Health Care's Global Invitation

The US will need to hire 2.3 million new health care workers by 2025 in order to adequately take care of its aging population, a new report by Mercer finds as reported in this Money magazine article from earlier this year. This point is not new. I recently came across an article entitled "Health Care’s Foreign Invasion" by Dr. Kate Tulenko that ran at Salon a few years ago, but remains very relevant. (It's adapted from her 2012 book.) A brief excerpt: 

Approximately 15 percent of all health care workers and 25 percent of all physicians in the United States were born and educated elsewhere. This means that 1.5 million health care jobs are “insourced,” occupied by foreign-born, foreign-trained workers brought into the United States on special visas earmarked for health care jobs. This number is 50 percent greater than the total number of jobs in the U.S. auto-manufacturing industry.

This point is also highlighted in a May 2018 report from KPMG, quoting their Global Chairman, Mark Britnell,: “The three [drivers of change] I consistently see are: firstly, the shortage and crisis in our healthcare workforce globally, forcing most organisations to think about the balance between short-term financial control and medium-to-long term health and prosperity”.

Tulenko sees this situation as deplorable, and in exploring its causes largely focuses on the demand side of the situation. In essence, she argues that American society blocks most would-be homegrown health care workers from the industry by making training too competitive and costly; that the healthcare industry takes advantage of the fact that foreign health care workers accept lower wages and worse working conditions; and that in failing to restrict their immigration Congress and the President are falling down on the job.

But let's look at the supply side here--that is, the question of where these foreign-trained workers are coming from, and why they'd want to come here. They're coming from middle and low-income countries where decent jobs are often hard to find, and good jobs are nearly impossible to find. Getting trained for health care jobs--typically nursing--is one way out. But those better-paying nursing jobs aren't in their own countries, they're here in the U.S. and in other more-affluent nations. Why? Well, yes, part of the reason is that there's a shortage of healthcare workers here. But perhaps a more important reason is that it's because there is a lack of good health care infrastructure in their own countries. They don't by and large come here only because they admire our way of life, they come here because we have lots of good hospitals and other care facilities in which they can effectively use their skills, and their countries don't. Tulenko points out some of these disparities herself:

The WHO Global Health Workforce Alliance estimates that there are a billion people alive today who will never see a health worker in their lives. In Ethiopia, one in 10 Ethiopian children will die before his or her fifth birthday — yet there are more Ethiopian physicians in the Chicago area than in all of Ethiopia, which, with 80 million people, is the second most populous country in Africa. As their most skilled nurses emigrate to work in U.S. nursing homes, countries such as Jamaica and Trinidad have nurse-vacancy rates of 60 percent or higher.

We could enact protectionist legislation to bar healthcare workers who come to the U.S., as the article seems to vaguely recommend. But here's another suggestion: Why don't we work with these countries to help them build the sorts of health care infrastructure that would provide good jobs, eliminating the main reasons for their looking to other countries for employment? We've seen that happen again and again in the countries in which US academic health systems have worked with local partners on health care capacity-building projects. The emergence of quality medical facilities even spurs people to return to their home countries. 

And, though it may seem counterintuitive, helping other countries build better health-care-related educational institutions, whether it's schools of nursing, medicine or pharmacy, would also be a double win. Right now, people in these countries who want good health care training often have to go to other countries to get it--and once they leave and are trained elsewhere, they're much less likely to end up in their home country than if they had been trained at home in the first place. 

And here's the kicker: When developing countries build better hospitals, they often find that the local supply of healthcare workers suddenly becomes a shortage of well-trained and experienced doctors, nurses, administrators, pharmacists and others. And guess what country they often turn to in order to import that talent? That's right, the U.S. Wouldn't it be nice if instead of having to import health care workers, we became an exporter?

I'm all for training more health care workers in the U.S. for our own needs, as Tulenko urges. But I'd also emphasize looking at how to help those elsewhere in the world in ways that pay off for us, too.