Immigration

Foreign Lung Doctors Can Help Coal Country Residents. We Should Let Them.

But we first need to pass a bill to let more of them into the U.S.

|

Since 1903, the plaque at the foot of the Statue of Liberty has extended a warm welcome to the "huddled masses yearning to breathe free," the first sign of respite for immigrants arriving to America in pursuit of a better life.

But these words can just as easily describe 26,000 coal miners fighting for their health as they suffer from the largest black lung epidemic in a quarter century. Miners in Appalachia were exposed to silica dust, a substance that is 20 times more toxic than dust from regular coal, and now as many as one in five miners from Central Appalachia are showing signs of black lung disease.

For years, coal country has relied on physicians from around the world to help manage their chronic health conditions. In Hazard, Kentucky, the only two practicing pulmonologists—doctors who specialize in lung and respiratory care—are from Syria and Bangladesh. On the national level, 30 percent of America's pulmonologists graduated from medical schools abroad, as did 87 percent of pulmonologists currently in training.

But coal country needs even more of these foreign doctors. By the next decade, almost 89 percent of America's practicing pulmonologists will have reached retirement age, and there won't be enough doctors to replace them.

The nation at large needs them, too. Even as America's supply of lung doctors dwindles, over 16 million U.S. residents live with chronic obstructive pulmonary disorder (COPD), a progressive lung disease that often affects elderly people with a history of smoking. Over one in 10 people in Kentucky and West Virginia suffer from COPD, and roughly a quarter of residents in both states are smokers. They also face greater risks of exposure to asbestos, which has been found in Appalachian waterways and soil. According to Thomas Tucker, the associate director for cancer prevention at the University of Kentucky Markey Cancer Center, smokers exposed to asbestos can be 300 times more likely than nonsmokers to develop lung cancer.

There are a number of reforms Congress could enact to enable more foreign physicians to practice in the United States and save these American lives. Some of them are included in the recently reintroduced Conrad 30 Physician Reauthorization Act.

For starters, the bill expands the Conrad 30 J-1 Waiver, a program that allows foreign physicians who completed their medical residency on a J-1 visitor visa to remain in the United States.

Normally, these physicians would be required to return to their home country for a minimum of two years before they could practice in the U.S. But preventing fully qualified doctors from providing much-needed care immediately is nonsensical. Eventually, this provision should be scrapped entirely, but for now, the Conrad 30 Waiver exempts these doctors from the requirement if they agree to practice in a medically underserved area for at least three years.

The bill would also add five extra physician slots annually to every state's 30-physician annual quota so long as these states use 90 percent of the available waivers. States using less than five of their physician slots would be excluded from this calculation so they won't impede the program's expansion in other states. This will allow states that have a high incidence of COPD to sponsor pulmonologists to help care for their residents.

The bill also offers a streamlined pathway to a green card through the National Interest Waiver (NIW), which participating physicians can qualify for if they practice in an underserved area for a total of five years, three of which can include the service required under Conrad 30. If passed, the bill would exempt NIW physicians from the worldwide green card caps, which have trapped some eligible physicians in decades of backlogs.

These reforms will be important for statewide efforts to attract more pulmonologists. The Virginia Department of Health, for example, has identified target areas where the Conrad 30 program can alleviate pulmonologist shortages. Some of these locations, like Buchanan County, are in the Southwestern region of the state, which contains the largest concentration of advanced stage black lung ever reported. When taken together, however, the number of Virginia counties listed as high priority shortage areas for pulmonologists, OB-GYNs, and primary care doctors far exceeds the program's 30 physician limit. So this is a really modest bill that should be considered only the first step in broader reforms to let far more foreign physicians in.

One such reform would be exempting them from repeating medical residencies and fellowships if they already completed them in a country whose medical standards are similar to the United States. Under the current system, an experienced pulmonologist trained abroad needs to complete a three-year residency in internal medicine plus a two-to-three-year pulmonology fellowship in America before they can practice in the United States.

Because of these duplicative requirements, there are as many as 65,000 foreign-trained physicians unable to practice in the United States, and others are taking their talents to countries that better recognize their qualifications. (In Canada, physicians from a handful of countries can bypass residency requirements for certain specialties, such as internal medicine.) Better yet, hospitals should be allowed to assess the competency of these physicians for themselves, and take responsibility for any additional training and supervision they may require.

Despite the myriad of obstacles they must jump through, foreign doctors continue knocking at America's door, eager to use their skills to care for Americans. Enacting policies that encourage more of them to come is one of the best ways to relieve the nation's doctor shortage. America has an obligation to its own citizens to welcome all the help it can get.

Sam Peak is a writer at Young Voices who specializes in immigration policy.

Advertisement

NEXT: The Universalist Principles of the Declaration of Independence

Editor's Note: We invite comments and request that they be civil and on-topic. We do not moderate or assume any responsibility for comments, which are owned by the readers who post them. Comments do not represent the views of Reason.com or Reason Foundation. We reserve the right to delete any comment for any reason at any time. Report abuses.

  1. But… but… but … immigrant “deplorables?” 🙂 (sarc font off)

    1. Yup, you reflect the view of the Democrats: skilled immigrants (like myself) are deplorable.

      Democrats only like immigrants when they are poor, low-skill, and in need of government assistance.

  2. Why aren’t more Americans going into this specialty?

    1. Because the AMA won’t admit them to medical school because they want a permanent shortage of doctors to keep wages for physicians in the top .05%.

      1. Lol

        The AMA does not admit anyone to anything.

        1. But they do work to constrict supply.

          1. No they don’t. Please explain how the AMA “constricts” supply. Again the AMA has zero control over the number of med schools or the number of practicing doctors.,

        2. True but they’re very influential with the lawmakers. Lawmakers set physician licensing rules. Lawmakers set residency training requirements. Lawmakers allocate money to build and expand medical schools. This is not some free market where American kids simply don’t see a career in medicine as being worth their time.

          1. State lawmakers usually punt the details to the local MA and board of medical practice. So it’s a case of doctors setting rules for the state and evaluating complaints against other doctors (kind of like police review boards composed entirely of cops).

          2. State legislatures have been falling all over themselves to build med schools. Texas state legislature has approved 7 new med schools in the last 5 years. So let’s quit pretending that there’s some artificial bottleneck.

      2. This is false. There are over 80 new medical schools created in the last 15 years. The AMA has nothing to do with the creation of med schools.

    2. Because young physicians don’t want to live in Appalachia.

      1. That’s not entirely true. There are locals who would like to stay local (at least sort of, but the economics of the area are bad and only getting worse.)

        Yes, right now there is a decent sized (for a small town) cohort of older retirees or semi-retirees, many with black lung. But once they age out there isn’t going to be much of anybody left in the area. So the idea of starting a practice in the region is pretty daunting.

        So Buchanan (pronounced Buck-an-en, for those not familiar) County will simply not financially support a pulmonology specialty practice. Pikeville KY is about a 30 minute drive, and has an Osteopathic school of medicine. That’s the place to go for those sorts of specialty services.

        1. It’s absolutely true. Doctors don’t want to live in those rural areas, and that’s borne out by post-residency practice locations.

          BTW, there’s not many PhDs or JDs who want to live in rural Appalachia either. Are we supposed to be that suprised that MDs dont want to live there?

      2. Fallout 76 ruined it for everyone.

    3. The insurance industry copied Medicare’s nonsensical billing system, which added a huge paperwork burden and incentives to order unnecessary tests. It also underpays for talking to the patient about their medical history. Honest people don’t want the job.

    4. How many training programs are there? As I understand it (mainly from watching “Grey’s Anatomy”, a training program requires a major hospital and a good supply of patients – but for black lung, many of the patients are in rural Appalachia, far from the big hospitals. That might cause a shortage of training slots even if everything else were equal.

      Not that the average medical student dreams about working in extremely rural areas, nor about serving poor people (even the urban populations of COPD will be poorer than average, because smoking has become mainly a lower-class cultural trait) at Medicaid/Medicare rates.

  3. I’d like to remind everybody that lab coats are a top-tier fetish.

    1. And the guy is pretty handsome too…

  4. This is the point of the immigration reforms that Trump has proposed. The propose reforms would allow more people with the skills that is needed in the US to immigrate.
    But, alas, this cannot be made to happen by Trump but will require cooperation between the republicans and democrats to get the law passed that would allow an increase in immigration. We have seen how well the two parties have cooperated over the last two decades.

    1. So, basic labor isn’t a skill that is needed? It would seem that it is since people are willing to pay a pretty decent amount for dudes to move heavy shit from one place to another. Seems to me people value this skillset and there are relatively few people that are willing to do it that you can make well more than min-wage doing so.

      1. Manual labor pays about half on an inflation adjusted basis today than it did 30 years ago. So no, nobody is paying a pretty decent amount of money for dudes to move heavy shit from one place to another. Try to keep your talking points straight. Remember how increasing supply results in lower prices? Well it doesn’t magically change when the market is labor.

        1. You’re not making the point you think you are making. That labor doesn’t pay as well as it did 30 years ago doesn’t mean it doesn’t pay well.

          Increasing the labor supply, driving labor costs down, reduces the incentive to come over here as a laborer even as it increases demand for labor. Until those two curves meet again.

          And depending on where you are and what you’re doing, there’s tons of people who think it pays well enough.

          But, of course, *other* people feel the need to get in between transactions between consenting adults because *they* know better.

      2. What do you think movers make?

      3. So, basic labor isn’t a skill that is needed?

        Here, let me fix this so you might understand–

        So, basic labor isn’t a skill that is needed?

      4. So, basic labor isn’t a skill that is needed?

        No. America has plenty of people without skills. They simply go on welfare or “disability”. That’s why the labor participation rate keeps dropping while we import low skill third world blue collar labor.

        Furthermore, many of the jobs done by cheap foreign labor would be better done by fewer people with more capital goods investments; that would provide higher paying jobs for Americans. That’s happening in Europe, but it’s not happening in the US because of the supply of cheap labor.

        1. Maybe they’re going on welfare not because they can’t do anything but because welfare is so generous and easy to get that its *not worth doing anything*.

          FFS, I thought we were libertarians here.

          Furthermore, many of the jobs done by cheap foreign labor would be better done by fewer people with more capital goods investments; that would provide higher paying jobs for Americans.

          So you’re saying don’t trade with those people over there because these people over there have a moral hold on your resources?

          1. So you’re saying don’t trade with those people over there because these people over there have a moral hold on your resources?

            No, I’m saying that people like you are advocating taking away my private property to subsidize the import of cheap consumer goods and low skilled labor from abroad, and you pretend that that makes you a libertarian.

        2. This is exactly right. Immigrant labor basically encourages lazy Americans to stop working on go on disability instead. So there’s actually very little competition between Americans and immigrants in low labor jobs because the Americans have an “out” that they can just go on disability.

          Immigrants dont get that option — it’s work or starve for them. Immigrants make Americans act lazy.

    2. Letting them immigrate is not the same as letting them practice medicine. There are already many people here who were physicians in their home country but who are doing something else here because they weren’t allowed to practice.

      1. Bill,

        It isn’t just that they aren’t allowed to practice.

        They cannot practice as a) they haven’t passed any of the US medical board tests like the MLE and b) they have not completed a US residency proving they are qualified to practice medicine.

        A doctor in some third world shit hole is rarely the equivalent of a Western educated doctor on a skills determined basis.

        The AMA may be a bunch of dicks, but I really don’t want to be treated by someone who 1) paid off his local medical examiners to get a license and 2) cannot really speak English.

        You have to verify the people involved are actually qualified to practice medicine to an acceptable standard and the reality is many are not.

    3. But, alas, this cannot be made to happen by Trump but will require cooperation between the republicans and democrats to get the law passed that would allow an increase in immigration.

      We don’t need an increase in immigration. We need a sharp decrease in unskilled immigration, a sharp decrease in unskilled illegal migration, and an increase in skilled immigration. The net effect will likely that anybody with skills can immigrate freely (because finally, the immigration system will be unclogged) but that fewer people overall will be immigrating (because fewer people meet the requirements).

  5. But we first need to pass a bill to let more of them into the U.S.

    What, and ‘race to the bottom’? What about American doctors? I’m informed that they have a special moral hold on my wallet?

    1. Spoken like the type of overstuffed fat sack of shit suburbanite who has never had to be diagnosed and treated by a third world physician who doesn’t speak English.

      1. What a maroon you are.

        Dude, I get my medical care across the border. I’m treated by those third world physicians that can speak better English than you can.

  6. Just as with the illegal immigrants risking their lives crossing our southern border just for a chance to enjoy the racism, oppression, deprivation and inhumane conditions of Trump’s concentration camps, I have to wonder why doctors would desert the rational paradise of the universal health care systems in their home countries for the chaotic, horrifyingly disgusting, shockingly deplorable sewer that is the American health care system. Not to mention which, it is a well-known fact that the United States is the most evil of evil empires ever to befoul the face of our planet so why do people continue to come here when the millions of emigrants fleeing this shithole on a daily basis should give them fair warning of what a horrible place this country is?

    1. in before the indignant replies across the sarchasm

    2. I have to wonder why doctors would desert the rational paradise of the universal health care systems in their home countries for the chaotic, horrifyingly disgusting, shockingly deplorable sewer that is the American health care system.

      That problem will be fixed by Democrats turning the US healthcare system into the same deplorable sewer. That way, physicians from Cuba and Venezuela will feel right at home.

  7. I love this line of reasoning. First set up a guild that restricts access to the medical profession in the United States so that the number of physiciancs is perpetually capped at something like 1 order of magnitude less than the demand for their services in order to keep physician wages in the stratosphere. Then when people get pissed because medical care is expensive and nearly impossible to obtain import a bunch of street shitters to provide third rate care. Oh and pass laws capping liability so they can’t be sued for it after the fact.

    1. Yep.
      The AMA is pure shit and, unsurprisingly, one of the biggest spenders in DC

    2. Nail on the head.

    3. This ^ And let’s add to that…

      Lobby politicians to make buying health insurance mandatory and to set up health insurance so that medical providers can charge almost unlimited amounts.

      Medicalize more and more conditions (mental health, gender dysphoria, etc.), expand coverage to elective procedures (abortion, etc.), largely eliminate charging people more for self-inflicted conditions (obesity, etc.), get kids hooked on drugs early on (ADD, bipolar, etc.), and require coverage for all of that.

      Force coverage for almost completely ineffective, very expensive new procedures.

      Restrict access to common drugs that people can buy OTC in other countries so that people are forced to have extra doctor visits.

    4. Except medicine is not a free market economy. More doctors = higher costs, not lower.

      Consider the case of McAllen Texas. In 1990 it was a healthcare desert, only 1 hospital and about 15-20 doctors.

      Then big healthcare moved in. Between 1990 and 2015 McAllen opened up 7 new hospitals and 20+ surgery centers. The number of doctors per capita increased from the lowest in Texas to the 3rd highest concentration in Texas behind Dallas and Austin.

      With all those doctors moving in, costs went down, right?

      Wrong. Costs skyrocketed. In 1990 McAllen was #798 in Medicare costs per capita by city rank. In 2015 that # increased to 58.

      More doctors/more hospitals = more testing/more diagnoses = more procedures = higher costs, not lower.

  8. […] Foreign Lung Doctors Can Help Coal Country Residents. We Should Let Them.  Reason […]

  9. Is that why all those Guatamalens are here, to get an appointment with one of their doctors?

  10. It’s weird that Reason would publish an article endorsing Trump’s position…

  11. Simple answer is yes. If they have skills similar to US trained doctors and we have unfilled positions, then why not let them work. It sounds like many of them will be working with Medicare or Medicaid patients. They will be working for lower reimbursement rates. The job will be tough as they will likely be managing patients on a down hill slide and not curing them. So its like a lot of immigrant jobs, they accept less and take the hard jobs, Americans don’t really want.

    1. “”It sounds like many of them will be working with Medicare or Medicaid patients. They will be working for lower reimbursement rates””

      If the first is a yes, then the second is probably not. Most places that handle the bulk of Medicare or Medicaid patents these days are not small offices that only make their money on insurance reimbursements. They end up working for hospital, FQHC, CHCs, ect that make more money on grant funding. They pay their doctors fairly well.

      1. FQHCs pay their doctors “fairly well”? Nonsense. They are chronically understaffed because of low wages. Immigrant doctors go there because they have no other choice. It’s also a haven for doctors who have bad marks/reps on their medical licenses and cant get jobs at a real hospital.

  12. Always exciting to hear DC think tankers tell us what we need here in flyover country.

  13. Combine that with critical care you have something.

    Three year fellowship.

  14. Hear hear. The residency thing especially is the most absurd form of rent seeking in the whole US medical system and it drives up physician salaries and healthcare costs. The human body works the same all over the world. It makes no sense not to accept as valid training from all over the world – or at least the industrialized world.

    1. Most immigrant doctors come from 3rd world shitholes and barely speak english. Go to your local VA hospital and I’ll give you $100 if you can understand everythign those foreign docs say.

      It’s not like the USA is getting a bunch of doctors from the UK or Canada. We’re talking about doctors from Syria, India, Bangladesh who have barebones English skills.

  15. Big thank-you to Reason for publishing this story. It’s a lot easier for me to support expanded labor migration if it applies somewhat equally across industries.

  16. How does a med student select a specialty in Foreign Lungs?

    1. “”Foreign Lungs?””

      Vulcans?

  17. Please, can we stop importing ‘doctors’ from nations where two thirds of the population feels it’s more sanitary to shit outside on the ground? Or countries where ‘doctors’ prescribe poached rhino horn for impotence. snake venom for virility, and spend more time trying to align your humours chi than attending to the gash in your skin?

    Please can we kill residency, the AMA, and all the government backed programs that see to it that we have 5 times as many lawyers as doctors?

    1. Practicing law should also not be restricted by licensing. But that’s besides the point.

      Increasing supply of doctors is obviously one of the most direct ways to address rising healthcare costs, so of course the powers that be are against it.
      My doc is a lady from Baghdad, and she’s the first one I’ve actually liked and been confident in

      1. Increasing the number of doctors may help somewhat with timeliness or closeness of access. But thinking it is going to control costs is like thinking that making more Rolls Royces is going to drive down the price of automobiles.

        Even if the price of med school was cut in half it is still a tremendous amount of time and energy that intelligent hard working people are going to expect to be compensated for having completed.

        Medical needs can be defined any number of ways, but medical demand – like any other market force – must be looked at in terms of money. That’s the main reason there is a lack of physicians in places like southwest VA. Yes there are people who need care, but the dollars are not there in sufficient quantity to signal an unmet demand. And given the way healthcare is going overall – especially the public running out of other people’s money – that is not going to change for the better.

        1. Making more Rolls Royces will dramatically drive down the price of Rolls Royces.

          Even if the price of med school was cut in half it is still a tremendous amount of time and energy that intelligent hard working people are going to expect to be compensated for having completed.

          Yup. Half as much compensation as they want now. Because it cost them half as much.

          Eliminate residency and it will cost them less time as well.

          It should not be so expensive to provide medical care. It IS so expensive because the medical profession has been bound by regulation to the point where a doctor must pay to prove that a need exists in an area in which they wish to provide care.

          1. ” Half as much compensation as they want now.”

            Oh come one, you are smarter than that. Ditch digging requires no formal education, does that mean ditch diggers are free?

            Eliminating residency is likewise nonsense. Do you really think four years of medical school remotely qualifies you to perform general surgery, much less anything like ortho or thoracic surgery?

            Physicians are not cheap, but physician services are a relatively small fraction of total healthcare costs. The problem largely isn’t that there aren’t enough of them. The high cost comes from using them too much or using them when someone with a lesser skill set would do just fine.

      2. Except that increasing doctors makes healthcare costs higher, not lower.

        You flood Appalachia with pulmonologists and I guarantee you per capita costs will increase.

    2. Eliminating residency was already tried in the early 1900s and it was a colossal disaster. Read the Flexner report about how doctors in 1905 were ROUTINELY ignorant on medicines and surgery and basically winging it.

      In fact there was an article in Harpers Weekly in 1909 advocating the disbanding of the medical profession and described them as a bunch of “snake oil charlatans”

  18. I work with a lot of doctors who complain about the artificial constraints that lead to expensive drugs. “Why is this drug 10x the price of that drug?”

    My livelihood would suffer if I asked them why they make 3x what a family doc makes.

    1. My livelihood would suffer if I asked them why they make 3x what a family doc makes.

      You make more money based on how immediately life and death your actions are.

  19. “huddled masses yearning to breathe free,”

    The Anglo American conception is shared and desired by a tiny percentage of people around the world. It is the exception, not the rule.

    Import Not Americans, become Not America.

  20. I work in Central Appalachia near Hazard. We have a large group of pulmonologist’s and physicians who are from foreign countries. They do an exceptional job taking care of the patients in this area. I agree that we should offer an accelerated citizen track if they help provide care. I agree with the new regulations to increase reimbursement for rural poor areas as well . If you want to increase physician concentration in poor areas increase the reimbursement.

Please to post comments