A recent commentary offers a stark glimpse into future healthcare demands (Harris & Marshall, 2024). During the first two years of the pandemic, the U.S. economy saw a loss of 400,000 workers in residential care facilities and nursing. Presently, there remains a shortage of approximately 130,000 workers compared to pre-pandemic levels (U.S. Bureau of Labor Statistics). With the last cohort of baby boomers turning 65 by 2030, the U.S. Census Bureau estimates that 73 million seniors will soon constitute about one-fifth of the population, outnumbering children (Vespa, Medina & Armstrong, 2020).
In 2017, immigrants made up 18.2% of healthcare workers and 23.5% of long-term care workers, both formal and non-formal. Additionally, immigrants comprised 27.5% of direct care workers and 30.3% of nursing home housekeeping and maintenance staff (Zallman et al., 2019). Given these figures, it seems logical to streamline processes for employers seeking foreign nationals to fill staffing shortages in the healthcare industry. Unfortunately, healthcare-based immigration options are minimal at best. This article will not delve into physician-based alternatives due to space constraints.
Paths for Healthcare Workers
Immigration is plagued by bureaucratic complexity, often obscuring potential game-changing steps. For instance, employers must navigate employment-based immigrant (permanent residence/green cards) visa options alongside nonimmigrant (temporary work) visa alternatives. The timeline and steps toward permanent residence depend heavily on the individual's nationality, qualifications, and the job's category (e.g., degree requirements, experience, training).
Immigrant Visas
Each year, 140,000 immigrant visas, including visas for dependent spouses and eligible unmarried children, are allocated between the U.S. Department of State (DOS) and U.S. Citizenship and Immigration Services (USCIS) for new and pending applicants seeking to immigrate to the U.S. Due to demand surpassing supply, some applicants face waiting periods of several decades (Anderson, 2024). The priority date, determining an applicant's place in line, hinges on the filing of a labor certification with the Department of Labor (DOL), where applicable, or an I-140 petition with USCIS. Monthly, DOS issues a Visa Bulletin based on demand, backlogs, and processing by USCIS and consular posts abroad, establishing priority dates to initiate immigrant visa processing (Visa Bulletin, July 2024).
The July 2024 Visa Bulletin delivered disappointing news for prospective employers of nurses, typically categorized under the third employment-based category (EB-3) due to not requiring a bachelor's degree. This category saw priority date retrogression by nearly a year for Mexican, Filipino, and other nationals, excluding those from China or India. Consequently, staffing shortages faced by employers were delayed by a year due to this bureaucratic adjustment. DOS indicated that if demand continues high for immigrant visas in the EB-3 category, further retrogression or even unavailability (U) of filings may occur until the start of the new federal fiscal year in October.
Thus, nurse applicants from Mexico, the Philippines, or other regions (except India and China) find themselves in limbo, unable to immigrate and commence work in the U.S. for potentially another year or longer (Weixel, 2024). Despite acknowledging the nursing shortage by exempting foreign nurses from a test of the U.S. labor market (Schedule A), no such exemption applies to the allocation of immigrant visas. Proposed solutions include:
- Allocating additional immigrant visas specifically for documented healthcare shortages, exempt from the annual cap, citing public health and safety concerns. These shortages could be certified by states for allocation.
- Exempting family members from the 140,000 employment-based visa cap.
- Expanding Schedule A to include additional healthcare positions beyond nurses and physical therapists.
- Considering exemptions from immigrant visa caps for workers educated or trained in the U.S.
Implementing these solutions requires legislative action, a challenging prospect even during times of critical shortages.
Nonimmigrant Visas
The nursing profession has seen targeted adjustments to nonimmigrant visa options in the past. For instance, in the 1980s and 1990s, Congress created the H-1A category for foreign nurses in facilities facing healthcare professional shortages certified by the DOL. This was followed by the H-1C category with stricter criteria and a cap of 500 visas annually. From FY1990 to FY2012, the U.S. issued 36,743 H-1A visas and 1,042 H-1C visas to foreign healthcare workers (Congressional Research Service, 2023).
Nonimmigrant visa categories for addressing healthcare shortages typically include:
- H-1B, H-1B1 (Chile and Singapore only), and E-3 (Australia only) for specialty workers requiring a bachelor's degree or equivalent.
- TN visas for professionals from Mexico and Canada, limited to certain professions.
- O-1 visas for individuals of extraordinary ability.
- H-2B visas for temporary, intermittent, peak load, or seasonal needs.
- J-1 visas for international medical graduates (physicians).
These categories each come with their own considerations. For example, nursing positions primarily fall under the TN category due to not typically requiring a bachelor's degree, excluding them from other nonimmigrant options like H-1B, H-1B1, or E-3 visas. Unfortunately, extending work authorization (Optional Practical Training – OPT) for recent nursing graduates in the U.S. isn't possible as nursing isn't classified as a STEM field.
Legislative Proposals
Several legislative proposals have been suggested but not enacted:
- The Immigrants in Nursing and Allied Health Act of 2022 (H.R. 8021, 117th Congress) aimed to provide grants to assist noncitizens lawfully present in entering nursing or allied health professions.
- The Professional's Access to Health Workforce Integration Act of 2022 (H.R. 8019, 117th Congress) proposed grants to aid unemployed or underemployed skilled immigrants, trained internationally, in joining the U.S. health workforce.
- Suspension of statutory requirements for certain healthcare workers to obtain healthcare worker certificates, even if educated in the U.S., during national healthcare emergencies.
The failure to enact legislative fixes hampers efforts to provide additional trained healthcare workers to meet population needs. Understanding the current immigration landscape is crucial for identifying even modest changes that could secure critical staffing.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.