Foreign Doctors in the U.S: Is This Fair?
Each year, developing nations spend $500 million to educate health care workers who leave to work in North America, Western Europe and South Asia. In other words, as the most recent issue of the Journal of the American Medical Association (October 24-31) puts it: “developing nations are subsidizing healthcare in wealthier nations.”
And we are not talking about a small clutch of physicians: close to 25 percent of U.S. doctors are foreign-born. According to JAMA, “These unchecked flows of health workers leave regions with the greatest health care needs the fewest workers…37% of the world’s health care workers live in the Americas, predominantly in the United States and Canada , yet these countries carry only 10% of the global disease burden. In contrast, Africa is home to only 3% of the world’s healthcare workers, yet it has 24% of the global burden of disease.”
Yet as the American Medical Association points out, we don’t have enough home-grown physicians to serve our needs here. Some 35 million Americans live in areas where there are not enough doctors. Nationwide, primary care doctors are in short supply, in large part because they are paid so much less than specialists. Medical students who know that they are going to be graduating with $100,000 in loans report that that they just can’t afford to become internists or family doctors.
Moreover, according to the Kaiser Family Foundation “the nationwide physician shortage is affecting rural and inner-city residents the most,” and following 9/11, “restrictions put in place on foreign doctors who want to practice in the U.S.” have made the situation worse.
Thirteen years ago, the federal government began issuing J-1 visa waivers which allow foreign physicians to work in rural areas like Appalachia and the Mississippi Delta for three to five years and then seek permanent residency. But since, 2001, the government has hiked fees for the waivers, made tests that foreign doctors must take harder, and tightened rules determining what counts as an “underserved area.” According to the Government Accountability Office, the number of physicians in training with J-1 visa waivers declined by nearly half over the last 10 years, from 11,600 in the 1996-1997 academic year to fewer than 6,200 in the 2004-2005 academic year. In addition, in 2003 HHS took control of a Department of Agriculture foreign doctor program and has approved only 61 J-1 waivers since that time, according to the AP/Inquirer. The visa program is set to expire in 2008.
We sorely need those doctors, advocates of the program say. Moreover, those who support opening our doors to more foreign physicians contend that by welcoming these doctors to our shores we might begin to curb runaway health care inflation. TPM Cafe contributor Dean Baker has argued, on more than occasion, that “increased competition from foreign professionals could lead to dramatic reductions in the salaries of workers in the highly paid professions.”
In a 2003 study Baker, who is co-director of the Center for Economic and Policy Research, estimates that by adding roughly 100,000 physicians to our current pool of about 760,000, we could pull doctors’ salaries down from an average of $203,000 to somewhere between $74,000 and $126,000. For the average middle-class American family of four he reckons that would lead to savings of $2,200 to $3,700 per year
What he ignores is that, by and large, foreign doctors who work in the U.S. practice in a separate market. Indeed, an analysis of where these doctors work shows they are likely to be found in geographic areas where the physician-patient ratio is low and the rate of infant mortalities is high. Typically, they are found in rural areas where their visas have sent them and in inner cities where they treat the Medicaid patients that many American doctors refuse to see because Medicaid reimbursements are so very low. The fees Medicaid pays vary state by state, but Princeton health economist Uwe Reinhardt gives an example of just how parsimonious the government can be: “federal and state legislators may be willing to pay pediatricians $10 to see a poor child covered by Medicaid, but to pay the same pediatrician $50 or more to see these legislators’ own children in the commercial corner of the market.”
As we noted recently on The Century Foundation's healthcare blog, Health Beat, even when foreign and American doctors practice in the same area, “medical apartheid” is the rule (see the relevant posts here and here.)
In New York City, for example, well-insured white patients see one set of doctors, while minority and poor patients see another group, many of them foreign-born. Typically those doctors charge less (or are paid less by their employers.) In the late 1990s, when it seemed we had a surplus of physicians in this country, the AMA fretted that doctors emigrating from other countries might pull down physicians’ salaries. Not to worry. While Medicare has put a brake on some doctors’ incomes in recent years, foreign doctors have had little effect. What they charge low-income patients ultimately has no influence on what the market will bear at the high end—and that’s the end that feeds health care inflation.
Moreover, even if a flotilla of foreign docs could bring down medical fees—is it fair to poach physicians from countries where tens of thousands of children are dying of treatable conditions? To put it as bluntly as possible, how many children are we willing to let die each year so that the average middle-class American family can save $2,000 to $3,700?
Baker recognizes and addresses the ethical problem. His solution is to pay for the doctors we are taking: “it would be reasonable to expect that developing countries would want to recoup the costs of educating professionals who have left the country,” he writes, “and it would be reasonable to expect that a rich nation like the United States would be willing to share some of the economic gains that it receives as a result of an increased supply of highly educated workers from poor nations. “
But money won’t replace able-bodied phsyicians. And in developing countries there are a very limited number of individuals who have had the necessary educational opportunities as children to prepare them to study medicine as young adults. Keep in mind that, in Africa, AIDS has wiped out tens of thousands of children and young adults who might have become health care workers.
Moreover, as Laurie Garrett pointed out in Foreign Affairs earlier this year, thanks in part to Bill and Melinda Gates and Warren Buffett, “there are now are now billions of dollars being made available for health spending” in the developing world. “But much more than money is required,” Garrett observes. “Decades of neglect have rendered local hospitals, clinics, laboratories, medical schools, and health talent dangerously deficient, much of the cash now flooding the field is leaking away without result. [my emphasis]
“The fact that the world is now short well over four million health-care workers s all too often ignored” she continues. “As the populations of the developed countries are aging and coming to require ever more medical attention, they are sucking away local health talent from developing countries.”
Garrett offers stark evidence of the "brain drain.” For example, 604 out of 871 medical officers trained in Ghana between 1993 and 2002 now practice overseas. Zimbabwe trained 1,200 doctors during the 1990s, but only 360 remain in the country today.
She also discusses how other developed countries are arranging short-term exchanges of physicians that could help train doctors from developing countries. And she describes a World Health Organization program designed to “eliminate recruitment of physicians in poor countries without the full approval of host governments. . . No such code exists in the United States,” she adds, “but it should.”
For more detail on the death of doctors in developing countries and programs that might work see this post on Health Beat
Comments (23)
Thanks Maggie for the post and giving me an opportunity to respond. First, I should correct one arithmetic item which is probably my fault for not being sufficiently clear in my paper. I was assuming that we could bring enough foreign doctors to cut average salaries by around 50 percent. Doctors in the U.S. on average receive a bit more than $200k a year (net of malpractice). We have around 800,000 doctors, which means that if we cut their pay by an average of $100k each, that saves us $80 billion a year or about $800 per family. I think the larger number was based on a situation in which we had free trade for all high-paying professional services.
Let me make three points on the substance:
1) It is easy design a mechanism to ensure that developing countries benefit also from having their doctors work in the United States:
2) While foreign trained doctors may now be in a partially segregated market, it does not follow that this would be the case if their numbers doubled or tripled.
3) The enormous price differences between the pay of doctors in developing countries and the U.S. makes it inevitable that people in the U.S. will increasingly use the services. The only question is whether we go there or they come here.
On the first point, it would be a very simple matter to impose a modest tax on the pay of foreign trained doctors, which would be repatriated to their home country. This money would be used to finance the education of more doctors. For example, if 100,000 foreign doctors worked in the U.S., earning an average of $100,000 each, a 10 percent tax on their earnings would translate into $1 billion a year to support the education of more doctors in the developing world. This should allow developing countries to train 3 or 4 doctors for every doctor that works in the United States. And, this is before counting the benefits of remittances or doctors who choose to work in the United States for a period of time and then return to work in their home country.
Just as people in countries that sell clothes to the United States don’t go around naked, it is possible for developing countries to both send doctors to the U.S. and get better medical care for their own populations.
As far as the second point, it is always dangerous to extrapolate the effects of a small opening on the margin to a full scale transformation of the market. The United States has always imported some amount of clothes from the rest of the world. However, foreign made clothes did not transform the market until we removed the barriers that prevented foreign made apparel from flooding our market.
It is very difficult to imagine how we could have a huge expansion of the supply of foreign-trained doctors and it would not have an impact on the wages received by U.S. doctors. Would I be arrested if I went to see a foreign-trained doctor who charged half the fee of a U.S. trained doctor? Would insurance companies decide they didn’t feel like making more money and instead pay U.S. trained doctors twice as much as what they could pay an equally competent foreign doctor? This scenario seems highly unlikely to me.
On the third point, medical tourism is already a multi-billion dollar industry and its size if exploding. People will no go to India to be treated for bronchitis or other relatively minor ailments. However, for major operations, the savings can be more than $100,000, with patients receiving care that is of comparable quality to what they get in the United States. At the moment, most medical tourism takes place at the individual level, by people who lack health insurance. However, it is only a matter of time (likely very little time) before insurance companies start offering large price reductions to people who are agree to use their facilities in the developing world. There is no way to prevent this, unless we threaten to arrest people leaving the country for medical care.
It makes much more sense to have the doctors come to the United States then to have sick people travel half way around the world to get the care they need. We can organize this in a way that ensures that everyone benefits (except maybe U.S. trained doctors). The sooner we get on this track the larger the benefits will be.
October 31, 2007 10:48 AM | Reply | Permalink
Rather than try to bring down doctor salaries, we should bring in foreign health insurance executives to run our insurance companies for reasonable salaries.
Kidding, of course.
But the problem with our medical system isn't that doctors make too much money. Why make them the villains when it's the private insurance industry that's causing all of the problems?
thosethingswesay.blogspot.com
October 31, 2007 10:59 AM | Reply | Permalink
I thought it was Big Pharma that was the problem, or was it the Medical Industrial complex? What the hell, let's just blame it on the Jews.
October 31, 2007 11:32 AM | Reply | Permalink
I incline to thosethingswesay's attitude. GPs in the UK make about $200,000, basically salaried rather than fee-based, and the UK has way cheaper health care.
It is kind of glib to compare clothing exports to trained health care workers, nurses as well as doctors.
For a poor country the training and investment within a healthcare worker represents something irreplaceable as these countries mostly have a smaller educated elite, as well as fractional GNP per capita compared to the USA.
This all goes to show that health is not a normal market and that supply and demand as modelled by this industry does not give the results the consumer wants or needs.
Of course, lowering doctors pay significantly would reduce US trained doctors, with their debt load, and increase our reliance on foreign-trained "cheap" workers.
It really gets to me that their are about 26 other Western health care systems out there as examples, models to study. They all have their problems but give their populations better and cheaper health care for everyone, while we tinker in the delusion that this market can be made to work for us when we have 30 years clear and one-way experience that tells us it cannot. It excludes and under serves a large minority of the nation to our ultimate cost, both economically and morally.
We need to train our own workers. And if it is so much cheaper to go elsewhere for treatment, let's do that. Leave them their doctors and nurses and boost their domestic economy.
October 31, 2007 11:36 AM | Reply | Permalink
That's pretty uncalled for. Disagree with me if you want, but I'm not scapegoating anyone in a Nazi fashion.
thosethingswesay.blogspot.com
October 31, 2007 12:04 PM | Reply | Permalink
The population of the US has increased by perhaps 40-50 million over the last 50 years, but the number of slots in Medical and Nursing Schools have been fairly flat, with Nursing actually decreasing. The solution would be to find the incentives that would cause states to increase the size of their medical schools, vastly expand Nurse training, so it would meet need over the next 40-50 years. We would also need to subsidize medical education so that graduates with new MD's would not have a huge outstanding loan. In the sciences, most grad school work is covered by fellowships or TA and RA positions -- the only exception has historically been Medicine.
At the same time, we need to plan to accomodate the medicine of the future likely to be based more on biotechnology. Attention needs to be given to training the cohort of workers for these services. Since I fully expect the Health Care System as it exists today to crash if leadership is not applied to thorough going reforms, it just might be better to do some intelligent planning for easily understood needs, and do what is necessary to force states to train enough Doc's, Nurses, and techies for what their projected population likely will require 40-50 years into the future. It may be that we need to pay some attention to recruitment -- identifying potential Medical Professionals of the future when they are still in High School, and making certain they move through Undergraduate School, and move on to professional training programs. We also might have to make the conditions under which they work a bit more attractive -- perhaps deal with the needs all workers have for a life outside of the office, wards, nursing stations and clinics.
Paul Wellstone used to call this the necessary Grand Bargain if some form of Single Payer system was to be built. In exchange for an essentially free education, Doctors, Nurses and Techies would accept essentially salaried jobs within planned service frameworks. During his 12 years in the Senate, Paul became convinced that the actual delivery system for health care had to be a State responsibility -- with the Feds essentially paying for research, public health, and maintaining the menu of services, but the states would actually run the systems. States, in his view, could be far more competent, and Governors and Legislators far more politically sensitive to service needs -- and innovations in how to provide the menu of services at the most efficent cost. (He thought something like a Board of Regents that oversees Universities ought to be created in each state to hold the Health Care System in trust.) He noted that the EU finances most of its Health System from a Value Added Tax, and he thought that could replace the insurance model. In particular a Value Added Tax could be structured so as to model a progressive tax, that would make everyone a payer, but would tax the higher level consumers at a higher rate. A Value Added Tax would also apply to imports, which would have the effect of making at least some off-shoring less desirable.
But unless we can face up to the notion that the Medical System should not be a huge profit center -- where big Pharm and the Insurance Industry expect 20% return annually on investment, we can't really fix it before it crashes. We have to change the incentive system -- not how expensive can you make the new whiz bang new pill, but how you manage costs and design new proceedures and products with economy in mind.
October 31, 2007 12:37 PM | Reply | Permalink
Is this influx limited to developing countries? Are Canadian and British docs headed this way as well?
The real question is what is limiting these doctor's income in their home country. Addressing this root cause may be may be more productive than special costly to enforce taxes on foriegn workers.
The sons of the prophet are noble and bold,
and quite unaccustomed to fear.
But the bravest by far in the ranks of the Shah
was Abdul Abulbul Amir
October 31, 2007 12:53 PM | Reply | Permalink
Dean, Destor 23, Not There and Robert Brown,
First, Destor 23, I really like the idea of importing $50,000 a year insurance executives.
But seriously, the insurance exutives are not the central problem. Vritually every part of our for-profit health care industry is part of the problem. It's not just that we overpay insurance executives or certain specialists--we pay too much for Everything from drugs to devices to paying for hospitals to install waterfalls. (I've written about the hospitalbuilding boom on www.healthbeatblog.org)
Dean--But what we don't pay too much for is primary care physicians, family docs and pediatricians. And fully 40% of all foreign-born docs practice in these areas. Meanwhile, a tiny percentage of foreign-born docs from developing countries are trained in the highest-paid specialties--their countires can't afford the technologies and equipment needed to train in these areas.
So, even if foreign physicians could lower the salaries of U.S. phyaicians, they would be lowering the salaries of physicians who are Not overpaid. In fact, primary care doctors and other generalists are underpaid. Look at the numbers: Two years ago, the average salary for a family practice physician or general internist in the U.S. was $146,000. And that's an average--in the middle of a career, after years of education that leaves teh avearge doctor with $120,000 to $140,000 in debt.
And a newly-minted primary care doctor earns much less than $146,000.. Right now, the going rate for a newly-graduated hospitalist in Manhattan (where doctors are better paid than in most places) is $105,000. (And hopsitalists earn more than plain vanilla primary care physicians.)
After city, state and federal taxes, that leaves the hopsitalist with about $72,000. If he or she is paying off $120,000 in loans, and trying to rent or buy an apartment near the hospital (as a new doc, you're on call--there is no way you can commute) you are going to be living on a tight budget.
And what you can look forward to, in middle age, is earning an average of $146,000--which, depending on where you live, may mean $105,000 to $120,000 after taxess. This is certainly a perfectly comfortable living in many parts of the country, but if you are trying to send a couple of children through college and your spouse does not bring in a large income, you'll have to be very careful with your money.There are many easier ways to earn that salary without going through years of medical education or carrying and paying off $120,000 of compounding debt.
So no, I don't think we want to bring down the salaries of the primary care physicians, family docs and pediatricans (who are also at the low end of the scale) that more foreign docs from developing countries would replace.
In addition, even if we imported many more foreign doctors the majority would continue to work in inner citites and rural areas, treating our poorest patients.
Medical Apartheid would continue because many Americans are wary of "less expensive doctors"--especially if they are seriously ill. And since 80% of our healthcare dollars are spent on people suffering from serious illnesses, we can't expect to save much by offering them "discount care." In general, when people are that sick they are not bargain-hunting.They would rather take out a loan--or even sell their home--than to go to a doctor they don't trust.
Granted, there is a certain amnount of prejudice at work here. Many Americans assume (without evidence) that foreign docs are not as well trained as American doctors. And when they do encounter foreign docs in an ER or a hospital, Americans complain that they can't understand them--even though an Indian doctor may be speaking perfect English.
When you talk about how, once trade barriers were removed, foreign cloth brought down the cost of cloth in the U.S. you seem to suggest that healthcare is a commodity, just like cloth.
While Americans are perfectly happy to wear cloth made someplace else, there are much less comfortable talking to a doctor from a different culture who they may not understand--and who may not understand them. I am not saying this prejudice is correct, but I am saying that if you are very sick and elderly, suffering from one of the serious diseases that accounts for 80% of healthcare spending, it's understandable that you might be frightened if you weren't sure the doctor understood you. (Just as, in Africa, European and American AIDS workers have run into problems communicating with African patients.)
And when you talk about sending money to developing countries to "pay them" for the loss of doctors, you ignore
Garrett's point--Buffett, Gates and others are already sending billions of dollars to developing countries to help with healthcare.
Money is not what they need. They need trained healthcare workers who are famliar with the language, customs and fears of people in those countries. And there just aren't that many literate, bright, healthy and willing young people available to be trained.
Not There-- I agree with you: "the training and investment in a healthcare worker represents something irreplaceable as these countries mostly have a smaller educated elite. Keep in mind,too, that tens of thousands of young peole have been (and are being) killed by AIDS. Others are succumbling to other infectious diseases, reducing the number who might become heatlhcare workers..
And Dean, it takes more than a year or two to train a doctor--meanwhile, these countires are looking at a crisis.
Dean --You wrote, "Just as people in countries that sell clothes to the United States don’t go around naked, it is possible for developing countries to both send doctors to the U.S. and get better medical care for their own populations."
Here I can only say that weaving cloth and treating patients suffering from complicated virulent diseases are very different tasks. The latter calls for an especially bright, dedicated and compassionate person who has had years of education.
If it were so easy to train more docs don't you think that some of these countries where tens of thousands of children are dying would have done so?
Finally, Dean-- in the end, you don't seem to be facing the ethical implications of suggesting that we should recruit doctors from countries where children are desperate for healthcare in order to come here and shave $800 per family off our national healthcare bill.
As Rashie Fein once put it: "We live in a society, not just in an economy." I would add: "We live in a global society, not just in a domestic economy."
Not there-- I agree that Dean's "free trade" solution is a market solution that pretends that the heatlhcare market is no different than the markets for shifts or socks. As you point out, "we tinker in the delusion that this market can be made to work for us when we have 30 years clear and one-way experience that tells us it cannot. It excludes and under serves a large minority of the nation to our ultimate cost, both economically and morally.
"We need to train our own workers. And if it is so much cheaper to go elsewhere for treatment, let's do that. Leave them their doctors and nurses and boost their domestic economy."
October 31, 2007 12:58 PM | Reply | Permalink
So basically you think you get to decide what a doctor can make? Give me a break. Payments to physicians and other clinical services account for 21% of health care dollars spent. Clearly we are all gaming the system. Maybe we should have a national pay scale for "journalists" too.
October 31, 2007 12:59 PM | Reply | Permalink
Abdul and Pathman--
Abdul-- While 25% of U.S. physicains are foreign, only 1.3% are from Canada. And one-fifth of those are Americans who went to Canada for medical school.
Similarly, very few of our foreign doctors are from the U.K.--or other parts of Europe.
This tells us that doctors in these countries are relatively happy where they are.
It's doctors from much poorer countires who are coming to the U.S.--India, Mexico, China, as well as African countries
They are coming here, as you suggest, because of limited opportuntities in their own countires. It's not just that income would be limited at home--the terrible shortage of doctors in developing countries means that doctors are working very very hard, often underr impossible conditions, and many are getting sick. A tragic number of heatlh care workers are dying of AIDS and infectious diseases.
I agree that we need to address these problems, not just with money, but by encouraging doctors and other heatlhcare workers to volunteer to go to these countires and help train more home-grown health care workers.
Pathman-- i wasn't suggesting putting a cap on doctors' salaries. Lower salaries is Dean's idea.
In fact, I think we need to either pay primary care doctors more, or make medical school much more affordable. Some specilaists, however, are overpaid; the Medicare Payment Advisory Commission wants to review fee schedules which provide perverse incentives to perform very expensive procedures which are not always necessary.
October 31, 2007 1:14 PM | Reply | Permalink
Let me make a couple of quick points here.
1) Developing countries are losing doctors and getting zero for it now. I am proposing a system in which they would get compensation. Unless we put up walls, we will not keep developing country doctors out or prevent people in the U.S. from going to Thailand and other such places to use the services of doctors trained in developing countries. So, I see my proposal as being far more beneficial for developing countries than what is currently in place or anything likely to be on the table in our lifetimes.
2) If we change the system, then the mix of developing country doctors will change. We import steel, cars and clothes from the developing world because our trade negotiators sat down with the folks who wanted to import steel, cars and clothes and said "what is preventing you from getting this stuff produced in the developing world?" We then wrote the trade agreements to get rid of those barriers.
If we did the exact same thing with the hospitals and others who employ high priced specialists and said "what are the obstacles that prevent more neurosurgeons, cardiologists, and other highly paid specialists from coming here from India, Mexico, etc.?" and then constructed our trade deals to insure that doctors in developing countries that got this training could work in the U.S., then there is no doubt that we would be flooded with top notch specialists from these countries.
There is no shortage of bright and ambitious students in the developing world who will get the skills they need to fill these occupations, if we allow them the opportunity.
btw, I am not trying to decide what doctors should get paid -- I just want to eliminate the protectionist barriers that they enjoy. Auto workers and textile workers have to compete in the global economy, I can't see any reason why doctors (or lawyers or economists) should get a special exemption.
October 31, 2007 1:44 PM | Reply | Permalink
A couple of hours later, the charge nurse came in to ask what I had done to Dr. X. They said he normally hates everyone, but he came out of your room with a big smile, and made it clear he wanted you to have the finest treatment.
If I had only known, I'd have asked for a Pakistani diet...
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
October 31, 2007 1:59 PM | Reply | Permalink
Sara, Howard and Dean--
Thank you for your comments--
Sara--I agree with virtually everything you say. I would add only that research shows that , despite the aging of the boomers, we probablhy don't need more specialists. (Dr. Eliott Fisher wrote about this in "Health Affairs" sometime in the last year or two).In many parts of the country, we tend to overuse specialists without improving outcomes.
But we definitely need more family docs, internists, pediatricians and gerontologists. And we have a huge need for more nurses, nurse pratcitoiners, etc.
Wellstone's model sounds very interesting--though I have some reservations about ccounting on the states to meet their citizens' needs. Relying on Minnessota and Wisconsin to do the job is one thing; trusitng Mississippi and Florida is another. As a doctor in Florida once said to me: "Florida never has and never will take care of its poor."
But I definitely like the idea of a "Grand Bargain" that provides a free education for health care workers in exchange for service in our heatlh care system. Did you know that there are only two applications for every place in our medical schools--most of them from upper-incojme familes? This is because the cost of medical school is so high. We could have a broader, deeper pool of applicants if we subsidized medical school education. I'm writing about this tomorrow on www.heatlhbeatblog.org.
Howard-- I can only imagine how pleased that doctor was.
Dean-- First of all, it's not a matter of putting up walls to prevent docgtors to come from the developing--we are actively recruiting doctors from these places. Please see Barrett's article in Foreign Affairs which I refer to in my post.
With regard to increasing the number of specialists you come to the U.S. you suggest that we ask " hospitals and others who employ high priced specialists and said 'what are the obstacles that prevent more neurosurgeons, cardiologists, and other highly paid specialists from coming here?'
You don't seem to understand that there are very few high-priced specialists in developing countires. And theydeperately need them there. This is not about saving money here or giving developing countries money to compensate for the lives lost when we "import" their doctors. This is about human lives, needlessly lost, to treatable diseaes.
AS I pointed out in the post, billions of dollars are already pouring in to developed countires to help with healthcare, but those dollars are being wasted (drugs sitting on the dock, etc.) because they don't have the doctors they need to treat patients.
Secondly, human beings are not commodities like steel, cars and clothes. When you talk about "paying countries" to "import" their doctors, it sounds very much like a slave trade--or perhaps indentured servitude woudl be a better model. The research shows that the majority of foreign doctors working in the U.S. are very unhappy about working conditions, and relatively low wages and feel that they are being exploited by the hospitals and clinics that employ them.
Finally--and this is the important point. As global citizens we have an obligation to try to improve healthcare in other countries. This means setting up exchange programs (as other countries are doing) sending healthcare workers to help train workers in those countires, while brining foreign doctors here, for two or three years--to train in our academic medical centers, particualry those that serve inner cities.
November 1, 2007 8:14 AM | Reply | Permalink
Maggie,
I am talking about lives too. And, as I pointed out foreign doctors will continue to come here and they get no compensation for it now -- I am quite certain that my plan will save more lives in the developing world than anything currently on the table.
As far as saying that what I'm talking about sounds like the slave trade -- give me a break. Doctors will come to the U.S. if they want to. Can you identify anywhere I said anything about forcing doctors from developing countries to come to the U.S.? I am talking about increasing options available to professionals in the developing world. Is it necessary to remind you that slaves were dragged here in chains. They didn't voluntarily come here to make a better life for themselves and their families.
November 1, 2007 9:09 AM | Reply | Permalink
I do respect the concern for other nations, but I'd have thought the bigger problem wasn't too much influx of trained professionals but rather too much of the combination of Lou Dobbs and the GWOT making it harder for science and medical students to come to the United States. I'd love them to have every opportunity and then let it be their choice. If we want to help poor nations create incentives to get people to stay put, great.
John
http://www.haberarts.com/
November 1, 2007 12:28 PM | Reply | Permalink
There's also a circularity that due to the frustrations of practicing medicine in a managed care environment, plus the crushing debt load, fewer American students go into the sciences. I include here the basic medical researchers that set so many directions for clinical medicine.
IIRC, there is now more competition for veterinary school than medical school slots. There have been a number of editorials favorably comparing the quality of veterinary care to the quality of human care, as well as practitioner satisfaction.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
November 1, 2007 12:49 PM | Reply | Permalink
Dean --
I apologize-- You're absoutelyright--paying countries for doctors that we recruit to come here is very different from bringing people over in chains. That's why I quickly corrected myself to say that "indentured servitude" would be a better analogy.
Indentured servants came voluntarily, but, because their employer paid for their passage, once they came here they were expected to work for low wages or no wages under what were often terrible working conditions.
Similarly, about half of all foreign doctors begin their U.S. medical careers by obtaining J-1 visas that I talked about in my original post. (The vast majority of docs from developing countries work under these visa waivers. )
Here is how the program is set up: if a foreign doc trains as a resident in the U.S., he must leave the U.S. for at least two yers before applying to return--UNLESS he obtains a J-1 visa waiver, which usually requires agreement to practice for a specified period in a federally designated health professional shortage area (HPSA).
Here are the terms of these waviers: " This J-1 visa waiver allows foreign-born, nonimmigrant physicians on exchange visas to remain in the United States during a period of obligated service employment . . The International Medical Graduate (foreign doctor) must work full time for at least three years in a federally designated HPSA, . . . Physicians who fail to fulfill their commitments must return immediately to their home country and may not apply for an immigrant visa or any other change of nonimmigrant status."
As I mentioned, we actively recruit these doctors to take care of patients in places that U.S. doctors shun: impoverished rural areas and inner cities. As a 2003 article in Health Affairs explains: "To receive a J-1 visa waiver recommendation through the program a foreign doctor must secure an employment agreement with an eligible employer (located in a HPSA), often with the assistance of an attorney or a recruitment firm. The employer and physician together then ask the state health department to recommend the waiver to both the State Department and the Bureau of Citizenship and Immigration Services (BCIS ."
If they were free to practice anywhere could foreign doctors from Ghana, Kenya, China, Pakistan and India find work in our suburbs, affluent neighborhoods in our cities, or in our middle-class and upper-middle-class rural areas? The answer is no. We have more than enough specialists in these areas, and insofar as we don't have enough primary care docs, a combination of prejudice and genuine cultural differences keep both affluent patients and doctors' practices from embracing doctors from developing countries--even if the patient paid less per visit. (Moreover,foreign doctors would see no reason why they should be paid less than their American peers--see below.)
Foreign physicians are not happy with their pay or working conditions. "Three-fourths of respondents said that their state’s foreign doctors had problems with employers changing work practices after the employment agreement was signed. Half said that they had problems with employers’ requiring physicians to work under poor or unfair working conditions, and more than half encountered problems related to compensation disputes "
The foreign physicains feel that they should be making more money and that they are being exploited. "in some circumstances," the study reports, "physicians could be reluctant to report violations for fear of adversely affecting their immigration status. Reports of contract violations by employers, many of them private practices, are troubling and apparently widespread. Immigrant physicians who are exploited or mistreated by employers have little access to justice in the absence of any enforcement of rules. Independent interviews we conducted with twenty-one IMGs in one state for a different study substantiated this concern . . ."
This is why I compare the foreign docs to indenturedservants--we recruit them to come here, then often change the terms of the contract, and ask them to do work that American doctors are reluctant to do for what the doctors see as sub-standard pay. They feel that they, too, should be averaging $200,000 a year--particuarly if they are working in areas where American doctors don't want to work.
Dean, the problem is not that we pay primary care doctors too much; the problem is that we pay them too little, particularly when they are caring for our poorest patients (Medicaid patients.) There is no reason to pay a doctor less because the patient is poor; indeed these cases are often the most complicated.
Meanwhile, low-income patients suffer. According to the study "Most respondents felt that their state’s rules failed to ensure that low-income clients were well served, further clouding the issue of who benefits most. "
The 2003 study concluded that as an alterntive to bringing in foreign doctors, the "United States could expand the National Health Service Corps, which has been demonstrated to induce American medical students to practice primary care in underserved areas. While that program was expanded by 20 percent in 2003 and an additional expansion is proposed for FY 2004, it is costly to provide scholarships and loan repayments. [under teh program, med students are given scholarships in return for agreeing to work in an underserved area for a certain number of years.] By contrast, the study points out " The J-1 visa waiver programs essentially provide 'free physicians," whose education was obtained in locations where U.S. taxpayers have no obligations. "
Jason--you say fine, we'll pay developing countries for their physicians." I'm afraid that's what made me think "slaves" (though as I said above, that's not the right term.) But you are talking about buying people from countries that need those professionals at home. As Garrett points out, they don't need money--billions are pouring in from Buffett, Gates et.al.--they need physicians and healthcare workers who understand the language and customs of the country,.
As the Health Affairs study concludes: Most of the foreign physicians "are from low- or lower-middle-income countries (as defined by the World Bank).The continued reliance on poor countries to supply U.S. physicians represents a decision to transfer wealth from poor countries to rich ones.
And this is wealth that cannot easily be replaced. It is human capital.
November 1, 2007 12:54 PM | Reply | Permalink
J Haber and Howard
I agree that we should make it easier for foreign science and medical students to train here. Though I think we should give financial aid to the ones coming from poor countires who plan to go home, for say, 4 or 5 years, and help train others.
We also need much better scholarship and loan programs for American students to train as scientists and as doctors--something I plan to write about tomorrow on www.healthbeatblog.org
Howrd--You are right--there are only two applicants for every place in U.S. medical schools, largely because medical school is so expensive, and,unlike other countries, we don't subsidize medical education.
November 1, 2007 1:01 PM | Reply | Permalink
Maggie,
I think that we are talking past each other. I realize that foreign doctors are not treated fairly under the current system -- that is precisely the point of the original paper and what I want to change. I want there to be an open door for foreign doctors -- no restrictive visas that tie them to specific employers. Let them practice wherever they choose (subject of course to a tax on their wages to reimburse their home country for their education.)
As far as prejudice discouraging people from using foreign physicians -- sure that it exists, but I don't think we should design our medical system to accommodate bigotry. Let me go to a foreign-born physician and save money if I choose. Furthermore, as an employer who selects a health insurance plan for my think tank, I assure you that we will sign up in a second with a plan that offers us lower costs because it has top-quality foreign trained physicians on its list. I suspect that many other employers will do the same thing as me.
The people who prefer to follow their prejudices will be able to do so, although they will have to pay a premium for their health care as a result. Of course even for them there will be savings -- because people like me go to foreign trained physicians, the demand for U.S. trained physicians will fall and they will have to charge less.
I don't like to get into arguments over what doctors should be paid, because I don't know how much they should be paid. I don't know what autoworkers should be paid or custodians either. I do know that autoworkers and custodians have had their wages seriously depressed because of foreign competition. I also know that autoworkers and custodians get paid much less than doctors -- in the case of custodians about one tenth as much on average. I am hard-pressed to see an argument that we should be protecting are most highly educated workers while subjecting those at the middle and bottom to the rigors of international competition. To me, that looks like bad health care policy, bad economic policy, and bad social policy.
November 1, 2007 2:07 PM | Reply | Permalink
Maggie, thanks for your comments. What I know about Wellstone's notions are the result of a conversation we had about six weeks before he died at a Campaign event. We had been friends for many years, and I had worked very hard on that 1990 campaign. I simply asked him, "Paul, since you now have 12 years Senate Experience, what do you think are the necessary political conditions to get to a Single Payer bill with some reasonable hope of passage?" First answer was non-verbal -- He looked quizacle, said "Bush" and did a thumbs down. Then he mentioned a major national organizing strategy around an agreed plan or model, (no more Harry and Louise, except as our advocates), and then he said he had come to understand that it was quite unwise to assign the Feds responsibility to plan and administer a workable delivery system. The quality of a delivery system would need to be politically sensitive to folk who could not hire lobbyists in DC (and all that) -- and the best place to focus that would be in State Capitols, in legislative races for the state legislature, and in Governor's races. But Paul also wanted to remove it one step -- put the power in the hands of a Regents Board that would be elected by legislators for fairly significant terms say 6 years with the possibility of one re-appointment, and qualifications for Regents such as representation of all regions of a state, of all Health Professions, of consumer organizations, and all, so these appointments would be unlikely to be ideological. Paul actually thought that responsibility for the quality of delivered medical services in a state would vastly improve the quality of State Governors and Legislators. He also believed that planning how to deliver services needed to be at least regional. Minnesota (and yep, I am from Minnesota) is probably best prepared to figure out how to make accessable the full menu of medical services to folk who live in little towns of 2500, on farms, in mining areas, perhaps 100 miles from a regional medical center. Since the demise of local drug stores, we have places in Minnesota where people have to drive 75 miles to fill a prescription -- something difficult for the elderly or those without transportation. The state would be more likely to design an effective and efficent program.
Paul also thought you had to provide a clear path for existing practices to bid their way into a new framework -- HMO's (ours are all non-profit) and group practices would, in his mind, bid for jobs of providing agreed sets of services in particular areas. He felt a state agency would be a far more responsive employer than a bureau in DC., you would still federally mandate the menu of required services, since there would be universal access, wealth or poverty would be less relevant. Failed States would be treated as Failed States (I suppose we could invade Mississippi!!). At any rate, he thought a successful Political Strategy would be one that provided a highly attractive path to docs and nurses to effectively self manage service groups, so as to practice high quality medicine, and they would in turn become strong political advocates for the new framework, leaving the insurance industry in a most dusty wake. I think this was great insight 5 years ago, but today there is even more hostility between doc's, nurses and all and the Boss Insurance Administrators. That is political leverage and it needs to be fully appreciated and used. If the "Grand Bargain" were part of the package -- that would put the patients and most docs on the same side in what will be a huge political struggle.
Paul also had come to appreciate that great savings might be possible with the application of Broadband to medical delivery. He had apparently attended some sort of Seminar that was rather futuristic, and had been more than inspired. Normally Techie stuff did not impress him -- but he saw all sorts of cost saving and quality heightening solutions to problems in broadband medical applications. He thought selling the political package to the public ought to include such a core idea -- and in Jest, he thought maybe advocates ought to hire Steve Jobs to make it Apple Sexy. Always the Organizer -- Paul didn't think anything would happen till people understood a plan of action, and were willing to put out to force action.
November 1, 2007 3:25 PM | Reply | Permalink
Sara--
Thank you for your second post. What you have to say about Paul Wellstone's ideas is much-needed nourishment for thought.
I do agree that in many ways, states could (or at least should) understand their citizens' needs better than Washington could. And the idea of recognizing "Failed State" is great--I wish we could apply that to SCHIP!
But I can only imagine the firestorm the concept of "Failed States" would ignite in Congress . . .
.
November 1, 2007 7:10 PM | Reply | Permalink
Having been born and mostly brought up in northern New Jersey, there is a promised land beyond failed states. Eventually, they become toxic waste dumps, such that if one grows up in that environment, one is largely immune to toxins and microorganisms.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
November 1, 2007 7:31 PM | Reply | Permalink
Dean-
You write: "I want there to be an open door for foreign doctors -- no restrictive visas that tie them to specific employers. Let them practice wherever they choose (subject of course to a tax on their wages to reimburse their home country for their education.) "
Dean: Here's the problem. When foreign doctors finish their visa commitment, they wind up staying in the rural area (or inner city) where they have been serviing--or they go home. They can't find jobs in more affluent areas where they would be competing with high-priced doctors for the reasons I've outlined. This isn't because of gov't putting up any barriers to letting them move around. The "market" is making the decision. Health care consumers in these more affluent areas just won't voluntariy go to doctors from other counries--in part because of reserach that suggests that oucomes are worse for foreign-trained doctors. (The studies may well be flawed, but they are out there without countervailing evidence.)
Finally, this piece from a 2005 article in the NYT headlined "Devastating Exodus" underlines just how much suffering the loss of foreign doctors is causing: "
Dr. Agyeman Akosa, the director general of Ghana's health service, said in a phone interview that:
''I have at least nine hospitals that have no doctor at all, and 20 hospitals with only one doctor looking after a whole district of 80,000 to 120,000 people,'' Dr. Akosa said. Women in obstructed labor all too often suffer terrible complications or death for lack of an obstetrician, he said.
The study found that Ghana, with only 6 doctors for each 100,000 people, has lost 3 of every 10 doctors it has educated to the United States, Britain, Canada and Australia, each of which has more than 220 doctors per 100,000 people.
"Tkhe biggest losers are the small to medium-size countries of Africa and the Caribbean. Dr. Mullan's research found that Jamaica, for example, has lost 41 percent of its doctors and Haiti 35 percent, while Ghana has lost 30 percent and South Africa, Ethiopia and Uganda 14 to 19 percent.
November 2, 2007 12:22 PM | Reply | Permalink