The United States is in the midst of a prolonged nursing shortage, one that could reach a deficit of 800,000 registered nurses (RNs) by 2020. Increasingly, foreign-trained nurses are migrating to the U.S., particularly from low-income countries, seeking higher wages and a higher standard of living. Increased reliance on immigration may adversely affect health care in lower-income countries without solving the U.S. shortage. This Issue Brief analyzes trends in medical migration, and explores its short and long-term effects on the health care workforce in the U.S. and in developing countries

Aiken, Linda H

Cooper, Richard A

Polsky, Daniel

Sochalski, Julie

English

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics5-21-2007Medical Migration to the U.S.: Trends and ImpactDaniel PolskyUniversity of Pennsylvania, polsky@wharton.upenn.eduJulie SochalskiLinda H. AikenRichard A. CooperFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/66For more information, please contact repository@pobox.upenn.edu.Polsky, Daniel; Sochalski, Julie; Aiken, Linda H.; and Cooper, Richard A.. Medical Migration to the U.S.: Trends and Impact. LDIIssue Briefs. 2007; 12 (6). http://ldi.upenn.edu/brief/medical-migration-us-trends-and-impactMedical Migration to the U.S.: Trends and ImpactAbstractThe United States is in the midst of a prolonged nursing shortage, one that could reach a deficit of 800,000registered nurses (RNs) by 2020. Increasingly, foreign-trained nurses are migrating to the U.S., particularlyfrom low-income countries, seeking higher wages and a higher standard of living. Increased reliance onimmigration may adversely affect health care in lower-income countries without solving the U.S. shortage.This Issue Brief analyzes trends in medical migration, and explores its short and long-term effects on thehealth care workforce in the U.S. and in developing countries.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/66Leonard Davis Institute of Health EconomicsLDI Issue BriefVolume 12, Number 6April/May 2007Daniel Polsky, PhD, MPPLDI Senior Fellow,Associate Professor of MedicineUniversity of PennsylvaniaJulie Sochalski, PhD, RNLDI Senior Fellow,Associate Professor of NursingUniversity of PennsylvaniaLinda H. Aiken, PhD, RNLDI Senior Fellow,Claire Fagin Leadership Professorof NursingUniversity of PennsylvaniaRichard A. Cooper, MDLDI Senior Fellow,Professor of MedicineUniversity of PennsylvaniaContinued on next page.U.S. is now the world’slargest importer of nursesMedical Migration to the U.S.:Trends and ImpactEditor’s note:  The United States is in the midst of a prolonged nursingshortage, one that could reach a deficit of 800,000 registered nurses (RNs)by 2020.  Increasingly, foreign-trained nurses are migrating to the U.S.,particularly from low-income countries, seeking higher wages and a higherstandard of living.  Increased reliance on immigration may adversely affecthealth care in lower-income countries without solving the U.S. shortage.This Issue Brief analyzes trends in medical migration, and explores its short-and long-term effects on the health care workforce in the U.S. and indeveloping countries.The U.S. has almost 20% of the world’s stock of professional nurses and about halfof all English-speaking professional nurses.  With such a large labor force, even amodest imbalance between supply and demand exerts a strong pull on global nurseresources.• The nursing shortage has produced RN vacancy rates of 10%-15% in U.S.hospitals and nursing homes.  Domestic nursing schools cannot keep up withdemand; in fact, the American Association of Colleges of Nursing found thatnearly 40,000 qualified applicants were turned away from baccalaureate nursingprograms in 2006 because of shortages of faculty, resources, space, and clinicalplacement sites.• This unmet demand, coupled with relaxed immigration policies, has led to aninflux of nurses from other countries.  Between 1994 and 2005, the number offoreign-trained nurses passing the RN licensing exam tripled to almost 15,000annually.• The increasing numbers of migrating nurses has raised concerns about the impacton their countries of origin.  These are often developing countries that can ill-afford to lose the nurses they train.Increasingly, migrantnurses come from low-income countriesPolsky and colleagues used U.S. Census data to describe trends in nurse migrationand to compare characteristics of U.S.- and foreign-trained entrants to the RNworkforce in 1990 and 2000.• In 2000, about 181,000 foreign-trained RNs were working in the U.S.,representing 9.1% of the nursing workforce.  This is a 40% increase from 1990,when there were 113,000 foreign-trained RNs (6.5% of the nursing workforce).• In 2000, 15.3% of RNs entering the workforce in the previous 10 years wereforeign-trained, compared to 8.8% in 1990.• Foreign-trained entrants earned more than U.S. trained entrants.  In 2000, theyearned an average of $44,000 compared with $33,000 for U.S.-trained entrants.From 1990 to 2000, foreign-trained entrants experienced 8.5% real growth inincome, whereas growth for U.S-trained entrants was flat.• The investigators estimate that half of the difference in earnings could beexplained by the fact that foreign-trained nurses were older, worked more hours,and had located in states with higher nurse wages.From national census and state licensing data, Polsky, Aiken, and colleaguesidentified the primary source countries for migrant nurses.• Almost one-third of foreign-trained nurses come from the Philippines.  In recentyears, many physicians in the Philippines have retrained as nurses in order tomigrate to the U.S.• The second most important source of foreign-trainednurses is the Caribbean and Latin America, followed bydeveloped regions such as Canada, Western Europe, andAustralia.• Migration from developed countries can have a dominoeffect on poorer countries.  Developed countries largelyreplace the migrating nurses by recruiting from lessdeveloped countries.• The source countries for foreign-trained nurses changedbetween 1990 and 2000 (see table), with more comingfrom Africa and fewer from Asia.  Compared with 1990,new foreign-trained RNs in 2000 were twice as likely tocome from low-income countries and 30% more likelyto come from countries with a low supply of nurses.The investigators used census and licensing data to explore the geographicdistribution of foreign-trained nurses.• Foreign-trained nurses tend to settle in states along the coasts and in central cities.New York, New Jersey, Florida, and Illinois have the highest density of foreign-trained nurses.Between 1990 and 2000,the percentage of foreign-trained nurses entering theU.S. workforce nearlydoubledForeign-Trained Nurses   1990         2000Census     CensusNew entrants in the U.S. labor force        41,374      62,066Continent/country, %Europe   10.9 11.5Asia   62.8 52.1Americas (excluding Canada)   15.3 10.9Canada     6.1 13.6Africa     4.1 11.1Oceania     0.7   0.9Annual per capita country income, %Low (<$755)   11.1 20.7Middle ($755-$9265)   70.9 54.0High (>$9266)   18.0 25.4Foreign-trained nursessettle along coasts and incentral citiesContinued on back.Medical migration is alsosubstantial for physicians• Foreign-trained nurses are much less likely to reside in rural areas than U.S.-trained nurses and are not likely to have much of an impact on nurse shortages inrural areas.  Less than 2% of foreign-born nurses live outside of metropolitanareas, compared to 18% of native-born nurses.• The geographic distribution of foreign-trained entrants changed between 1990and 2000, while the distribution of U.S-trained entrants stayed the same.  Forforeign-trained entrants, there was a dramatic shift from the Mid-Atlantic andPacific census divisions to the South and Midwest.Not surprisingly, foreign-trained nurses tend to work in settings with the highestnurse vacancy/turnover rates.• Compared to U.S.-trained nurses, foreign-trained nurses are more likely to workin hospitals, in intensive care, and in nursing homes, settings in which the nurseshortage is the greatest. They are less likely to work in community settings or inambulatory care.• Nursing home employment of foreign-trained RN entrants grew by nearly 3times between 1990 and 2000.  Historical difficulties in maintaining adequatestaffing levels may have influenced the growth in numbers of foreign-trainednurses in long-term care settings.  In 2000, 17.5% of foreign-trained entrantsworked in nursing homes, compared to 6.6% of U.S.-trained entrants.Cooper and Aiken point out that the U.S. has both a nurse and physician shortage,and that the circumstances that surround these shortages are interrelated.• As in nursing, one half of all physicians in English-speaking countries are in theU.S.  Despite this reservoir of roughly 750,000 physicians, Cooper and colleaguespredict a shortage of approximately 200,000 physicians by 2020.• In the 1980s and 1990s, many experts predicted that the U.S. would have asurplus of physicians by now.  However, growing evidence suggests instead thatthe U.S. does not train enough physicians to meet its needs. About 22% ofphysicians in the U.S. are foreign-born and foreign-educated.• The consequences of medical migration of physicians and nurses can bedevastating for low-income countries with a high burden of disease and too fewhealth care professionals to meet even basic health care needs.The United States plays an important role in global nurse migration because of thesize of its nurse workforce and its growing demand for more nurses.  Continuedshortages threaten to undermine health care delivery in the U.S. as well as indeveloping countries.• Even a small increase in the numbers of U.S. RNs from low-income countriesmight represent a large proportion of the source country’s nurses.  For example,the 11.1% of foreign-trained RNs who entered the U.S. from Africa between1990 and 2000 alone represents more than 1% of the entire stock of Africannurses.  These losses, especially in sub-Saharan Africa, are dearly felt.Nursing homes attractmany foreign-trainednursesPOLICY IMPLICATIONSThis Issue Brief is based on the following articles:  D. Polsky, S. J. Ross, B.L. Brush, J. Sochalski.  Trends in characteristics and country of origin amongforeign-trained nurses in the United States, 1990 and 2000. American Journal of Public Health, May 2007, vol. 97, pp. 895-899; L. H. Aiken.  U.S.nurse labor market dynamics are key to global nurse sufficiency.  Health Service Research, June 2007, vol. 42, pp. 1299-1320; R.A. Cooper, L.H.Aiken.  Health services delivery: reframing policies for global migration of nurses and physicians—a U.S. perspective. Policy, Politics, & NursingPractice, August 2006, vol. 7, pp. 66S-70S; R.A. Cooper. Weighing the evidence for expanding physician supply.  Annals of Internal Medicine,November 2004, vol.141, pp. 705-714.  See also the Special Issue on International Nurse Migration, Health Services Research, June 2007, vol. 42,edited by L.H. Aiken, P. Pittman, and J. Buchan.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104-6218.Janet Weiner, MPH, Associate Director for Health Policy, Editor (215-573-9374)David A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and social and ethicalissues that influence how health care is organized, financed, managed, and delivered in the United States and internationally. The LDI is a cooperativeventure among Penn schools including Dental Medicine, Medicine, Nursing and Wharton, and the Children’s Hospital of Philadelphia. For additionalinformation on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).Nonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue Brief Published by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTED© 2007 Leonard Davis InstituteVisit us on the web at www.upenn.edu/ldi• It is not likely that the global impact of medical migration can be minimizedwithout greater self-sufficiency in the U.S.  This country must increase itsdomestic capacity to produce the health care professionals it needs.  This willrequire a national health care workforce policy, as well as a commitment to buildits educational infrastructure for nursing and medicine.• U.S. policies to manage medical migration must balance the rights of migratinghealth professionals and their families, the needs of their countries of origin, andU.S. needs.  Employers, professional associations, and other stakeholders withinterests in having an adequate supply of health care professionals should workwith the federal government to promote more coherence between internationaldevelopment and immigration policies.POLICY IMPLICATIONSContinued

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