Flattening the curve is the justification for just about every social distancing measure, voluntary and coerced, enacted since COVID-19 became a serious health threat on American soil. Flattening the curve means that the number of COVID-19 cases should be spread out to prevent the health care system from being overwhelmed at any given point in time. If it is overwhelmed, many people who contracted the virus will die who otherwise would have been saved had the health care system not been overwhelmed.
Another way to prevent the health care system from being overwhelmed is to increase the number of doctors and other health care workers. Immigration has already increased the supply of health care workers in the United States and can do a lot more going forward. A new bill called the Healthcare Workforce Resilience Act, introduced by Senators David Perdue (R-GA), Dick Durbin (D-IL), Todd Young (R-IN), and Chris Coons (D-DE), would help increase the supply of health care workers further. It would recapture 40,000 unused employment‐based green cards for health care workers—25,000 for nurses and 15,000 for physicians—and recapture an additional 160,000 unused green cards for their family members. The Healthcare Workforce Resilience Act is a step in the right direction and it’s bipartisan to boot.
Immigrants are overrepresented in health care in the United States overall and in most states. In 2018, immigrants were 16.3 percent of the U.S. population that was at least 16 years old and were 17.3 percent of all health care workers, as defined in this blog post. Without their contributions, the United States would be much less well prepared for the pandemic.
We estimate the number of health care workers by state and occupation using the 2018 American Community Survey (ACS) public use microdata. We include physicians, surgeons, physician assistants, registered nurses, nurse practitioners, vocational nurses, nursing assistants, nurse anesthetists, paramedics, medical assistants, phlebotomists, and respiratory therapists as health care workers for the purposes of this post.
There are many other health care workers who increase the supply of health care. Although supporting occupations such as hospital janitorial staff and receptionists are important, they do not provide direct health care services. To avoid criticisms of overinclusion, we kept our analysis focused on the 12 occupations mentioned above. The occupations we selected are the workers who most obviously have the greatest impact on the supply of health care during this pandemic.
We categorize the workers as native‐born, legal immigrants, and illegal immigrants. We identify illegal immigrants in the ACS using the modified Gunadi method that we employ here. Because of restrictions intended to protect individual privacy, ACS public use microdata are not optimized for subgroup analysis of hard‐to‐survey populations, such as illegal immigrants, at the subnational level. We look at all 50 states and the District of Columbia. All population numbers in this post are for those aged 16 and above in the year 2018, as we are interested in the working‐age population.
This commentary complements the excellent research by the New American Economy, the Center for American Progress, and the Center for Migration Studies. The Center for Migration Studies report, for instance, finds that 16.3 percent of workers in occupations designated by the Department of Homeland Security as critical to infrastructure health care are foreign‐born. Their estimate is similar to our estimate of 17.3 percent. The difference is attributed to the slightly different way that we both define these occupations, as the Center for Migration Studies relies on the Department of Homeland Security designation.
All Health Care Workers by Immigration Status and State
Of the 9,094,576 health care workers in the United States in 2018, 1,361,653 were legal immigrants and 207,076 were illegal immigrants. Legal immigrants are 12.1 percent of the population but 15 percent of all health care workers, which means that they are about 19 percent more likely to work in health care occupations than their share of the population would suggest. Illegal immigrants, on the other hand, are 4.2 percent of the population but only 2.3 percent of health care workers in the same age group—about 45 percent less than their share of the population. The lower, although still substantial, number of illegal immigrants in health care can likely be attributed to occupational licensing, educational requirements, and other barriers restricting their entry into health care occupations. With these restrictions eased, and with equal educational opportunities, the share of illegal immigrants in health care would likely increase.
Despite being a relatively low share of health care workers, 207,076 illegal immigrants work in health care in the United States. That’s a substantial number of health care workers, especially when they are in high demand during a pandemic. The nation’s health care system will only shrink if those workers are not available to increase the supply of health care. Table 1 shows the estimated numbers of natives, illegal immigrants, and legal immigrants by health care occupation.
Table 2 breaks down the number of health care workers by state. Unfortunately, due to sample size limitations in the ACS public use microdata, it is not possible to produce reliable data on specific health care occupations by state.
Table 3 breaks down the share of health care workers and the population who are foreign‐born in each state by immigration status. In 43 states, legal immigrants are more likely to be health care workers than native‐born Americans (Table 2). Arkansas, Delaware, Kansas, Kentucky, Louisiana, Maine, New Mexico, and Vermont are the only states where legal immigrants are a lower share of the health care workforce than that of the general population.
Health Care Workers by Occupation, Nativity, and State
All immigrants are also overrepresented in most of the health care occupations that we examine here. For the following tables, sample size limitations in the ACS public use microdata prevented us from separating the number of legal immigrants from illegal immigrants at the state level. Because of these data limitations, we divided the workers into the categories of natives and all immigrants.
About 28 percent of all surgeons and physicians in the United States are immigrants, about 72 percent greater than their 16.3 percent share of the entire population aged 16 and older. Furthermore, immigrants are more likely to be physicians and surgeons in every state except for Alaska and Wyoming (Table 4). Those two exceptions are likely due to the small number of responses counted in low‐populations states with few immigrants (which can result in silly results, such as the estimate that there are zero physicians or surgeons in the states of Alaska and Wyoming).
The roughly 6.9 million nurses in the United States account for more than 76 percent of all health care workers. Of those, about 1.1 million are immigrants and 5.8 million are native‐born Americans. Nationwide, immigrants are about 16.3 percent of all nurses, which is exactly their share of the total population in the same age group (to one decimal point). Table 5 breaks it down by state, 18 of which have an immigrant share of the nursing workforce above their share of the total population.
Immigrants make an outsized contribution to supplying Americans with health care relative to their share of the workforce. Reducing the death toll from COVID-19 requires many policy actions but increasing the supply of health care by liberalizing immigration for medical professionals is the cheapest way to rapidly boost the number of health care workers who can aid Americans during this crisis. The bipartisan Healthcare Workforce Resilience Act is an important step in that direction.