The Executive Order restricting visas for citizens of Iran, Libya, Somalia, Sudan, Syria, and Yemen has many legal, political, and moral implications. But here we will focus on the medical implications of the executive order, by considering its impact on the physician workforce in the United States and the patients that rely on these immigrant doctors. There are 14 million doctor’s appointments provided each year by physicians trained in those six countries. These doctors are working all across America, but they are especially concentrated in the Rust Belt and Appalachia, seeing many patients in communities in Ohio, Michigan, West Virginia, Indiana, and Kentucky.
We are part of a team of economists from Harvard and the Massachusetts Institute of Technology (MIT) who have analyzed available data to understand the contribution of physicians from targeted countries to the health care workforce in the United States. Using data from Doximity, an online professional network for doctors, we have estimated the number of doctors trained in affected countries working in every area of the United States, and the number of appointments they provide to patients each year (see note 1). Below we have included a map of the doctors from the six targeted countries working in each “Commuting Zone”—a group of adjacent counties that have close economic ties—within the United States.
An interactive version of this map is available here.
What We Found
The results of our analysis are clear: physicians from banned countries provide an important contribution to the health care workforce of the United States. There are more than 7,000 physicians trained in countries targeted by the executive order working in the United States. Together, they see an estimated 14 million visits from patients each year. Furthermore, our analysis finds that these physicians make up a larger share of the workforce in several Rust Belt and Appalachian states. They provide 1.2 million doctor’s appointments per year in Michigan; 880,000 in Ohio; 700,000 in Pennsylvania; and 210,000 in West Virginia. The five cities in America with the highest share of doctors from these countries are Detroit, Michigan; Toledo, Ohio; Los Angeles, California; Cleveland, Ohio; and Dayton, Ohio.
Physicians in targeted countries also provide 2.3 million patient visits in areas with physician shortages. They work in these areas at the same rate as American-trained doctors. Rural and underserved communities in the United States have long struggled to attract high-quality physicians in sufficient quantities. Incentive programs have attempted to bridge this gap, but shortages remain. Our analysis suggests that physicians entering from these countries do not cluster preferentially into the major metropolitan areas, but rather are situated on the front lines of medical need.
We find that the areas of practice most affected by the ban include cardiology, neurology, gastroenterology, pathology, and internal medicine. In remote areas, a single cardiologist or neurologist can be responsible for management of life-threatening conditions for hundreds of individuals. Given the shortages of specialists in these areas, their departure can have deleterious consequences for the management of these conditions.
What Our Findings Mean
The concerns raised by this analysis are two-fold. First, there are concerns for physicians already in the United States. Not all of these physicians have stability in their immigration status; even for those that do, their ability to see family members and loved ones from affected countries is now highly curtailed. Second, this analysis shows that the six banned countries have been an important pipeline to the health care workforce, while the United States faces shortages, particularly in rural and underserved areas. We know from evidence as well as our own experience that these physicians tend to be among the highest performing in their location of origin. The United States, in upholding this ban, stands to lose an important source of high-skilled labor, of health care, and of biomedical innovation.
Prosperity and health in America depend upon a physician workforce which can reach all the patients who need its services. The Executive Order will affect the patients who rely on these doctors. And it will affect the lives of these people who have been living and working in the United States for many years.
Doximity assembles the data from a variety of sources, including the American Board of Medical Specialties, specialty societies, state licensing boards, and collaborating hospitals and medical schools. Doctors are classified as immigrants from an affected country based on the country in which they went to medical school. Although not a perfect measure of citizenship of the affected countries, we believe this to be a useful proxy. If anything, it may understate the number of doctors from affected countries, since we will not capture doctors who are citizens of these countries but received their medical training in the United States.
Doximity contains data on the address of a doctor’s practice. We group doctors based on the commuting zone (CZ) of their practice address. Commuting Zones are groups of adjacent counties that have close economic ties; for instance, seven counties in the eastern part of Massachusetts make up the Boston commuting zone. We characterize commuting zones as having a shortage of doctors if the population of the CZ is more than 3,500 times the number of doctors with an internal medicine specialty in the CZ. Population information is from the 2015 American Community Survey. This definition corresponds closely with one of the main criteria used in the federal Health Professional Shortage Area (HPSA) designation — whether the ratio of population to primary care providers exceeds 3,500.
The numbers of appointments provided by physicians from the six targeted countries are calculated by multiplying the number of physicians trained in these countries by a rounded estimate of the average number of appointments provided each year by a physician in the United States.
A fuller explanation of our methodology is available here.