Denied: How the Proposed Travel Ban Could Affect Health Outcomes

Posted on  June 5, 2018

 

No matter your political beliefs, one of the unintended consequences of the media concentration on Stormy Daniels, the Mueller investigation, and whether attorney Michael Cohen had improper dealings, is that many important issues fade away.

One of those issues is immigration and particularly how immigration bans may affect us. The “Muslim travel ban” is a contentious and provocative issue to argue in any public forum. It is one that everyone involved in the medical industry in America needs to think about.

According to Rural Health Web, 20% of U.S. citizens live in country areas, but only 10% of physicians choose to practice there. It’s also a fact that demand for doctors will always be greater than supply, with an estimated shortage of between 46,100 and 90,400 doctors by 2025.

When it comes to the ban, President Trump says it’s a matter of security. The Association of American Medical Colleges (AAMC), however, says this move will create a health security issue. Executive Vice President Atul Grover, MD, PhD states that the idea of the order “… is that we have to keep people out to keep us safe. But you’re keeping people out who are going to take care of us.”

Slightly more than 25% of doctors practicing in the U.S. are born in a foreign country. In areas that have the highest rates of poverty (i.e. 30%+ of occupants live below the federal poverty rate), however, this number rises to just under 30% of foreign trained doctors. If household income is below the $15,000 per annum rate, that number rises again – 42.5% of doctors working in these areas are foreign-trained.

A few more statistics to consider:

Enough statistics, let’s talk.

No matter what your political beliefs, this poses a serious threat to the ongoing healthcare of some of the communities who are in the most need. For U.S. trained doctors, a move to a country area requires a choice to be made.

This comes from the choice of the physicians and not a community, many of whom fight long and hard for the healthcare rights of its inhabitants.

Some communities are fighting back including lobbying hard against one of the last publicly owned and operated hospitals in Ohio to be turned into a non-profit private corporation.

As more rural hospitals close, some health policy analysts say it’s time communities made some hard decisions. Most agree that communities need to completely change the healthcare structure in small towns. This includes an increase in telemedicine, expanding loan forgiveness and residency reimbursement proposals.

While no one wants to admit it, foreign-trained doctors are simply more open to living in rural areas than U.S.-trained doctors. That is why hundreds of small towns and rural areas are worried about the travel ban. Despite the expected individual patient anxieties about doctors who were trained in a mainly Muslim country, communities usually embrace them.

Is it a matter of sorting the wheat from the chaff? Most experts agree that’s not possible. It’s worth noting that no fatal terrorist attacks post 9/11 have been perpetrated by an individual from any of the seven countries listed in the ban (although there have been several non-fatal incidences committed by individuals from these countries).

This is not an easy issue to discuss. Yet, it’s not going to go away. So, even though we may not have all of the answers, it’s nevertheless a vital issue deserving of serious debate.

 
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Comments 25

  1. Thanks for sharing with others the NATIONAL security risk we have because the AMA controls the number of medical students accepted every year or if not then why have they not be on the forefront creating more schools to fill our needs? We have had this problem for the past three decades and no one did anything about it. It’s time for leaders to lead or get the hell out of the way. How about allowing for more medical schools and nursing school to open so we hire American doctors and nurses and eliminate the need to import foreign talent?

    Thank you so much for exposing the REAL PROBLEM – The AMA and a corrupt medical system.

    1. Totally agree with this statement and will take it to the next level. The door opened for foreign students to attend US medical schools because the healthcare system that asks so much of physicians is paying them so much less that say 20-30 years ago. I think any physician that endures 10+ years of education and residency, on call hours, high risk situation, etc. etc.deserves to be very well compensated. Capitalism works in medicine too! I want my cardiologist to be the best of the best. However, more and more top caliber American students are running away from medicine and finding other areas of higher profitability (IT sector). Why? Because the reward does not match the demand. I am a nurse and have been in healthcare my entire career. Many of the foreign physicians (not all of course) have gotten into US medical schools when 10 years ago could not have competed on an academic level. I have experienced first hand the negative impact that has had on healthcare. Thankfully for my family, I am an advocate and push aside mediocrity and search for top caliber physicians and surgeons. Not everyone has this knowledge and ability. So, the problem is the healthcare system itself and why the middle men (hospital administrators, GPO’s etc) are making all the cash but the providers and patients are not getting the same quality of healthcare and reward they used to. PS did not realize North Korea and Venezuela were predominately Muslim (stop already). Do you let strangers walk into your house? No, you want to know who they are before they enter! Same theory – VETTING.

    2. AMA is a anti-American communist organization. I am MD myself and I chosen not to be the member of that ugly scam that doesn’t represent the American physician but only promotes ultra-liberal agenda instead.

  2. Well said. If this article is a pitiful argument against the travel ban, you went to great lengths to cover the real problem. The physician shortage is not, nor will be, because of a travel ban. Robert, you are on the right track as to where the problem lies. We have failed to acknowledge here the “dummying down” of the education system in this country. If Billy or Suzy isn’t making the grade (literally), then the education system simply lowers the bar so that “no child is left behind”. The public education system is looking more like it’s leadership is concerned about student scores on government required achievement scores because of the impact on funding, than they are concerned about what and IF students are actually learning. Our society rewards a student far more for his/her athletic ability or entertaining ability than it rewards for academic ability. If you don’t think that is accurate, then why do collegiate and professional sports broadcasts, entertainment shows such as The Voice, American Idol, etc. have such high ratings with viewers. What is the topic of many discussions at the water cooler or the dinner table (if there even IS a family mealtime). It surely is to discuss who won on the Jeapordy show the night before and what the favorite question may have been. A large part of our society has placed more importance on sports an entertainment than they do on academics. They spend far more time, money, and energy on perfecting skills and abilities in those areas than they do in the area of academics. There is nothing inherently “wrong” with sports or entertainment. But when society rewards talent and accomplishments at the insane monetary levels and when those who Excel in these two area are held in such high esteem, then it’s no small wonder there’s a shortage of physicians…. and teachers, and many other professions which require excelling in academics. And I won’t even start to elaborate on how many physicians are retiring earlier than they had planned because of government regulations and malpractice insurance costs. Add to that the skyrocketing costs if education and student loan burdens and it’s no small wonder there is a shortage of physicians. But surely is because of some travel ban that is trying to prevent flooding this country with more people to be supported and favored with government subsidies and grants. You did an excellent job at trying to divert attention from the real reasons there is, and will be, a shortage of physicians in this country, but you failed in reaching your goal.

  3. Very interesting. Even in the counties outside of Philadelphia, there are more and more foreign educated doctors (my doctor is one). Perhaps there should be an exception made for doctors and others who provide/have needed skills and services. I dont have the skillset to suggest anything other than my small idea to resolve this issue.

    1. I DO NOT AGREE – this is the problem why our doctors are so underpaid – CHEAP FOREIGN LABOR. This is no different than how cheap illegal labor is affecting the wages of American Service. We need to stop looking at the symptoms and start looking at the cause – feckless leadership.

  4. Being a healthcare industry insider of several decades, I share the following brief thoughts:

    1) The travel ban definitely impacts healthcare outcomes.
    2) The increasing healthcare expenditures in the US is not sustainable. Current healthcare expenditures are over $3 trillion it is expected to reach $5.7 trillion by 2026.
    3) Our policy makers have been trying and failing to address the problem partly because they approaching it in silos. This has been a ticking time bomb and will continue degrading our capability to compete effectively.
    4) Any credible solution to the problem should include: immigration reform, school system reform, tort reform, income tax reform, etc.
    5) Taking school reform as an example, I was a mentoring director in one of the University of California system where I counselled graduates with 2 or more degrees, drowning in tuition debt ($40,000 to $200,000), working 2-3 jobs, and living with their parents… What is the message here? Our school system is sadly anachronistic and out of alignment with 21st century realities. The same applies to immigration, tort, income tax and other reforms.

    US Healthcare Expenditures

    https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf

    https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf

    https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends
    https://www.theatlantic.com/health/archive/2017/06/how-we-spend-3400000000000/530355/

    https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

  5. This is so amazingly thoughtful accurate and effective
    I had an opportunity to travel through the rural Midwest as the owner of a small spinal implant company
    The competition there is incredibly weak and the reimbursement is much higher. If I graduated from a top med school in a desired specialty I can work in Manhattan or Georgetown DC for x dollars and compete like crazy or work in Norfolk NE or Mars Iowa for 2x. I ran across my Muslim immigrant specialists in the Midwest that were quiet content for the higher pay any high employer appreciation. They are also very pleased to not have to Market a practice in areas that are severely underserved.
    The sad irony is the patients that need them the most are the voters most supportive of these misguided policies. BTW Muslim Americans have the highest percentage of medical professionals amongst them in the land. On another front educating and training a specialist in the US is insanely expensive compared to all developing nations around the world without any measurable metrics towards the ability of homegrown docs providing superior outcomes
    Well thought out and written

  6. Very thought provoking and well written. It will be fascinating – and perhaps unsettling – to see how this situation plays out over the next few years.

  7. While your article is thought provoking for most, I felt it failed to address any of the recently implemented, innovative solutions as strategic responses to this rural physician shortage.

    Residents of rural communities (myself and my family among them) are often forced to drive long distances (in terms of hours) to avail themselves of specialist consultation and treatment, diagnostic testing.

    More mHealth solutions are being released: I paid $200 for a device that inserts into my smartphone that enables me to produce a quick electrocardiogram, have it read by a board certified cardiologist, saved as a PDF and emailed to my physician (telehealth). With two fingers on the device the size of a matchbox, I can record an ECG in less than a minute. With a finger on the back of my phone where the camera is, I can record a pulse or a pulse oximetry.

    Domestic health travel is being more formally developed. One doesn’t merely make an appointment and then book an overnight accommodation. There are health travel professionals who arrange all the end-to-end logistics for driveable medical travel. Hospitals and ASCs are now examining how they can attract new market share and a wider catchment reach never previously considered. They offer cash price bundled case rates, financing connections so they don’t have to act as a bank, and are using inactive wings and rooms as accommodation for the patient and/or companion travelers in places where the hotels may not meet the needs of the traveling patient. I’ve set up about 40 of these programs in rural areas to date.

    Telehealth connectivity using template-driven, store and forward technology enables people to fill in a symptom-driven questionnaire that is sent to their physician who knows them (not some stranger) and the entire exchange is stored in the EMR, billed as an E&M service, paid inside the application, and any medications ordered through the pharmacy connection to be delivered at the patient’s local pharmacy. If a real-time synchronous discussion is required, the doctor picks up the phone and makes the call. These asynchronous eVisits are billed as E&M because the same cognitive services are performed as in a face-to-face, but require less time thus increasing physician capacity for volume without expanding the time at work.

    I could continue. But I guess what I am trying to say is widen your perspectives to what’s new and what’s working rather than lament these beltway decisions and AMA fiats we can’t waste time trying to change-right now. There are patients that need to be seen no matter what the laws enacted do to the infrastructure. We’ve got lemons. Let’s make lemonade and serve it to all who are thirsty. If we have to make it a little thinner than we’d like, so be it. No one should leave thirsty. It’s out job to figure out how to accommodate them- at least for now.

  8. What an interesting series of comments!

    A couple of conspiracy-theory posts, some tolerant and thoughtful comments, and a general sense of a problem that isn’t amenable to local measures.

    A post on environmental or public health problems would probably elicit the same spectrum of opinion.

    During my 30-year career in academic medicine, I met and worked with trainees from all around the world. A few trends were evident, even in the day-to-day life of academic medical centers: the numbers of women in medicine have steadily increased, and the numbers of bright foreign graduates have increased. There’s little evidence to support generalizations, but the few facts do support the contention that foreign grads overall are more willing to practice in underserved areas than US grads. I don’t think we have any answers to the question, “Why?”

    When we discuss the potential effects of a “Muslim travel ban” on the US supply of healthcare professionals, let’s approach the discussion with a pledge to engage in a civil, factually-based conversation, and to avoid polemics. The facts, such as they are, suggest that an individual’s cultural background and national origin don’t put any constraints on performance as a physician.

    The impact of the travel-ban idea, if implemented, would be local and could be severe in critically under-served communities. Remember Tip O’Neil’s words, “All politics is local.” If you live in an under-served area, get involved; make your voice heard.

  9. This highlights the very definition of a dilemma involving access to medical care. I have been in practice long enough to have seen the influx of International Medical Graduates to fill Neurosurgery training programs in the United States. While I don’t have the exact statistics for the metropolitan area of Chicago these trainees of the 1970s and 1980s stayed in the Chicago area to practice. This parallels the overall preference of US graduates. Hence aside from providing labor to teaching hospitals not many rural specialists in Neurosurgery were provided. No easy answers to this dilemma in the same vein (pun intended) as to the utility and value of healthcare as a whole in the context of the untenable costs.

  10. The Crop that is planted today of peoples who can Help this World and the USA should be allowed to grow. Not be stamped into the ground and have salt poured on it.
    This is a very interesting article and a true one.

  11. In a manufacturing environment you would do more exporting and less importing to make financial ends meet. In the medical field I see less students entering the medical field, more insurance companies cutting the payments to doctors for services performed and more hospitals closing. Does this make sense?

  12. I agree with everything you said.
    I have a couple of friends who are foreign grads and applying for the j1 visa waiver to serve in underserved areas. This is a very tough process and lots of doctors end up leaving the country

  13. Great article. Thankful for the expanding roles of Nurse Practitioners who are assigned more frequently in recent times to fill these gaps in providing medical services in the more rural areas.

  14. Great article. My heart surgeon was Indian and he did a great job. I’m still here.
    Without foreign doctors, proper medical care would be very difficult to obtain. During my recovery blood was drawn several times a day. The foreign (Indian) nurses were very skilled and pain free. Sorry to say, the American nurses did not care and collapsed many of my veins and surrendered after 3 attempts. Why are foreign nurses more careful? Perhaps better training and truly caring for the patient. Or perhaps they feel they need to give that extra bit to show they are good. Well, they are good. Josh

  15. The War on Terror has cost five trillion dollars: that’s $16,000 per American; $64,000 for a family of four. Osama bin Laden predicted economic collapse following 9-11. He wasn’t too far off: http://nation.time.com/2011/06/29/the-5-trillion-war-on-terror/

    America was founded and built on diversity, it is our legacy and that stands to suffer as we strain to keep out terrorists. Your article shows one of many areas negatively impacted by draconian measures to try to accomplish that objective, in the interest of our nation’s safety and security.

    Whether a more reasoned approach should be taken I truly don’t know, as even in London and in Germany, where their leader’s approaches seem to have backfired by allowing terrorists into their countries, I think we simply must accept the fact that the world has changed today. Violence and terrorism is a reality, and no leader can eliminate it completely.

    So now we trade anticipated safety from preventing entry of terrorists, to increased risk of poor medical care in rural parts of the country. It appears that we are faced with lose-lose propositions all around; and finding that optimal mix of policies and edicts is not going to be easy for any nation.

  16. This is a very complex and interesting issue. Healthcare has had so many changes and does not have the draw it once had — which leads to fewer people going into medicine and science.

    I would like to add an additional factor –the cost of Medical schools in the United States is very high. Yet we are paying Doctors less and less. Medical school tuition is prohibitive and those that do go through the system end up with “mortgages” for school loans. If school tuition would be consistent with the rate of pay-perhaps we would have more American doctors and more need for additional medical schools- just thought

  17. I agree this is a topic that needs to be resolved. I agree we need to have qualified physicians available to all areas including rual areas where they are needed for our elderly more than anything. If you can pass a background check & have the necessary training why would we not welcome them?

  18. While I dont agree with band…objectively this was meant to be a short term ban. I dont see how a short term ban of seven countries will affect care in the US in the long run. There are many Muslim nations not in the ban.

  19. Insightful article. It is a complex issue that precipitates emotion on both sides. These blanket rules are often the product of fear.

    I have always been someone who judges a person by who they are and how they act rather than where they come from, what they look like, or what titles they have. On a personal level, my grandparents came here seeking asylum in 1937, and I would not exist if they had not been let in, so I am obviously in favor of inviting in the stranger. Especially now, with the immigration travesty at our southern border, we see the insanity of keeping whole peoples at bay.

    That being said, I think the more important issue has always been to carefully vet those entering our country, just as we should those entering our homes. They should be evaluated based on whether they are criminals or terrorist sympathizers, not on what color skin they have, or what language they speak. This goes for medical professionals as well as victims of violence journeying from South America.

    Unfortunately, people fear what they can not understand.

    I have also had the beyond frustrating experience of trying to work with foreign specialists who do not speak English clearly. Even as a physician myself, I could not understand what the infectious disease doctor was telling me about my 81 yo mother. He became rude and asked me if I were “really” a doctor, since he was advocating for a “wow” replacement. I finally realized he meant a mitral “valve” replacement.

    I fired him, 1: because he couldn’t speak English and I couldn’t make decisions about her health care if I could not understand him, and 2: because it was ridiculous to contemplate open heart surgery on an 81 yo woman in chronic renal failure, with COPD, septic pulmonary emboli, and on a dilaudid pump, just because she had vegetations on her mitral valve. If he were American, I might have been able to discuss her condition more easily, but I would have fired him, too.

    Why am I bringing this up? Because each scenario is different. Being from another country does not mean you can’t speak English (many speak quite well), and being from this country does not mean you can see beyond the “protocol” of subacute bacterial endocarditis. I do believe fluency in English should be part of the equation in hiring anyone in this country who will be dealing with other English speaking humans in important and sensitive matters. When fearful people encounter “foreigners” they can not understand, it is that much harder to trust them.

    My opinion: evaluate each individual for integrity and willingness to learn our language and follow our laws. Whenever we make judgments based on conformity to a group, we all lose. We lose their talents and expertise and they lose the respite and opportunity they came for.

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