We need H1B in healthcare, but it must be reformed
Widespread physician shortages in the US require us to import foreign grads, but they are often underpaid and trapped in their jobs
A few weeks ago, debate erupted over different factions of MAGA world over the H1B visa program, a temporary visa given to high-skilled workers overseas to live and work in the United States. While Vivek Ramaswamy and Elon Musk both argued to expand the program given the shortage of domestic high-skill workers, more America-First conservatives like Laura Loomer and Steve Bannon argued that these programs undermine American labor by allowing large corporations to increase profits by importing overseas workers at lower wages.
While typically used in the technology and engineering sectors, these visas are also utilized occasionally by international medical graduates (IMGs) to complete residency and practice in the United States (the J-1 visa is the most common).
The H1B program was initially introduced in 1990 under the George H.W. Bush Administration. While the number of visas issued often change from year to year, it has typically hovered between 50,000 to 200,000 per year. The visa period lasts 3 years for the initial stay, which may be extended to 6 years before the holder may choose to leave the US or reapply. H1B holders may become eligible for permanent residency (Green Card) status and eventual naturalization. A 2019 USCIS report estimated that there are nearly 600,000 foreign nationals currently on H1B visas in the US. Since its inception, there are likely over 1 million current US citizens who originally came in as H1B holders.
Over the past three decades, over 70% of H1B visas have been issued to Indian applicants. Given that my own parents immigrated to the US under the H1B program, this issue hits close to home. My mom always jokes that she continues to thank President Bush for allowing her to come to this country.
When it comes to this debate, I stand somewhere in the middle of the two aforementioned extremes, especially when it comes to healthcare. Here’s why.
As I have discussed extensively in other posts, there is an ever-increasing shortage of doctors in every specialty nearly everywhere around the United States. This is one of the primary drivers of access to healthcare in resource-limited localities. The AAMC has estimated that this shortfall of care in underserved communities amounts to about 202,800 physicians.
To a large extent, the number of residency spots available to train new doctors is controlled through federal funding through CMS. Despite there being about 41,000 residency spots each year in the US, only about 21,000 US seniors graduate medical school each year (MD or DO). In order to fill these extra spots, programs will offer positions to IMGs. Despite opening up the Match to IMGs, there are still residency spots that go unfilled each year mostly in primary care specialties, which are the disciplines where shortages are felt the hardest.
On a slightly unrelated note - the numbers also reveal that in a typical year, there are about 50,000 applicants to the Match, more than the number of seats. The fact that positions still go unfilled makes me think about the true effectiveness of the algorithm as well as the systemic issues (lower pay/documentation burdens/insurance haggles) that make primary care less attractive to graduating medical students. Regarding the former, there has been a litany of criticisms that have been levied at the Match algorithm for not optimizing outcomes for programs nor applicants. I’m quite interested in this and may discuss this in more detail in an another post.
All in all, H1B is one of the limited clear cut pathways that IMGs can take in order to come to the US, train, and ultimately provide greatly-needed services to our population. Even with the H1B program where it is now, we still have a large shortage and even among patients tapped into the healthcare system, many still do not receive routine care. I have written about this extensively. Downscaling or eliminating this program would be a threat to our health as a country and worsen existing healthcare disparities.
However, the H1B program is far from perfect. While the visa is seen as a way to attract the world’s best and brightest to come to the US, it also become a tool by which large companies can maximize their margins through undermining American labor and paying foreign workers lower wages.
Because maintenance of visa status (and the ability to stay in the US) depends on continued sponsorship by the employer for the duration of the job, this creates an unbalanced power dynamic between employers and H1B employees that is not seen among American counterparts. As a result, H1B employees are often locked into jobs and must accept lower pay and worse conditions for fear of their visa being taken away if they do not comply. They also have decreased bargaining power as their ability to recruit for jobs at competing firms is restricted.
This has already resulted in measurable worse outcomes among the largest firms that use H1B. The Economic Policy Institute has released a report finding that nearly 60% of H1B holders are paid well below the local median wage, ranging between 17-34% below specifically for those in the tech industry. And despite many companies being eligible to use H1B, nearly 1 in 4 visas are granted towards the largest 30 H1B firms - which includes behemoths like Amazon, Walmart, Microsoft, and Google. These large companies are knowingly using this program en masse to save millions in wages they would have to pay out to domestic workers. These same top companies laid off about 85,000 domestic workers in the years of 2022-2023, but at the same time hired about 34,000 workers from overseas.
There has not been much analysis into if the same is happening among the physician workforce, but it is not a great leap to make mentally. Such pay disparities are not likely to be seen among residents or fellows, as salaries for those jobs are relatively standardized, but I am almost certain they are happening systematically at the attending level. I recently heard a story from one of my mother’s family friends, who is an IMG from India and on the H1B visa. Even as an attending orthopedic surgeon at a hospital affiliated with a top academic center, he claimed he was paid over $100k less than his American peers because of his visa status.
Combine this with a changing practice landscape where many clinics and hospitals have been scooped up by large healthcare conglomerates and private equity. These companies are essentially the “Amazons” of the healthcare industry and are known to do anything to drive costs down and push their margins. Studies have found that they are already taking harmful actions favoring profit over their own patients - it only makes sense that they will do the same for their employees as well.
What can be done about this?
While it is debatable whether H1B (at least to this extent) is needed in the tech sectors where there are qualified American workers, we definitely need it in the healthcare field given the large shortage of domestic physicians and trainees like I described earlier. However, steps must be taken to reform the program and ensure that foreign workers are not exploited and so that American workers remain competitive. This includes establishing wage floors depending on occupation and beefing up regulation prohibiting below-market wages for visa holders. I would even go as far as to cap visas in sectors of the economy where there are clearly enough qualified domestic workers to work those jobs. In fact, a bipartisan Senate bill has already been introduced with some of these provisions by Dick Durbin (D-IL) and Chuck Grassley (R-IA) in 2017. Unfortunately, this bill succumbed to the Washington gridlock and has remained in committee hell since. It is unlikely that this will ever make it to the floor.
Despite the renewed interest and apparent support from factions on both sides of the aisle to reform the H1B program, we have yet to see actual policy agendas from either Party to address these concerns. And with the promotion of Elon Musk to a special government employee with unprecedented power, it is not difficult to see which way the Trump administration is going in terms of H1B - keep it as-is without reform. I am sure this has nothing to do with Musk’s Tesla and SpaceX being among the top users of the program…
For policymakers of either party who came out of the woodworks to join this recent debate, it is time to put your money where your mouth is - as this program not only affects when you get your Amazon package delivered or the new iPhone, but also if you can get access to healthcare.