How immigrant physicians solved a U.S. crisis

In the decades following the passage of the Hart-Celler Immigration and Nationality Act of 1965, the face of American medicine irrevocably changed. This bill expedited the rapid entry of physicians from post-colonial Asian nations into the U.S. in significant numbers. In this migratory flow, South Asian physicians, in particular, have become a ubiquitous, familiar presence populating clinics and hospitals across the country. Yet, the story of how this came to be, and its enduring impact on the profession, requires explanation.

By the 1960s, newspapers around the country were sounding the alarm about a doctor shortage. In 1962, Howard Rusk wrote an article in the New York Times, “Doctor Shortage Grows: Congress Again Fails to Allocate Funds to Expand Medical Schools,” in which he lamented congressional inaction in the face of mounting evidence that showed increasing health personnel “could save more lives.” By 1967, the discourse surrounding doctor shortage intensified as a headline in the New York Times warned, “Doctor Shortage Nearing a Crisis.”

Congress convened special hearings to investigate factors affecting the supposed crisis. They discovered that while the supply of U.S.-educated physicians remained relatively stagnant, demand for medical services was increasing rapidly. Among the major causes for the increase were shifting social and political expectations regarding health care access, demographic changes, and the expansion of Medicare and Medicaid, which became law in July 1965, only three months prior to Hart-Celler.

Then, as well as now, stakeholders contested how to identify a shortage, or what constituted a shortage area, or even when to declare a crisis. Lawmakers, lobbyists, economists, practitioners, and patients all adopted different metrics and calculations motivated by their specific interests. Should the shortage designation be made based on a physician-to-population ratio? If so, how would distinctions between general physicians and specialists figure into this calculation? And should nurses and allied health professionals be considered? In terms of demand, should this be calculated based on need or actual use? How would barriers to access such as transportation (an acute issue in rural communities) affect the use/need calculus? And what of communities with a higher frequency of users such as the elderly and young children?

In this dizzying array of questions, one thing was certain: The medical labor market defied simplistic laws of supply and demand, a free-market orientation was unable to address the complexity of the problem. For the sake of expediency, however, policymakers adopted the physician-to-population ratio with the knowledge that this flattened the complexities of the shifting medical landscape. But it would have to suffice, in the meantime.

Congress responded to the domestic shortage in physician supply using immigration legislation. They inaugurated a short-term mechanism to address the market imbalance by inviting foreign physicians to staff shortage areas in exchange for legal status. Shortage areas were generally populated with people who were low-income, elderly, homeless, incarcerated, and migrant laborers: poor, medically complicated patients with public insurance and a likelihood of premature death. In a matter of months, hospitals in shortage areas were able to use the Hart-Celler Act to quickly fill their vacancies, especially in primary care specialties, with resident physicians from India, Pakistan, and the Philippines.

Between 1965 and 1975, over 75,000 physicians from predominantly postcolonial Asian nations entered the labor force.

By the early 1980s, there was a marked rhetorical shift in political discourse from physician shortage to physician oversupply. During the 1960s, legislators implemented meagre medical education and infrastructural reforms with the hope that, by the late 1970s and 1980s, these programs would yield enough U.S.-trained physicians to meet population needs. As a result, they argued, the immigration of foreign physicians was no longer necessary.

However, there was one glaring problem with this new restrictive posture: Foreign physicians provided essential services in shortage area communities at rates much higher than their U.S. counterparts. And undoubtedly, these restrictions would exacerbate health inequities for marginalized urban and rural communities that relied heavily on their services.

In other words, the issue remained, where exactly was the shortage crisis and for whom? Hospitals in shortage areas in urban and rural communities were certainly not experiencing this predicted glut of providers on their staffs. In fact, hospital administrators in these areas created special piecemeal programs and vouchers to continue to attract foreign physicians to their facilities. These arrangements make clear that market-based logics aimed at increasing physician supply with hopes that this scarce resource would eventually fill in the gaps were misguided. Simply growing the domestic labor force had minimal impact on the equitable distribution of health resources. Instead, it produced a scenario where scarcity exists alongside surplus, an ongoing crisis for the most disadvantaged.

In the last 60 years, declarations of health labor crises have become the norm. It seems crisis has become the very condition of the system, an “ongoing state of affairs,” as anthropologist Janet Roitman writes, where foreign physicians are added or subtracted to negotiate the political moment. This begs the question: Should the term “crisis” be used to designate what has become a perpetual state? The term has morphed “crisis” from a surprise or unexpected event with a discrete beginning and end to something that is a predictable outcome of years of deliberate political decision-making that has failed to prioritize the growth and development of the domestic health care workforce.

Health care worker shortages are not inevitable. COVID-19 reanimated a flurry of discussion and activity around this issue, all in the name of emergency. We must rethink the crisis and emergency narratives that have long framed the problem and address this structural deficiency with a comprehensive, deliberate approach that does more than repeat the strategies of the past. Currently, the U.S. has the worst performing health system among comparable countries. To decelerate this trend, the nation must grow the labor force, reorganize health care delivery and distribution, attract and retain a diverse group of practitioners, in addition to creating smoother pathways for immigrant physicians. The migration of foreign physicians since Hart-Celler has shown that immigration as a stopgap measure for physician shortage can barely sustain the system. It’s time to transform it.

Eram Alam is an associate professor specializing in the history of medicine. She is the author of The Care of Foreigners: How Immigrant Physicians Changed US Healthcare.