Immigration-related orders issued by the Trump administration have captured the media’s attention since Inauguration Day and have sparked a robust political debate across the country. Politics aside, these orders have a real effect on the daily provision of health care at essential hospitals.

One of the defining characteristics of essential hospitals is their commitment to training future health care professionals, including key support staff such as nurses, physician assistants, and social workers. The average essential hospital trains 228 physicians a year, or nearly three times the number of residents trained at other teaching hospitals. Because of their own diverse workforce and experience treating diverse patients, essential hospitals are uniquely situated to provide the culturally competent care their patients need.

Unfortunately, even as these executive actions undergo court challenges, they already have limited the ability of teaching hospitals to recruit the world’s most qualified medical graduates.

Details of Executive Orders

On Jan. 27, the Trump administration issued an executive order temporarily halting immigration from seven countries. After the order was challenged in federal courts, the administration released a revised executive order on March 6 that clarified the ban applies only to new visa applications and reduced the number of countries affected by the 90-day U.S. entry ban to six: Iran, Libya, Somalia, Sudan, Syria, and Yemen. Lower courts halted enforcement of the revised order, but the Trump administration has asked the Supreme Court to reinstate it.

On June 26, the Supreme Court ruled that the Trump administration can partially implement the executive order. Specifically, the Supreme Court said before it makes a decision on the legality of the executive order, the administration can bar the entry of citizens of the six countries except for those who have a “bona fide relationship” with a person or entity in the United States. Examples of such relationships include educational commitments, employment offers, and close family members, with some exclusions. The Supreme Court will hold oral arguments on the executive order in October.

Orders Cause ‘Upheaval’ in Medical Education, Workforce

Foreign-born workers play an indispensable role in the American health care system. Sixteen percent of the health care workforce — or more than two million U.S. health care workers — are foreign-born. A disproportionate number of international medical graduates (IMGs) practice in specialties with physician shortages, like internal medicine. They also gravitate toward underserved rural and urban areas — places where patients have limited access to health care due to provider shortages.

As the Jan. 27 executive order was rolled out, stories emerged about physicians with valid visas who were denied entry into the country, including a medical resident from Sudan training at Cleveland Clinic and another resident of Sudanese origin training at a New York hospital. Since then, the March 6 executive order has directly affected medical residents from the six countries in question and has created apprehension among IMGs from other countries. Although enforcement of the order had been on hold, there already has been a decrease in visas issued to citizens of the six affected countries.

The potential effects of these executive orders cannot be understated — the Accreditation Council for Graduate Medical Education says there are 1,800 physicians in fellowship and residency programs from the seven countries targeted in the original order. Overall, reports show that there are about 13,000 practicing physicians and 60,000 health care workers in the United States from those countries. Foreign-born physicians from the seven countries in the original executive order treat an estimated 30 million patients annually, and uncertainty about their ability to enter or stay in the country could translate to increased costs, increased burden on other providers, and untreated conditions.

When this year’s residency match decisions were announced on March 17 — just 11 days after the revised executive order — both residents and teaching hospitals were reluctant to commit to residency program slots without knowing whether recent graduates would be granted a visa. In a statement on the executive order, the National Residency Match Program decried the “far-reaching” consequences and the “upheaval” caused in the graduate medical education world.

Executive Orders Hinder H-1B Visa Access

Meanwhile, another executive action postponed the availability of premium processing of H-1B visas — those used by IMGs for U.S. residency training — filed on or after April 3. The application process for H-1B visas can take up to a year, but teaching hospitals (that need to have a visa decision before the start of residency programs in July) often use premium processing to expedite the decision-making process. Without premium processing, teaching hospitals and their residents who were unable to file a visa application before April 3 have no guarantee of receiving a visa in time for the beginning of the residency program year.

On April 18, President Trump issued a separate executive order to “buy American and hire American.” The order calls for government agencies, including the Department of Homeland Security, to review the H-1B visa process to ensure visas are being awarded to the “most-skilled or highest-paid” applicants. The executive order has no immediate direct impact on the visa process for IMGs, but America’s Essential Hospitals will monitor the recommendations issued by the agencies and how they might affect the H-1B visa process.

Have These Orders Affected You?

As we pay close attention to these orders and follow-up actions from the administration, we want to hear from our members.

Have immigration policies affected your hospital’s workforce? Have they affected your patients’ access to care? If so, how is your hospital responding?

Please contact our Director of Policy Erin O’Malley at or 202.585.0127 to share your stories and concerns. And look out for a session this Friday on immigration policies at VITAL 2017 in Chicago, where you will hear perspectives from your colleagues and learn about the tools your hospital can use to respond to emerging immigration-related issues.