Foreign Born Healthcare Professionals in Massachusetts: Challenges and Opportunities

Jeff GrossDirector, New Americans Integration Institute (NAII) Massachusetts Immigrant and Refugee Advocacy Coalition

May 19, 2014 [Revised 5/23/14]

Diversifying the State Healthcare Workforce:Who Benefits?

• Affordable Care Act & aging population are expanding need for primary care providers and clinical staff at all levels.1

• Projected 22% growth in MA in openings by 2020 (12% physicians, 30% nurses, 28% allied professions).2

• More linguistically and culturally competent clinicians can help address access barriers for an increasingly diverse state population.• Foreign trained clinicians could help address needs at

“safety net” community hospitals & health centers.• Return on investment by supporting already trained and

experienced medical professionals.

1 Massachusetts Medical Society, 2012 Physician’s Workforce Study2 Georgetown University Center on Education and the Workforce, Healthcare State

Report: Massachusetts (June 2012)

Sources of Data on Foreign Born Healthcare Professionals

National Survey of College Graduates (NSCG) • Data valid mainly at the national level• Offers explicit information about source of

degree (U.S. vs. non-U.S.), field of study, and level of highest degree

American Community Survey (ACS)• Data valid at the regional, state and local levels• Source of degree (U.S. vs. non-U.S.) must be

estimated based on age of arrival in the U.S.• Only information on bachelor level field of study

National DataThere are more than 874,000 foreign born residents in the U.S. who are trained healthcare professionals—one fifth of U.S. residents who hold a bachelor’s degree or higher in medical or behavioral health occupations.

Foreign vs. US DegreesNationally, almost two-thirds of foreign born healthcare professionals (63.7%) received their training outside the U.S.—physicians at the highest rate (72%), psychologists at the lowest (20%).*

* Under the “Foreign Born” column, the % value equals only the foreign born share of professionals in that category.

Foreign Degree Holders by Region of Origin

49.2%

16.5%

18.1%

6.8%

5.4%3.9%

Medical Degree

Asia

Europe

Latin America and Car-ibbean

Africa

North America, Other

U.S.

76.1%

5.8%

11.6%

2.2% 3.6% 0.7%

Nursing Degree

Asia

Europe

Latin America and Caribbean

Africa

North America, Other

U.S.

Source: American Institute of Economic Research and NAII analysis of NSCG 2013 Microdata

US Degrees: Labor Market Outcomes• Foreign born physicians with U.S. degrees work outside of

their field of study at relatively low rates, though still twice that of those born in the U.S. (6.7% vs. 2.8%). • Underemployment is highest (28% for) psychologists• Even for professions where working outside field of study is

relatively common (e.g., 25.3% of nurses), mean annual salaries are still relatively high.

Foreign Degrees: Labor Market Outcomes• Physicians with foreign degrees are five times more likely to be

underemployed than with U.S. degrees (22% vs. 4.6%). • Those working outside their field of study earn 43.4% less than their

counterparts with U.S. degrees.• Allied professions, pharmacists, and psychologists with foreign degrees

also show significantly higher underemployment levels and lower salaries when employed in other occupations.

• Though foreign born nurses trained abroad have slightly lower underemployment levels compared to the U.S. trained (17.6% vs. 18.1%), for those working outside their field salaries are significantly lower compared to U.S. trained (22%).

Massachusetts Data• 37.7% of immigrants in the Massachusetts labor force hold a

bachelors degree or higher. • Approximately 14,804 hold bachelor level degrees in a healthcare or

medical field of study, half with a U.S. and half with a foreign degree.• Since the American Community Survey only reports bachelor level

field of study, these figures significantly undercount the total foreign born with foreign and U.S. graduate degrees in healthcare.

• The pool of medical talent in Massachusetts includes large numbers of refugee MDs, nurses, physical therapists, dentists, pharmacists, and other healthcare professionals.*

* MA Office for Refugees and Immigrants (ORI). A 2008 ORI study indicated 20% of 237 refugee professionals entering the state that one year were medically trained.

Foreign Born Nurses• Of 55,000 individuals in MA with undergraduate degrees

in nursing, some 7,400 (13 percent) are foreign born—approximately 3,400 foreign educated and 4,000 educated in the U.S.

• Foreign-educated immigrants with a nursing degree are over seven times more likely to have a low-skilled job (21%) than their U.S.-trained counterparts (3%).*

* High-skilled jobs typically require a bachelor's degree plus substantial work-related skills or experience; medium-skilled jobs typically require an associate's degree or vocational training, along with significant on-the-job experience; low-skilled jobs require a high school degree or less and moderate on-the-job training or less.

Boston Welcome Back Center: Countries & Regions of Origin

20%

6%

6%

4%4%

59%

Haiti

Brazil

China

Nigeria

Nepal

Other

The Boston Welcome Back Center assists internationally trained nurses become licensed to practice in Massachusetts. The Center is a partnership of Bunker Hill Community College, Roxbury Community College, Mass Bay Community College, The Massachusetts Department of Higher Education, and University of Massachusetts Boston. Since 2005 the Center has assisted over 1000 nurses from 58 countries. See www.bhcc.mass.edu/welcomeback.

24%

23%

10%

27%

17%

Africa

Caribbean

Americas

Asia

Europe

Foreign Born Physicians• 9200 foreign born individuals are employed as physicians and surgeons in

the state—27.9% of the 33,000 in the state• Two-thirds were trained abroad and one-third in the U.S.• The lower rate of foreign born employed (27.9%) than U.S. rate of foreign

born with medical degrees (29.6%) may reflect labor market barriers.• The lower rate of foreign born employed with foreign degrees (66.3%)

than U.S. rate foreign born who hold foreign degrees (70.4%) may suggest similar issues

• The higher proportion in MA of both U.S. born physicians and foreign born physicians with U.S. degrees could indicate state or provider-specific educational requirements that favor those trained in U.S. institutions

Factors Impacting Skill Underutilization*Individual• Limited English proficiency • US vs. foreign degree• Country of degree• Unfamiliarity with US job market• Lack of professional networks• Financial/job constraints

Systemic• Complex relicensure process• Lack of centralized, widely shared information • Lack of targeted career assistance• Constraints of workforce development system• Limited well-defined alternative career paths• Institutionalized bias* Jeanne Batalova & Michael Fix (2008), Uneven Progress: The Employment Pathways of Skilled Immigrants

in the United States, Migration Policy Institute; Neeta Fogg & Paul Harrington (2013), Labor Market Underutilization Problems among College-Educated Immigrants in the United States, Drexel University.

Potential RecommendationsShort Term• Centralized resources & career guides on state websites• State workforce agency guidance & training for career centers • Providers & professional schools promoting peer networksMedium Term• Loan fund for relicensing & education costs (NYC model)• Welcome Back Center model expanded to other professions & regions• Workforce services more targeted at needs & assets of foreign born • More diverse & higher level ESOL programming / TOEFL prep• More career pathways programs into higher-skilled occupations• Research on barriers & aligning policy with state’s healthcare needsLong term• High-skilled immigrant ombudsman role in state executive• Expanding medical training & residency slots• Options for limited / conditional scope of practice in high-need settings• Federal advocacy (Health Equity and Accountability Act)

Questions for the Task Force

•What are the key challenges here?•What are the key opportunities?•What additional data is needed to

better understand these issues?•What are possible short, medium and

long term solutions?•What other questions should we be

asking?