The Supreme Court’s recent ruling on the Affordable Care Act (ACA) will have monumental implications for the future of healthcare. Beyond the political posturing and legal scrutiny the decision has inspired, the fact of the matter is that the healthcare law is here to stay. Absent of legislation to modify or repeal the law, it will remain, for better or worse. In the immediate future—implementation, not resistance—will be the mantra of Washington.
At the same time, the enactment of the law presents substantial challenges. Especially daunting will be the assimilation of an estimated 40 million Americans as they join the ranks of the insured because of the individual mandate. Simultaneously, some 75 million baby boomers hurtle toward retirement, greatly increasing the demand for health services. In addition, almost 40 percent of the 850,000 licensed physicians are 55 years or older, many of them intending to retire in the near future.
Variables such as these have put the healthcare industry on a collision course with massive labor shortages. Traditional models have projected that there could be shortages of more than 150,000 doctors over the next 15 years. The ACA only exacerbates the problem: the Association of American Medical Colleges projected that when the provisions the healthcare law are in full effect, the shortages will grow 50% worse. Many American medical schools are expanding their enrollment capacities, but even those measures will not fully close the gap.
The answer to the shortage can come in the form of immigration. Already, 25% of the practicing physician workforce is educated internationally, leaving their native countries to work in the U.S. These International Migrant Graduates (IMGs) come from a diverse background; the top 5 countries that supply IMGs by nationality are India (41,800), The Philippines (13,200), Pakistan (9,900), China (4,900), and Iran (4,100). All international doctors that enter the U.S. are certified by the Educational Commission for Foreign Medical Graduates to ensure the quality of care. As the domestic need for doctors continues to grow, the need for foreign doctors will grow as well.
A common concern with the use of foreign nationals to meet American health needs is that of “medical brain drain.” The idea is that there are a limited of doctors in the world. When First World countries draw foreign physicians from less developed countries, they rob those countries of desperately needed health workers. Frequently cited is the example is Sub-Saharan Africa: while the region bears 24% of the global disease burden, it has access to only 3% of the world’s health workers.
Certain countries and groups are reacting to the perceived brain drain. In India, any doctor that travels to the U.S. for medical studies is required to sign a bond, promising to return after the completion of studies. The Philippines have considered compulsory government service before doctors leave the country. Some have gone so far as to say that the practice of recruiting doctors to go abroad in areas with acute shortages should be considered an international crime.
With all the clamor, what does the data about medical brain drain suggest? It varies greatly by country and situation. Some countries such as India generate a large surplus of doctors: the nation produces 30,000 medical graduates a year but only offers 18,000 postgraduate positions a year. After the Islamic Revolution of 1979, Iran significantly expanded their number of medical colleges and lowered the costs of attendance, a practice that continues to necessitate the migration of many Iranian doctors. Other countries have not fared so well. South Africa and Zimbabwe, along with 7 other African nations, have suffered the worst; a recent study revealed that over $2 billion in educational investment for medical personal has been lost as many of the doctors traveled overseas.
However, the movement of physicians from one region to another is not the end of the story. A newly developing theory is the concept of “medical brain gain,” the idea that emigration from developing countries can actually be beneficial. Individuals, considering their migration prospects, may obtain additional education for that purpose. There have been several studies that have found that, in moderation, some skills loss from migration creates a net gain in talent due to the fact that many seek a medical education for the reason of leaving, but do not do so. Another consideration is that of “brain circulation,” the idea that doctors eventually return—usually with greater knowledge—to their native countries because of visa requirements or independent desires. U.S. immigration policy has been particularly noted for brain circulation, due to its selectivity in distributing green cards for permanent residency.
As the demand for physicians increases to meet the needs of an aging population with increased medical coverage, foreign doctors will play a growing role in the U.S. healthcare system. A better understanding of the dynamics involved in the migration of medical personal will be beneficial to all.