Several states are extending medical licenses to foreign and assistant doctors to fill shortages of physicians that are projected to reach 86,000 nationwide, by 2036.
Tennessee will become the first state to give provisional licenses to physicians with clinical experience who migrate to the United States, in 2025. Governors Ron DeSantis of Florida and Glenn Youngkin of Virginia signed into law similar bills. The Florida bill will go into effect January 1 while the Virginia measure will be effective on July 1.
A bill removing the requirement for a medical residency is also moving through the Idaho legislature while a similar bill in Wisconsin was signed into law on March 23.
The state reforms are focused on extending provisional licenses to experienced foreign doctors and issuing licenses to assistant or associate physicians (APs), who are medical school graduates who have been unable to find a place in a medical residency training program.
Adding Foreign Doctors
Removing license restrictions on foreign-trained doctors would expand access to physicians in a state, according to Jeffery Singer, M.D., a senior fellow at the Cato Institute.
“Unlike Canada, Australia, the European Union countries, and many other developed countries, states require such doctors to repeat their entire residency training in an accredited residency program in the U.S.—even if they have been practicing for years in their home countries—and pass the standardized U.S. Medical Licensing Exam,” Singer wrote in a March 14 blog post.
Americans Study Abroad
Under the Tennessee law, foreign doctors and international medical graduates (IMGs), which includes Americans who studied abroad, can forgo the clinical residency requirement but must be licensed in their native countries, pass U.S. medical exams, and be supervised for two years by a licensed physician before receiving an unrestricted license.
The bills not only grow the ranks of physicians more quickly, and are helpful to U.S. medical school graduates who do not have residency places, Singer told Health Care News.
“By requiring experienced and practicing foreign doctors who migrate to the U.S. to repeat a residency program, you are adding them to the pool of med school graduates competing for an already scarce number of residency slots (that isn’t) enough to accommodate current U.S. med school grads,” said Singer.
Placing U.S. Graduates
In 2023, 40,375 medical residency slots were filled via the National Resident Matching Program (NRMP), which pairs medical school graduates with federally-funded clinical training programs, Matt Dean, a senior fellow in health care policy outreach for The Heartland Institute, which publishes Health Care News, in a March 26 research and commentary.
“But the real number is much lower as those who withdrew, delayed, or did not rank multiple programs were uncounted in this figure,” wrote Dean. NRMP data show that 2,590 U.S. IMGs and 5,118 non-U.S. IMG graduates were not matched to a residency in 2023.
Limits on Assistant Physicians
In 2014, Missouri became the first state to create a path for APs and now has 348 active licenses, according to Dean. Graduates train under licensed physicians, and their medical practices are limited in scope and confined to underserved areas.
Similar programs now exist in Arizona, Kansas, Maryland, Utah, and Washington. Alabama, Minnesota, and Oklahoma are considering similar legislation. Some states have a time limit on practicing APs, with the expectation they will eventually be placed in conventional residency programs.
Vetting Foreign Doctors
One concern about extending licenses to medical school graduates who have not followed the conventional training route is safety, as residency programs serve as a “vetting” process.
Graduates of fly-by-night or easy-entry off-shore medical schools could start medical practices that harm patients, as in the case of an assistant physician in Minnesota who owned multiple clinics, supplied drugs illegally to patients, and was convicted of fraudulently receiving $300,000 in federal funds.
Dean says he favors expanding the ranks of licensed physicians through the AP track for non-ranked U.S. graduates, instead of bringing in more foreign doctors.
“The medical training programs developed in the United States over the past century have set the global gold standard for clinical training,” Dean told Health Care News. “Clearly, the accreditation of non-U.S. training programs for U.S. licenses needs to be uniform and have as its goal the best interests of the patients who will be in their care.”
Less Qualified, Lower Pay?
Easing up on medical licensing won’t solve any problem until legislators address the dysfunction in the health care system, David Teuscher, M.D., wrote in an email discussion moderated by the Galen Institute.
“Rural and urban access issues are not primarily the result of an insufficient workforce,” said Teuscher. “The problem doesn’t exist in communities with a greater percentage of privately insured patients with stable and acceptable contracted rates for in-network services.
“If the IMGs fill the shortage, I’d anticipate declining government reimbursement to continue, a downward death march without any inflation factored in, essentially a race to the bottom,” said Teuscher. “The vast majority of IMGs that I have worked with locate to affluent communities for the very reason that American-trained physicians do—compensation is higher. It’s Economics 101.”
Fewer Places Than Graduates
Teuscher told Health Care News the federal government’s freeze on the expansion of graduate medical education (GME) residencies leaves some medical school graduates without a route to licensing.
“Medical school expansion without GME for every graduate is a disservice to the taxpayers, the physician graduates, and the patients who can’t access a physician,” said Teuscher. “If policymakers want to ease immigration for foreign fully trained, experienced, and equivalent physicians, and require additional GME in the U.S., that GME funding will be essential.”
AnneMarie Schieber (amschieber@heartland.org) is the managing editor of Health Care News.
