How a green card freeze will exacerbate the nursing crisis

And emergency room doctors say not having enough nurses is a top concern coming out of the pandemic.

“If that pipeline stops, it ain’t gonna be good — and I’m talking significant holes in the nursing field, which is already on such a razor-thin edge right now,” said Luke LeBas, an emergency medicine physician in Louisiana, who added that an “incredible number” of nurses have come to the U.S. from the Philippines to backstop hospitals on the West Coast.

The shrinking labor pool has ripple effects beyond the hospital walls. The reduction in foreign visas will affect nursing homes, assisted living facilities and hospice care, which could increase costs and delay care for the elderly and the dying.

An estimated 100,000 registered nurses in the U.S. left the workforce during Covid because of stress, burnout and retirements. About another 600,000 have reported “intent to leave” the workforce by 2027 because of the same issues. The U.S. is now facing a projected shortage of more than 200,000 nurses in the next few years.

International nurses have proven for many hospitals and health systems to be a useful tool at combating those staffing shortages — with foreign workers comprising about 15 percent of the workforce, a number that’s nearly doubled in the last decade.

But with the State Department’s freeze on green card petitions filed in the past year, health systems — already crushed under the weight of a workforce crisis that is crimping margins and hurting patient care — will be short one of their most effective hiring tools. The American Association of International Healthcare Recruitment estimated at least two-thirds of the thousands of international nurses on their pipeline to enter the U.S. this year won’t be able to immigrate because of the State Department’s freeze.

“You already have nurses who are over-stressed, overworked, burnt-out because of the last few years,” said Lesley Hamilton-Powers, vice chair of the AAIHR. “… About 15 percent of nurses are international, working in the U.S. today, and so you take those nurses away from the bedside and the nurses who are left continue to be overworked and delivering care in a vacuum of enough personnel.”

The State Department’s freeze is a result of higher-than-anticipated demand for employment-based visas in the EB-3 subcategory, a massive professional pool that includes all occupations that require at least an associate’s degree, but not a master’s degree.

That means nurses are in the same processing queue for green card applications as IT workers and engineers. Because the demand for work visas is greater than supply, the State Department prioritizes the oldest applications first, not the industry in which there is the greatest need.

The department has nearly exhausted the 40,000 green card annual limit for this fiscal year, ending Sept. 30. The annual limit will reset in October, but because of such high demand for green cards coming out of the pandemic, there will likely still be a cut-off date for eligibility come the fall, said Chris Musillo, an AAIHR-affiliated immigration lawyer.

If the cut-off for eligibility continues past October, international nurses who petition for green cards this summer might not be able to enter the U.S. until at least 2025, Musillo predicts.

A State Department spokesperson told POLITICO that “people from most countries who are seeking to immigrate to the United States” on an EB-3 visa “should expect to wait longer for a visa to become available than in prior bulletins.”

“We recognize the importance of health care workers to the U.S. economy and are continually monitoring the situation,” the spokesperson said.

The EB-3 category is numerically limited by the Immigration and Nationality Act, and Congress hasn’t updated the quotas for the green cards since 1990 despite population growth. This is one fundamental problem leading to the backlog, along with Congress’ decision to lump different professions into the same visa categories, “regardless of the benefit to the American public,” said Musillo.

“And we would submit that bringing in nurses is maybe more important than some of the other occupations,” he said.

‘A catastrophic interruption’

Paula Butts, the chief nursing officer at Piedmont Henry Hospital, outside Atlanta, said that since the pandemic, she has had about three to four international nurses join her staff per month. Butts contracts out about 20 percent of her workforce to nursing recruitment agencies to meet patient needs.

With 52 international nurses on staff and a pipeline of 20 coming in, she still needs about 50 more foreign nurses. The State Department’s green card freeze “is going to slow me down greatly,” she said.

“We have to have every tool in the toolbox in order to meet this crisis, and it’s just very disappointing when you have such a useful tool taken away from you,” Butts said.

The effects of the pause will expand beyond hospitals. Nursing homes and assisted living facilities have also heavily relied on a pipeline of international nurses in the last couple of years, as they’ve lost an estimated 200,000 workers since the pandemic began.

The American Health Care Association and National Center for Assisted Living have seen hundreds of facilities close in the aftermath of the pandemic, “related directly to the inability to staff the building,” said Clif Porter, the senior vice president of government relations for AHCA/NCAL.

International recruitment has “been a really important solution” to address nursing home staffing numbers that are still significantly below pre-Covid levels, Porter added. One nonprofit that works with AHCA/NCAL had recruited about 300 international nurses to come into the U.S. this year, but with the freeze, about 45 percent of those nurses likely won’t be able to enter until 2024, he said.

“Particularly in senior services, the demand for our services is exploding, in home care and institutional care and acute care, and we don’t have enough people,” Porter said. “And if we don’t do something about it soon, we’re going to be in a real, real bad situation.”

Erica DeBoer, chief nursing officer for Sanford Health, the nation’s largest rural health system, said the State Department’s visa freeze will likely affect 44 percent of the 800 international nurses they expected to join their health system over the next two to three years. The health system currently has about 200 international nurses working at its main medical centers, critical care hospitals, long-term care facilities and Good Samaritan locations — which provide housing and health services to seniors, DeBoer said.

“In the rural setting, probably one of our biggest challenges is, when we think about critical access hospitals and then the amount of staff they need to keep those hospitals open, our international nurses are key to that strategy,” DeBoer said. “Whereas in urban settings, we’ve got more flexibility, so I’d say it’s more catastrophic in our critical access hospitals and our Good Sam locations.”

All eyes on Congress

The executive branch can’t increase the quota for green cards, Musillo said, so health groups are pushing for change through congressional action.

They’re asking for the reintroduction of The Health Care Workforce Resilience Act, a bipartisan bill that would recapture visas that were issued but unused from the previous year for the express use of nurses and doctors. The bill didn’t make it out of the Senate Judiciary Committee last Congress, but Musillo is hopeful it’ll be reintroduced before the summer recess.

Several Senate offices that were supportive of the bill last Congress told POLITICO they had no updates.

AHCA/NCAL also proposed in a recent letter that Congress create a temporary visa option specifically for registered nurses and other health care occupations, where they’d be able to come to the U.S. and start working while waiting for permanent residency approval.

“The future is we have an aging population that’s exploding, and the need for nurses is going to explode,” said Porter. “So ultimately, we’re proposing that we ought to be looking at policies that essentially treat health care workers identically to how tech workers are treated, and that would absolutely help stimulate, supply and ultimately get more nurses here, ready to work.”

Daniel Payne contributed to this report.