Why does America shut its doors to foreign nurses?

Stuart Anderson Executive Director, National Foundation for American Policy
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The Affordable Care Act, widely known as Obamacare, could permit 30 million more people to gain access to health insurance, according to the Congressional Budget Office. Such a significant increase in the demand for health services combined with our aging baby boomer generation means the U.S. government needs to enact immigration (and other) policies that will ensure medical personnel are available to serve these patients. (See this new report on the topic from the National Foundation for American Policy.)

According to the 2012 “United States Registered Nurse Workforce Report Card and Shortage Forecast,” published in The American Journal of Medical Quality, “With an aging U.S. population, health care demand is growing at an unprecedented pace. … The number of states receiving a grade of ‘D’ or ‘F’ for their RN [registered nurse] shortage ratio will increase from 5 in 2009 to 30 by 2030, for a total national deficit of 918,232 RN jobs. There will be significant RN workforce shortages throughout the country in 2030; the western region will have the largest shortage ratio of 389 RN jobs per 100,000.”

We should train more nurses in the U.S. But a major problem with attempting to increase the supply of nurses only domestically is finding qualified instructors for nursing schools, leaving foreign nurses as an important additional source. U.S. health care providers find hiring a foreign nurse on a temporary visa is often not possible, depending on the job requirements and the country of origin. That leaves green cards as the only viable path for most foreign nurses. However, the wait for employment-based green cards is currently five years or more from most countries. Only about 6 percent of nurses working today in the U.S. were educated overseas.

Unlike other foreign nationals who can work in the United States in H-1B temporary status while waiting for their green cards, typically a foreign nurse must wait overseas. It is a testament to the need for foreign nurses that health care employers would endure the cost and the wait of at least five years until a foreign nurse could begin working in the United States, something unheard of in other fields. “The key issue is not just the overall number of nurses but their maldistribution geographically and the need for specialty nurses,” according to Bill DeVille, the CEO of Cincinnati-based Health Carousel, a provider of both domestically educated and internationally educated nurses.

One argument made by critics is that the H-1A temporary visas nurses used in the early 1990s resulted in the poor treatment of foreign nurses. A Department of Labor-commissioned study by economist Ruth Levine disputes that: “There was no evidence that the increased access to foreign labor under the law had negative short-term effects on the wages, benefits or working conditions in area hospitals. … In addition, and contrary to common beliefs, we found that foreign nurses were not paid less than U.S. nurses and were not exposed to worse working conditions.”

Another argument made against allowing foreign nurses to enter the United States is that it may cause a “brain drain” from other countries. Those who oppose employment-based immigration for other reasons usually offer this argument but are unlikely to care more about such countries than individuals who educate themselves to work abroad and send money back home to their families. Given the demand for their services, foreign nurses have many choices besides coming to America. That means blocking the entry of skilled foreign professionals hurts U.S. patients and only diverts these professionals to other Western nations.

In Medical Care (April 2011), Mary Blegen and other researchers found increased nursing care staff hours were associated with lower rates of dying from congestive heart failure, infections and prolonged lengths of stay. The conclusion: “Higher nurse staffing protected patients from poor outcomes.” According to a study published In The New England Journal of Medicine (March 2011), “Staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients’ needs for nursing care.” A Journal of the American Medical Association study found that increasing a nurse’s workload from four to eight patients would be accompanied by a 31 percent increase in patient mortality.

There is no such thing as a free lunch. The cost of policies that permit too few nurses to work in America is paid for by a greater rate of infection and increased patient mortality. There is a solution to this problem: Reform U.S. immigration laws to allow in foreign nurses who wish to serve U.S. patients and save lives.

Stuart Anderson served as executive associate commissioner for policy and counselor to the commissioner of the Immigration and Naturalization Service from August 2001 to January 2003 and is executive director of the National Foundation for American Policy, a nonpartisan research group based in Arlington, Va.