Description of the challenges and opportunities facing foreign born healthcare professionals in Massachusetts.

1. Foreign Born Healthcare
Professionals in Massachusetts:
Challenges and Opportunities
Jeff Gross
Director, New Americans Integration Institute (NAII)
Massachusetts Immigrant and Refugee Advocacy
Coalition
May 19, 2014 [Revised 5/23/14]

2. Diversifying the State Healthcare
Workforce:Who Benefits?
• Affordable Care Act & aging population are expanding need
for primary care providers and clinical staff at all levels.1
• Projected 22% growth in MA in openings by 2020 (12%
physicians, 30% nurses, 28% allied professions).2
• More linguistically and culturally competent clinicians can
help address access barriers for an increasingly diverse
state population.
• Foreign trained clinicians could help address needs at
“safety net” community hospitals & health centers.
• Return on investment by supporting already trained and
experienced medical professionals.
1 Massachusetts Medical Society, 2012 Physician’s Workforce Study
2 Georgetown University Center on Education and the Workforce, Healthcare State
Report: Massachusetts (June 2012)

3. Sources of Data on Foreign Born
Healthcare Professionals
National Survey of College Graduates (NSCG)
• Data valid mainly at the national level
• Offers explicit information about source of
degree (U.S. vs. non-U.S.), field of study, and
level of highest degree
American Community Survey (ACS)
• Data valid at the regional, state and local levels
• Source of degree (U.S. vs. non-U.S.) must be
estimated based on age of arrival in the U.S.
• Only information on bachelor level field of study

4. National Data
There are more than 874,000 foreign born residents
in the U.S. who are trained healthcare
professionals—one fifth of U.S. residents who hold
a bachelor’s degree or higher in medical or
behavioral health occupations.

5. Foreign vs. US Degrees
Nationally, almost two-thirds of foreign born
healthcare professionals (63.7%) received their
training outside the U.S.—physicians at the highest
rate (72%), psychologists at the lowest (20%).*
* Under the “Foreign Born” column, the % value equals only the foreign born share of
professionals in that category.

6. Foreign Degree Holders by Region of Origin
49.2%
16.5%
18.1%
6.8%
5.4%
3.9%
Medical Degree
Asia
Europe
Latin America and
Caribbean
Africa
North America, Other
U.S.
76.1%
5.8%
11.6%
2.2%
3.6%
0.7%
Nursing Degree
Asia
Europe
Latin America and
Caribbean
Africa
North America,
Other
U.S.
Source: American Institute of
Economic Research and NAII
analysis of NSCG 2013
Microdata

7. US Degrees: Labor Market Outcomes
• Foreign born physicians with U.S. degrees work outside of
their field of study at relatively low rates, though still twice
that of those born in the U.S. (6.7% vs. 2.8%).
• Underemployment is highest (28% for) psychologists
• Even for professions where working outside field of study is
relatively common (e.g., 25.3% of nurses), mean annual
salaries are still relatively high.

8. Foreign Degrees: Labor Market Outcomes
• Physicians with foreign degrees are five times more likely to be
underemployed than with U.S. degrees (22% vs. 4.6%).
• Those working outside their field of study earn 43.4% less than their
counterparts with U.S. degrees.
• Allied professions, pharmacists, and psychologists with foreign degrees
also show significantly higher underemployment levels and lower
salaries when employed in other occupations.
• Though foreign born nurses trained abroad have slightly lower
underemployment levels compared to the U.S. trained (17.6% vs.
18.1%), for those working outside their field salaries are significantly
lower compared to U.S. trained (22%).

9. Massachusetts Data
• 37.7% of immigrants in the Massachusetts labor force hold a
bachelors degree or higher.
• Approximately 14,804 hold bachelor level degrees in a healthcare or
medical field of study, half with a U.S. and half with a foreign degree.
• Since the American Community Survey only reports bachelor level
field of study, these figures significantly undercount the total foreign
born with foreign and U.S. graduate degrees in healthcare.
• The pool of medical talent in Massachusetts includes large numbers
of refugee MDs, nurses, physical therapists, dentists, pharmacists,
and other healthcare professionals.*
* MA Office for Refugees and Immigrants (ORI). A 2008 ORI study indicated 20% of 237 refugee
professionals entering the state that one year were medically trained.

10. Foreign Born Nurses
• Of 55,000 individuals in MA with undergraduate degrees
in nursing, some 7,400 (13 percent) are foreign born—
approximately 3,400 foreign educated and 4,000
educated in the U.S.
• Foreign-educated immigrants with a nursing degree are
over seven times more likely to have a low-skilled job
(21%) than their U.S.-trained counterparts (3%).*
* High-skilled jobs typically require a bachelor's degree plus substantial work-related skills or experience;
medium-skilled jobs typically require an associate's degree or vocational training, along with significant on-the-
job experience; low-skilled jobs require a high school degree or less and moderate on-the-job training or less.

11. Boston Welcome Back Center: Countries &
Regions of Origin
20%
6%
6%
4%
4%
59%
Haiti
Brazil
China
Nigeria
Nepal
Other
The Boston Welcome Back Center assists internationally trained nurses
become licensed to practice in Massachusetts. The Center is a
partnership of Bunker Hill Community College, Roxbury Community
College, Mass Bay Community College, The Massachusetts Department
of Higher Education, and University of Massachusetts Boston. Since
2005 the Center has assisted over 1000 nurses from 58 countries. See
www.bhcc.mass.edu/welcomeback.
24%
23%
10%
27%
17%
Africa
Caribbean
Americas
Asia
Europe

12. Foreign Born Physicians
• 9200 foreign born individuals are employed as physicians and surgeons in
the state—27.9% of the 33,000 in the state
• Two-thirds were trained abroad and one-third in the U.S.
• The lower rate of foreign born employed (27.9%) than U.S. rate of foreign
born with medical degrees (29.6%) may reflect labor market barriers.
• The lower rate of foreign born employed with foreign degrees (66.3%)
than U.S. rate foreign born who hold foreign degrees (70.4%) may suggest
similar issues
• The higher proportion in MA of both U.S. born physicians and foreign born
physicians with U.S. degrees could indicate state or provider-specific
educational requirements that favor those trained in U.S. institutions

13. Factors Impacting Skill Underutilization*
Individual
• Limited English proficiency
• US vs. foreign degree
• Country of degree
• Unfamiliarity with US job market
• Lack of professional networks
• Financial/job constraints
Systemic
• Complex relicensure process
• Lack of centralized, widely shared information
• Lack of targeted career assistance
• Constraints of workforce development system
• Limited well-defined alternative career paths
• Institutionalized bias
* Jeanne Batalova & Michael Fix (2008), Uneven Progress: The Employment Pathways of Skilled Immigrants
in the United States, Migration Policy Institute; Neeta Fogg & Paul Harrington (2013), Labor Market
Underutilization Problems among College-Educated Immigrants in the United States, Drexel University.

14. Potential Recommendations
Short Term
• Centralized resources & career guides on state websites
• State workforce agency guidance & training for career centers
• Providers & professional schools promoting peer networks
Medium Term
• Loan fund for relicensing & education costs (NYC model)
• Welcome Back Center model expanded to other professions & regions
• Workforce services more targeted at needs & assets of foreign born
• More diverse & higher level ESOL programming / TOEFL prep
• More career pathways programs into higher-skilled occupations
• Research on barriers & aligning policy with state’s healthcare needs
Long term
• High-skilled immigrant ombudsman role in state executive
• Expanding medical training & residency slots
• Options for limited / conditional scope of practice in high-need settings
• Federal advocacy (Health Equity and Accountability Act)

15. Questions for the Task Force
• What are the key challenges here?
• What are the key opportunities?
• What additional data is needed to
better understand these issues?
• What are possible short, medium and
long term solutions?
• What other questions should we be
asking?