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America's health worker mismatch

National View

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Despite high unemployment, there is one bright spot in the economy: While nearly all other sectors shrank during the recession, jobs in health care increased by more than 1.2 million, with most paying salaries of more than $60,000. And demand for those workers will keep improving: the Affordable Care Act will add 32 million people to insurance rolls over the next several years, while the aging of America will drive the need for health care for decades to come.

But for American health workers, this is hardly good news. Despite a labor shortage, our crowded medical professional schools are turning away hundreds of thousands of qualified applicants; to fill the gap, we are importing tens of thousands of foreign workers. Today about 12 percent of the health work force is foreign-born and trained, including a quarter of all physicians.

That's bad for American workers, but even worse for the foreign workers' home countries, including some of the world's poorest and sickest, which could use these professionals at home.

The wrong solution

The blame lies primarily with the woeful state of schools in the health professions. Despite increased demand for their graduates, they have done little to expand their output.

Even worse, although the cost of higher education increased faster than inflation for the past two decades, the per graduate cost of health professional education has increased even faster: Over the past 20 years, public medical school tuitions have increased 312 percent.

State regulators also artificially limit the number of health professionals we can train by effectively requiring that students be trained almost exclusively in teaching hospitals, even though most go on to work in clinics or community hospitals. Not only does this limit the number of people who can be educated, but the resulting increases in tuition and length of training reduce the number of students from poor and underserved communities who apply to health professional schools in the first place.

Then there's the phenomenon of credential creep: In fields like audiology, physical therapy and optometry, a therapist who once needed a master's degree must now have a doctorate to get a license, which means more years of school, higher attrition rates, higher debt, higher wage demands and fewer workers from underserved and low-income areas. The same licensing system actually favors foreign-trained health workers, who, for various reasons, do not have to meet these degree requirements.

It's no surprise, then, that the response to this self-made labor shortage has been to recruit inexpensive workers from abroad, including the 57 poor countries defined by the World Health Organization as having significant shortages of their own. Among them is India, America's largest source of foreign-trained doctors. A special visa program has made hiring these workers even easier.

A Gates Foundation study recently showed that immigration, with the United States as the most common destination, was siphoning off the largest number of African medical professionals.

The Global Health Workforce Alliance estimates that a billion people alive today will die without ever seeing a health care worker. Meanwhile, the W.H.O. estimates that below a threshold of 2.3 doctors, nurses and midwives per 1,000 people, countries are unable to provide even the most basic health services.

Multiple studies, even when controlled for poverty, show that access to health workers is directly related to mortality and health outcomes. A meta-analysis of 13 studies of developing countries showed that newborns who live more than three miles from a staffed health facility are almost twice as likely to die than infants who live closer to one. Health workers in developing countries don't just provide clinical care — they also manage their countries' health and disaster response systems, as well as nutrition and sanitation programs, all of which crumble in their absence.

Direct hit on the U.S.

There are other casualties, closer to home. Every study that has examined how to incentivize health workers to move to underserved areas has shown that training people from these communities is the most cost-effective approach. But because we've essentially given up on recruiting from underserved places in the United States, we've made their chronic lack of health workers much worse. Some 54 million people live in the 5,700 parts of the country defined as "health professional shortage areas," the communities with the worst health statistics and the worst unemployment.

In response, schools should be required to pay attention to cost effectiveness and train more workers with their existing budgets. Federal money could go toward helping these schools expand.

Meanwhile, the Departments of Education and Health and Human Services, which essentially let the health professions regulate their schools, could mandate that all new licensing requirements be justified with cost-effectiveness data; they could also require schools to communicate with employers to gauge the numbers and skills of workers needed.

It is irrational and immoral to recruit health workers from countries where one in five children die before their fifth birthday when we could be recruiting and training workers domestically. Doing so would help our economy, global public health and the 314 million Americans who rely on our medical system to provide high-quality, affordable care.

Kate Tulenko, the senior director of health system innovation at IntraHealth International, is the author of Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad. This piece originally ran in the New York Times.

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