America’s health care system is at a critical juncture. Experts have warned of an impending workforce crisis, forecasting the onset of shortages by the next decade. However, that timeline has proven optimistic, with shortfalls already impacting occupations across the field.

While it is difficult to quantify the gap since personnel shortages are exacerbated by myriad other inefficiencies in the system, a variety of performance measures strongly suggest the need for more practitioners across virtually the entire care spectrum. Compared to our high-income peers in the OECD, the U.S. ranks the lowest for life expectancy at birth, highest in death rates from avoidable or treatable conditions, and highest in maternal and infant mortality. The country also leads (if you want to call it that) in the prevalence of chronic degenerative conditions.

It should not be surprising, then, that Americans visit physicians less frequently than their OECD counterparts and face some of the lowest ratios of physicians and hospital beds per 1,000 people. While numerous factors contribute to these alarming statistics, it is evident that one driver of poor outcomes is workforce shortages.

Broad structural changes that correct policy mistakes of the past half century are essential to building a robust domestic health care workforce. However, addressing shortages requires immediate action. And one very practical short-term fix – arguably the only short-term fix – is leveraging the potential of foreigners eager to immigrate.

Why Are There Shortages?

The term “labor shortage” has become increasingly common in discussions about health care. But determining the numbers needed to close the gap is far from an exact science. We can, though, offer a convincing explanation of how we stumbled into this mess and how it would be extremely difficult to right the ship without more help from immigrants.

Demographics

One significant driver, of course, is the rapid, inexorable aging of the U.S. population. By 2030, all the baby boomers will have reached 65, and by 2040 some 80 million Americans will have hit what was long viewed as retirement age. More ominous from the perspective of health care system capacity, in that latter year the number of adults aged 85 or older will have quadrupled from 2000. This segment of the elderly population requires more intensive and prolonged medical care.

Note, too, that the health care workforce is aging alongside the general population. Currently, 45 percent of active physicians are over 55, and roughly one in three is expected to retire by 2030.

Professional Burnout

The issue extends well beyond aging out. Health care is notorious for the rate of turnover, with many professionals responding by switching specialties or retiring early. In a 2019 study, 54 percent of nurses and physicians – and an alarming 60 percent of medical students and residents – reported experiencing symptoms of burnout. A 2022 report from the U.S. Surgeon General explained it this way:

A rapidly changing health care environment, where advances in health information and biomedical technology are accompanied by burdensome administrative tasks, requirements, and a complex array of information to synthesize … [coupled with] … decades of underinvestment in public health, widening health disparities, lack of sufficient social investment … and a fragmented health care system have together created an imbalance between work demands and the resources of time and personnel.

And then, of course, there was the pandemic. While it is challenging to accurately quantify the dislocation in health care created by Covid-19, estimates suggest that about 18 percent of health care workers left their positions and haven’t come back. This wholesale flight included some 100,000 registered nurses and 117,000 physicians.

Too Few Teachers

A third factor contributing to the clinician shortage is the lack of medical educators to keep the pipeline full. This issue is especially pronounced in nursing schools. According to the American Association of Colleges of Nursing, faculty shortages largely explain why some 91,000 qualified applicants to undergraduate and graduate nursing programs were rejected in 2021 alone. In 2022, the AACN surveyed nursing programs nationwide and identified 2,166 full-time faculty vacancies. There is a parallel problem in medical schools, where heightened competition and lack of funds for tenured positions has stymied efforts to recruit and retain teachers.

Low Pay for Support Workers

One can debate whether the supply of physicians and nurses is currently responsive to financial incentives, but there’s no question they earn a whole lot more than the average American worker. In 2023, the median salary for physicians was $236,000, while the comparable number for registered nurses was $86,000. However, these jobs comprise less than one-fifth the health care workforce, and the other four-fifths are in a very different position. Last year, medical assistants and phlebotomists typically earned less than $14 an hour, while home health care workers earned less than $12. As a result, one-fifth of these workers live in poverty.

Maldistribution of Workforce

Nearly one in six Americans – over 60 million people – lives in a rural area. They are on average older, and experience higher rates of illness than those in cities and suburbs. Moreover, they are more likely to smoke and to live with inadequately treated chronic conditions like high blood pressure and obesity. These challenges are compounded by higher poverty rates, lower rates of insurance coverage, and access to care limited by geography.

A major contributor to access problems is the uneven distribution of health care workers. In addition to the issues that the broader health care workforce faces – burnout, turnover and demographic shifts – rural areas have also experienced significant hospital closures in recent years that leave many residents far from care when they need it most.

Academic medicine’s urban-centric focus intensifies the problem, as access to training and education is quite limited elsewhere. As a result, fewer students from rural areas enter the health care workforce – and those who do are often disinclined to return home after completing their training. Urban settings offer better pay and more amenities. Furthermore, providers trained in urban environments may have little clinical experience with rural areas’ systemic challenges. Consider, too, that while rural areas account for more than 60 percent of the underserved population, health care workforce maldistribution affects other at-risk populations – the homeless, migrant workers and Indigenous Americans.

Where the Jobs Go Unfilled

Personnel shortages affect most all health care workforce categories. But not all shortages are equal.

The Federal Government predicts a shortfall of some 64,000 full-time RNs by 2030. Meanwhile, the Association of American Medical Colleges projects a shortage of 86,000 physicians by 2036, with the most significant gap widening in primary care. This latter shortage in physicians is driven by demographic shifts, including an aging population that requires more intensive and specialized care. But another significant factor is the residency bottleneck.

Since the 1980s, in an effort to control spiraling health care costs, Medicare has capped the number of residency slots – the last stage in physician training – that the agency will subsidize. This limit has left thousands of medical school graduates unmatched with residency positions.

Importantly, current shortage estimates only reflect the existing allocation of doctors in the country. The AAMC estimated that to cover the needs of today’s underserved communities at the same rates as well-served communities, the U.S. would need an additional 202,800 physicians. Note that this figure is far higher than current shortage estimates, underscoring the severity of the maldistribution problem.

Shortages extend across virtually all health care occupations requiring advanced degrees, a category ranging from nurse midwives to speech-language pathologists. The problem in maternity care is particularly acute – one in three counties does not have a single obstetric provider. The U.S. has the highest maternal death rate of any high-income nation (22 per 100,000 live births). About 80 percent of these deaths are preventable, but only when proper care is provided throughout pregnancy, birth and the postpartum period. Midwives are particularly crucial in mitigating OB/GYN shortages nationwide, as they can substitute for the latter for most low-risk births. To meet demand, the U.S. will need at least 29,200 advanced-practice registered nurses, including nurse practitioners, nurse anesthetists and nurse midwives, annually through 2032.

Health Care Support Workers

Health care occupations requiring substantial training but no postsecondary degree run the gamut from medical records specialists to hospital orderlies. EMTs stand out in this category: the U.S. will need to add some 40,000 full-time EMTs and paramedics by 2030, and shortages are already eroding service quality in many communities. Turnover is startlingly high. More than one-third of new hires left the profession within their first year. Some states have even removed age requirements for EMTs in order to fill gaps, allowing individuals as young as 15 to serve.

Reducing shortages of the least celebrated direct care workers, home health and personal care aides, may actually be the most important challenge to the system. Some 5 million direct care workers provide essential services in private households, residential care facilities and nursing homes nationwide. And by 2031, an additional million will be needed to support the rapidly growing cohort of disabled elderly. A 2023 survey of nursing homes revealed that 54 percent had to limit admissions due to staffing shortages, leaving about one in four patients unable to secure a bed.

Immigration as a Solution

How does immigration – and current constraints on immigrant labor – fit in this picture? Immigrants already play a crucial role in the health care workforce, with nearly 2.8 million foreign-born workers employed in the sector as of 2021 – fully 18 percent of total industry employment. Indeed, one-quarter of all MDs, one in six nurses and a whopping 40 percent of home health aides are immigrants – with large numbers of undocumented workers among that last category.

Millions of foreigners are qualified and willing to fill the gaps in health care created in large part by myopic efforts in the past to rein in costs by constraining supply. But while increased immigration ranks high on every analyst’s checklist for ways to pare personnel shortages, the legal barriers are formidable. There are currently no visa pathways designed specifically for health care workers, forcing them to compete with college-educated professionals from all other sectors – notably high-tech – for the modest number of employer- sponsored employment-based visas available. All told, less than a half-million workers are in the U.S. on H1-B visas made available to skilled foreigners.

Pathways to legal entry with looser education requirements do exist. But the numbers admitted each year are peanuts in the national labor force of 170 million. Moreover, none of these paths is specifically designed for health care professions that typically require less than a four-year college degree.

There’s no way to spin the short-term supply problem in optimistic terms. The current system is flawed, expensive and too slow to adequately address the demand for foreign-born health care workers in the U.S. Comprehensive bipartisan immigration reform focused on the need to draw in workers in great demand, which just a few years ago seemed tantalizingly close, is a distant prospect at a time when Washington is laser-focused on ridding the country of the undocumented. But there may be opportunities to fly below the partisan radar to widen existing legal cracks in the border where health care labor shortages are most extreme.

The Camel's Nose

First, consider a very modest precedent. The Conrad 30 Waiver Program drops the requirement for foreigners who graduate from U.S. medical schools to return home for at least two years if they are willing to practice medicine in America for three years in designated medically underserved areas (mostly relatively poor rural counties). The catch is in the adjective “modest.” Each state can sponsor just 30 candidates annually.

Now, some states, including New York, California, West Virginia and Texas, typically use their full quotas of Conrad 30 waivers. But others, including Utah, Delaware, Alaska and Nevada, consistently leave waivers on the table. And under a rare bipartisan initiative (the proposed DOCTORS Act), these unused waivers would be redistributed equally among states that had fully utilized their 30 waivers.

A modest achievement? Yup. But a beginning – and perhaps a camel’s nose under the partisan tent. If Congress can live with Conrad 30, is it too much to hope for Conrad 300?

Credential Sidelined Immigrant Workers

In the same vein, researchers from the Migration Policy Institute estimate that approximately 270,000 immigrants with medical or health undergraduate degrees who are already legally in the U.S. are working in jobs below their skill levels – or have left health care altogether. This phenomenon, which MPI dubs “brain waste,” is primarily attributable to the daunting barriers these workers encounter when trying to have their foreign credentials recognized in the U.S.

State governments control the licensing of medical professionals, with each setting its own requirements. Migrant workers seeking licensure face challenges such as translating and verifying their foreign credentials, undergoing costly retesting, meeting stringent English-language proficiency requirements – and, for physicians, repeating arduous, poorly paid multiyear residency programs.

States can (and some have) taken steps to loosen the logjam. One small step would be to offer medical licenses regardless of immigration status. Currently, only immigrants with specific visas and a Social Security number can receive medical licensing. But some states, notably including California and Illinois, have removed immigration-related conditions for obtaining any professional license. Others, including Arkansas, Nebraska and New York, have offered professional licensure to all individuals with any sort of federal employment authorization, including those with Deferred Action for Childhood Arrivals (aka DACA dreamers) and Temporary Protected Status for refugee applicants.

Additionally, states can develop programs to polish medical professionals’ skill levels and to increase English language proficiency. Colorado, for example, has a clinical readiness program that helps international medical graduates prepare for residency programs. Maine and Washington, for their part, offer work-based courses to help with English proficiency and upskilling in a number of professions including health care.

Four states – Tennessee, Illinois, Florida and Virginia – have enacted laws that allow international medical graduates to bypass redundant residency requirements, granting an alternative pathway to licensure. Additionally, 11 states have introduced or passed legislation to streamline the licensure process for international medical graduates. Notably, the list includes some red states (Missouri and Alabama) that are under pressure to put the practical goal of improving health care above ideological opposition to immigration.

Replicate Conrad 30 for J-1 Trainees

While the J-1 visa – the entry category for various international exchange programs – is available to foreign medical graduates, it is not limited to physicians: it also includes a track for trainees. This track allows foreign nationals with at least a postsecondary certificate to gain up to 18 months of practical occupational experience and training within the U.S. workforce, and in the process provide much-needed services.

Despite its potential, the J-1 trainee program is underutilized – only 10,645 people participated across 91 employers in 24 states in 2023. If the State Department were to replicate the Conrad 30 program for J-1 trainees, enabling states to sponsor a specific number of health care trainees annually, it could incentivize greater participation.

Currently, J-1 trainees are prohibited from working in roles that involve direct patient contact or care, including childcare and elder care. However, “health-related occupations” are among the eligible categories in the J-1 trainee program. This includes roles such as medical transcriptionists, occupational health and safety specialists and technicians, medical records specialists and pharmacy technicians, among others. While these occupations are not direct-care roles, they are essential to the functioning of the health care system and could free up labor for direct-care.

Au Pairs for Elder Care

According to an AARP survey, 77 percent of American adults would prefer to age in their own homes, a preference consistent with the fact that the percentage of adults living in nursing homes has steadily declined over the past two decades. But aging in place in failing health is only possible for those with access to home health care. And it is precisely here that the worker shortage is the most pronounced.

One ingenious potential fix is to expand the existing 36-year-old Au Pair Program to include elder care. It makes good sense since the Au Pair Program has few political enemies, and the explosive growth of elderly dependents is virtually guaranteed to increase shortages of health care support workers to crisis proportions.

The Au Pair Program currently allows American families to host young foreigners for up to two years in work-study arrangements. Participants arrive in the U.S. with childcare training, English language proficiency and a comprehensive background check. While working as live-in caregivers for children, they can also earn college credits. The program operates without taxpayer funding, as private agencies charge administrative fees and host families pay (modest) wages. It is also highly popular – more than 21,000 families participated in 2023 alone.

Currently, there is no cap on J-1 visas for au pairs. And we expect that garnering bipartisan support for expanding the program to care for the elderly shouldn’t be difficult, as it would fill a big gap for middle-income families at no cost to Washington.

Schedule A Reform

Schedule A is a list of specific occupations exempt from tough immigration hurdles because the Department of Labor has concluded that immigrants would not adversely affect the wages and working conditions of U.S. citizens. Employers aiming to hire for Schedule A positions can largely bypass the requirement to demonstrate there was no qualified domestic worker willing to take the job, typically saving them six months of red tape and associated search costs.

The Schedule A list was first codified in 1965 and gave the Secretary of Labor discretion to amend the list “at any time, upon his own initiative.” But the last substantial changes to the list came in 1991 – and the only occupations on the list are nurses, physical therapists and a catchall “immigrants of exceptional ability.” There’s every reason to prioritize home health aides in an updated Schedule A list – something that could be done without congressional approval.

Green Card Recapture

In 1990, Congress established a cap on the number of “green cards” – permanent residency visas – that can be issued annually in some family-based and all employment-based quota categories. Washington intended for all allotted green cards to be issued each year and created a mechanism to roll over unused green cards from the employment-based category to the family-based category (and vice versa) the following year. However, the process is inadvertently flawed by the formula used to calculate the rollover numbers. Essentially, in years when a high number of family-based green cards are issued, no employment- based green cards roll over, leading to their permanent loss.

As a result, the green cards that Congress intended to roll over effectively evaporate. Complicating matters further, most of these would-be employment-based green card recipients are already living in the U.S., waiting to adjust to a different status – for example, physicians with H-1B temporary visas. These individuals risk their place in line if they travel outside the country, switch jobs or change employers. Moreover, their families also live in a legal twilight zone; spouses must struggle to obtain legal work authorization, and their children risk “aging out” – that is, losing their future eligibility to secure permanent residency as dependents of green card holders.

There’s precedent for a fix. Congress has “recaptured” unused green cards from previous years. Plainly, there would be ideological opposition in Congress. But presumably it would be less strident if the change were specifically tied to efforts to ease health care shortages, and fixing the flawed formula to ensure that all green cards allocated by Congress in a given year are used and do not go to waste.

Half Measures Better Than None

America’s health care system is buckling, squeezed between a rapidly growing population of elderly and a shrinking number of workers in the supply pipeline. While training more domestic workers is crucial – and AI may serve to increase the productivity of workers already on the job – the prospects of pulling ourselves up by the bootstraps anytime soon are dismal.

Indeed, immigration offers the most practical scalable solution in the near term. From physicians and nurses to direct care aides and home health workers, foreign professionals are already integral to care delivery. And strategic reforms could unlock this latent capacity. Rather than treating foreign-born talent as a last resort, U.S. policy should recognize immigration as a vital pillar of a strong, sustainable health care workforce – and act accordingly.