualify as specialty occupations.” However, previously, foreign nurses in the United States had their own visa category. In 1989, the year before the Immigration Act of 1990 created the modern H-1B visa, the Immigration Nursing Relief Act allowed nurses with H-1 work visas and at least three years’ residency in the United States to adjust their status to permanent residence and created the H-1A visa, the first visa category specifically for nurses.¹
In 1997, the H-1A program was superseded by the H-1C program, which was established by the Health Professions Shortage Area Nursing Relief Act. However, the H-1C category was extremely limited in its ability to bring more foreign-born nurses into the United States, as it only allowed 500 nurses per year to work at U.S. hospitals. Participating hospitals in the H-1C program were required to be located in designated health professional shortage areas, to have a minimum of 190 licensed beds, and to treat a minimum of 35% Medicare and 28% Medicaid patients. The hospitals could have no more than one third of their nursing staff composed of internationally educated nurses, and these nurses were only allowed to work at the hospital where they were originally hired. Introduced in 2001, the Rural and Urban Health Care Act (S. 1259) proposed expanding the H-1C visa category from 500 to 195,000 visas, but the bill died in committee and the H-1C category subsequently expired in 2009. While nurses today still qualify for EB-3 permanent visas, there are annual and per country caps and the wait time for a visa to become available can be years depending on an individual’s country of origin.

Most states require that foreign nationals wishing to practice as physicians in the United States meet their own licensure requirements as well as completing at least a portion of their medical training in the United States. The J-1 exchange visitor program for foreign medical graduates is the primary visa that enables immigrants to pursue graduate medical education or training, including medical residencies, at accredited U.S. schools of medicine, teaching hospitals, or other scientific institutions. Although the J-1 visa requires participants to return to their home countries for two years after completing the program, the Conrad 30 Waiver Program allows them to apply for a waiver for this requirement upon completion of their studies to remain in the United States. However, the doctor must meet specific requirements for obtaining this waiver from their state of residence.² If a doctor meets these requirements, they can work in the area on H-1B status for three years with the potential to apply for a three-year renewal.

As the federal government is looking at deployments of military health care resources in support of the COVID-19 response, it is worth noting that a military program that would have increased the ability of legal immigrants to serve the Defense Department in this capacity was ended in 2017. The Military Accessions Vital to National Interest, or MAVNI, Recruitment Pilot Program, allowed certain non-citizens who are legally present in the United States whose skills were considered vital to national interest, including those in health care fields, to join the U.S. military and apply immediately for U.S. citizenship without first obtaining lawful permanent residence. While only in operation during fiscal year 2016, the program was available to physicians, nurses and experts in certain languages with associated cultural backgrounds. The ultimate goal of the program was to recruit up to 5,200 individuals by September 30, 2016. However, MAVNI has not been renewed since it expired in FY2016.

Immigrants make up a significant percentage of the workforce and are undoubtedly vital to our health care system. Historically, foreign-born nurses have had their own visa category to facilitate their entry into the workforce, but the specialized H-1A/H-1C category is no longer in operation. While alien physicians can come to the United States through the J-1 exchange visitor program, they are required to return to their home countries for two years unless they apply for and are accepted into the Conrad 30 Waiver Program. While there are legal avenues for foreign-born doctors and nurses to work in the United States, our immigration system does not make it easy. As it becomes abundantly clear that more and more people across the U.S. will become infected with COVID-19, our system will need to consider how we can expand work authorization to foreign-born health care professionals. 

^{1 For more information see here: Masselink, L. E., & Jones, C. B. (2014). Immigration policy and internationally educated nurses in the United States: A brief history. Nursing outlook, 62(1), 39–45.
2 For instance, a candidate must agree to work in a Health and Human Services designated Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA), or Medically Underserved Population (MUP). These areas tend to be rural zones with major shortages in doctors to serve local residents.}