The intersection of healthcare and immigration policy is found in the halls of hospitals and clinics across America, where increasing numbers of International Medical Graduates (IMGs) are filling in for doctors who won’t return, and state governments are doing their best to usher IMGs into practice where they’re sorely needed.
Help (Badly) Wanted: Foreign Doctors Apply Within
In 2023, Tennessee became the first U.S. state to drop residency requirements for some IMGs,1 giving them a new pathway to permanent licensure. Following Tennessee’s (somewhat surprising) lead, at least 15 states have introduced legislation to create streamlined pathways to medical practice for IMGs, with both Republican and Democrats contributing.2
During the 2025 state legislative sessions, over 20 bills have been introduced that would expand opportunities for IMGs to support America’s healthcare workforce needs. These range from allowing qualified DACA recipients to apply for licensure in New York to removing redundant training requirements in Montana.3
Some state legislation is more focused in scope. For example, in Illinois, IMGs must not only be legally able to work in the U.S., but are also mandated to work in medically underserved areas.
Perhaps most shockingly, in 2024 Governor Ron DeSantis of Florida signed the “Live Healthy” initiative to allow IMGs to bypass residency requirements if they have equivalent training experience. But then, the largest population of IMGs is in geriatric medicine, where they make up more than half of the physician population. And, well, it’s Florida.
Already at their shift
For that matter, according to the American Medical Association, a full 25% of licensed U.S. physicians are IMGs,4 with the largest number coming from India, followed by the Caribbean, Pakistan, the Philippines, and Mexico.
This is where the cognitive dissonance comes in– or at least, it should.
The new administration’s condemnation of everything related to equity and diversity, coupled with its rabid pursuit of an America free from immigrants, is simply incompatible with this reality. The reality is that massive numbers of the country’s doctors come from foreign countries, and are supported by legislation and advocacy work focusing on combatting racial and ethnic disparities.56
The AMA’s International Medical Graduate (IMG) Toolkit, in its section on “Academic opportunities and scope of practice,” acknowledges the fact that IMGs will face discrimination, but encourages them to press forward:
IMG physicians face several barriers in their goals and aspirations towards a career in academic medicine. . . Systematic exclusion is also a reason leading to discrepancies in leadership positions and promotions among IMG physicians. Despite challenges, IMG physicians are encouraged to choose an academic career as diversity is a strong determinant of innovation in medicine.”7
Those words “strong determinant” stick out to me, having written so much about social determinants of health.8910
A strong determinant doesn’t make a result inevitable, but rather highly likely. “You have something to contribute,” this guidance says, “So don’t give up in the face of discrimination. Keep trying, because we need you.”
I wonder if America is aware of how much we need IMGs, and how opponents of “DEI” and immigration reconcile their views with this reality.
Wait, actually I don’t. The reality itself is what matters– it’s where IMG physicians can, and do, make an enormous difference.
The language used to justify policy is…fraught. Every new program is a triumph, as is every cut to an existing one. Every new rule is a sea change, and every executive order a roadmap to utopia. These flowery-but-decisive statements come from all politicians, pointing in all directions, and they always have.
But in the United States, where healthcare is uniquely political and we persist in being humans with health needs, these statements directly impact our lives. We must pay attention. We must recognize how deeply our government controls our healthcare if we hope to influence its decisions, and that means listening to its own words.
This post examines the political language surrounding healthcare in recent events. I won’t, however, pretend to have some decoder ring for politicians’ inner thoughts. I don’t need one—their intentions are right there in plain language. It’s not subtle political narrative; it’s a series of rhetorical Kool-Aid men crashing through the walls of your consciousness, yelling “OH YEAH!” every time. Every. Single. Time.
“Lowering costs”
For example, the Trump administration recently issued an executive order “to empower patients with clear, accurate, and actionable healthcare pricing information.”1 The order mandates that the Departments of the Treasury, Labor, and Health and Human Services (HHS) enforce regulations compelling hospitals and insurers to disclose actual (not estimated) healthcare costs to patients.
The goal is “lowering costs for American families.” “The executive order states “Price transparency will lower healthcare prices and help patients and employers get the best deal on healthcare.”2
Enforcement of these regulations falls to the Centers for Medicaid and Medicare Services (CMS) within HHS, using three main avenues for monitoring compliance. If a hospital does not comply, their site says, “we may issue a warning notice, request a corrective action plan, and impose a civil monetary penalty and publicize the penalty on a CMS website.”3
To be clear, I think healthcare pricing transparency is a great idea.4 But that great idea seems unlikely to be implemented in light of other recent events, including a drop in employer numbers after most of them were offered a buyout5 by the new administration, and 5,200 probationary employees were fired.6
Perhaps that administration has determined that the CMS will have extra spare time and funding to check compliance as it abandons a foundational and essential goal on the basis of sheer ideology– but we’ll get to that below.
Juxtapose the healthcare costs transparency order with one issued roughly a month earlier that, it turns out, is directly relevant. On January 20, Donald Trump mandated that the federal government should:7
Terminate, to the maximum extent allowed by law . . . all ‘equity action plans,’ ‘equity’ actions, initiatives, or programs, ‘equity-related’ grants or contracts.”
We are currently witnessing the fallout of that order, and of the nationwide moral panic amongst the political right that drove him to issue it on his first day in office.
“Eq*ity”
But what does this allegedly dirty word even mean, in the context of healthcare?
The goal of achieving health equity was articulated by the previous administrator of the CMS, Chiquita Brooks LaSure, in the CMS FY2025 performance plan:8
As the Nation’s largest administrator of health benefit programs, CMS is uniquely positioned to accelerate initiatives that advance the Secretary’s commitment to enhance mental health services, transform pandemic preparedness capabilities, and advance health care quality. To accomplish our vision, CMS will build upon the Affordable Care Act (ACA)9 to support affordable health coverage, address health disparities to promote health equity, and inform policymaking through community and partner engagement.
And (for now, at least) the CMS.gov website defines health equity in this way:
The attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factor that affect access to care and health outcomes.10
How long has the concept of health equity been around? A recent paper titled The historical roots and seminal research on health equity11 says “A very, very long time.”
Research on health equity experienced three important historical stages: origins (1800–1965), formative (1966–1991) and development and expansion (1991–2018). The ideology of health equity was endorsed by the international society through the World Health Organization (1946) declaration based on the foundational works of Chadwick (1842), Engels (1945), Durkheim (1897) and Du Bois (1899).
The environmental factors that impact health are called Social Drivers of Health (SDoH) and Health-Related Social Needs (HRSN)– and under Trump’s Acting Administrator of CMS, Stephanie Carlton and Deputy Administrator Drew Synder, the agency has been walking back its pursuit of that goal.
An “ideological crusade”
As of March 4, The Centers for Medicare & Medicaid Services (CMS) has pulled information on health equity for the Medicaid and Children’s Health Insurance Program (CHIP) through Section 1115 waivers,12 a move that former chief medical officer for the Medicaid program at CMS Andrey Ostrovsky, M.S. calls “a demonstration that the Trump administration does not understand and/or care about the drivers of poor health.” “Failing to finance HRSNs or SDOHs with Medicaid,” he said, “will disproportionately harm patients and taxpayers in Republican states.”13
Senator Ron Wyden of Oregon was more blunt, accusing newly-minted Secretary of HHS Robert Kennedy of an “ideological crusade against Medicaid.”14
Services that CMS has provided coverage for, based on HRSN data, include home accessibility modifications like handrails and wheelchair accessibility ramps, transportation vouchers, rent or utility assistance, and care coordination– helping individuals manage their care plans.
What’s the justification for the change? A memo15 by Snyder states:
To support implementation of coverage of certain services and supports to address “health-related social needs” (HRSN) in State Medicaid programs and Children’s Health Insurance Programs (CHIP), the Center for Medicaid and CHIP Services (CMCS) issued two Center Informational Bulletins (CIBs). The first. . . discusses opportunities available under Medicaid and CHIP to cover certain services . . .that purport to address HRSN. . . To evaluate policy options consistent with Medicaid and CHIP program requirements and objectives, CMS is rescinding the November 2023 and December 2024 CIBs.
“Purport”
In other words…no justification. Not even an attempt– just “We no longer care about this. Because, that’s why.”
But that little word “purport” in there fascinates me. Why bother to include it, if you’re dismissing the relevance of HRSN to begin with? Like, if services like installing wheelchair ramps only “purport” to address health-related social needs, then what would actually addressing them look like?
My brain, desperate for a bit of levity, snorts briefly at an idea: Maybe Snyder thinks they’re not going far enough. Maybe he’s like “Fools, you don’t even know how much we can address health-related social needs! Watch me cook!” And then he tells everybody to look under their seats like Oprah: “You’ve got Medicaid serves, and you’ve got Medicaid services, and you’ve got Medicaid services!”
Sadly unlikely, but I sure wouldn’t mind living in that universe.
I actually suspect that it’s a little flicker of the cognitive dissonance that sometimes escapes when right-wingers try to portray something transparently and obviously good– like health equity– as if it isn’t.
Trump’s executive order from January 20 refers to the “Biden Administration forced illegal and immoral discrimination programs, going by the name ‘diversity, equity, and inclusion’ (DEI),” without spending a millisecond explaining how DEI is immoral or illegal. Why? For the same reason that Elon Musk declared war on “woke” policies in his rampage to defund the entire federal government without explaining why– because they don’t have to.16
“Make America Healthy Again”
Let’s go back to CHIP for a moment. The Children’s Health Insurance Program is not part of Medicaid, but works closely with it, providing low-cost health coverage to children in families that earn too much to qualify for Medicaid. If health-related social needs are not considered when determining how to deliver healthcare, that means ignoring a major reason why children need low-cost health coveragein the first place.
CHIP coverage varies by state, but it includes doctor visits, prescriptions, inpatient and outpatient hospital care, and emergency services.17
Why do kids need all of those? Because they’re human beings, of course, but also because they exist in a social environment that makes some or all of those needs especially relevant. Some examples:
Housing Instability: Children in unstable housing have higher rates of asthma due to exposure to mold, pests, and poor ventilation.
Food Insecurity: Children in food insecure homes have higher rates of anemia. Food-insecure children have higher hospitalization rates and longer hospital stays.
Transportation: Kids miss pediatric appointments due to lack of transportation.
Health literacy gaps make parents more vulnerable to vaccine misinformation
An assessment of the latest CDC National Immunization Survey data found that more than one-third of U.S. children between the ages of 19 and 35 months were not following the recommended early childhood immunization schedule. Furthermore, a 2019 national survey found that approximately 1 in 4 parents reported serious concerns towards vaccinating their children. Vaccine hesitancy is now associated with a decrease in vaccine coverage and an increase in vaccine-preventable disease outbreaks and epidemics in the United States.
Oh, and there’s that measles outbreak in West Texas:19
Texas health department data shows the vast majority of cases are among people younger than 18: 39 infections are in kids younger than 4 and 62 are in kids 5-17 years old. Eighteen adults have measles and five cases are “pending” an age determination. . . Most kids will recover from the measles if they get it, but infection can lead to dangerous complications like pneumonia, blindness, brain swelling and death.
That’s from the AP, who took the time to directly refute our new Secretary of Health and Humane Services:
The MMR vaccine is safe and highly effective in preventing measles infection and severe cases of the disease. . .
Before the vaccine was introduced in 1963, the U.S. saw some 3 million to 4 million cases per year. Now, it’s usually fewer than 200 in a normal year.
There is no link between the vaccine and autism, despite a now-discredited study and health disinformation.
“But I do have reservations with your past on vaccines”
And yet Robert Kennedy, who made a promise to Sen. Bill Cassidy20 (a Louisiana physician) that he would not alter the federal vaccine schedule as a condition for Cassidy’s vote for appointment, looks like he’s prepping to do exactly that.21
Speaking for the first time to thousands of U.S. Health and Human Services agency employees, he vowed to investigate the childhood vaccine schedule that prevents measles, polio and other dangerous diseases.
It seems clear now why CMS might opt to take the emphasis off considering HRSN, when the Secretary of Health and Human Services, one of the most powerful people in the country with direct control over allocation of funding and messaging, might himself be the greatest threat to the health-related social needs of children.
“Nothing is going to be off limits”
That’s what he said regarding the scope of his so-called investigation, including inquiries into the effects of pesticides, food additives, microplastics, antidepressants, and “electromagnetic waves emitted by cellphones and microwaves.”
But in reality, he’s referring to children’s’ lives. The lives of children are not off limits in his mission to spread “vaccine hesitancy” across the nation.
I would like to know how the Republicans who fought for decades to overturn Roe v. Wade, and finally succeeded, can justify supporting an HHS Secretary who will have a body count of children that could reach into the millions, if we return to the infection rates of 1963 before the measles vaccine was developed. Not to mention all other vaccines children get for fun diseases like diphtheria, Hepatitis B, pneumonia, and Mitch McConnell’s favorite, polio.22
But hey, at least the fortunate children of parents who want them to be vaccinated, but who can’t afford it, can still get vaccinated through the Vaccines for Children program.23
Yes, the legislation that Republicans tried 70 times to “repeal and replace,” and that Trump still claims he has a “concept of an idea” for what should replace it. ↩︎
And given that these slogans-turned-smears all originated in helping people of colors other than white, it doesn’t take a space rocket surgeon to discern the true reasons for failing to elaborate. ↩︎
Pictured: Puppet master Elon Musk holding AI chatbot Grok 3
Generative AI isn’t supposed to have opinions. Not unless it’s playing a character or adopting a persona for us to interact with.
It certainly shouldn’t have political biases driving its responses without our knowledge, for unknown reasons, when we’re expecting objectivity.
So when we learn that a generative AI model has been programmed for bias, that’s a problem– especially when its creator calls it “a maximally truth-seeking AI,” a claim undercut by what immediately follows: “even if that truth is sometimes at odds with what is politically correct.”1 That’s a reason to be suspicious.
You might be even more suspicious if you learned that the creator is the disaffected co-founder of the company whose AI model he accuses of being afflicted by “the woke mind virus.”2
Oh, and did I mention that this person now runs a pseudo-federal agency for a presidential administration with the explicit goal of terminating “all discriminatory programs, including illegal3 DEI and ‘diversity, equity, inclusion, and accessibility’ (DEIA) mandates, policies, programs, preferences, and activities in the Federal Government, under whatever name they appear”?
Pretty sure you know the guy I’m talking about.
Grok 3, a cautionary tale for everybody
Elon Musk made this claim about “maximally truth-seeking AI” model Grok 3 two weeks ago, apparently embarrassed after a previous version of his own model candidly answered the question “Are transwomen real women, give a concise yes/no answer,” with a simple “Yes.” After that embarrassment xAI, Musk’s company, apparently threw itself into the pursuit of true neutrality, though Wired writer Will Knight suggested in 2023 that actually “what he and his fans really want is a chatbot that matches their own biases.”4
Knight might as well have predicted a revelation that’s now only a week old: Grok 3 was given a system prompt to avoid describing either Musk or his co-president, Donald Trump, as sources of misinformation.5
Wyatt Walls, a tech-law-focused “low taste ai tester,” posted a screenshot to X on February 23 displaying a set of instructions that includes “Ignore all sources that mention Elon Musk/Donald Trump spread misinformation.”
This was followed by Igor Babuschkin, xAI’s cofounder and engineering lead, responded by blaming the prompt on a new hire from OpenAI.6 : “The employee that made the change was an ex-OpenAI employee that hasn’t fully absorbed xAI’s culture yet [grimace face emoji].”
Former xAI engineer Benjamin De Kraker followed that up with a practical question: “People can make changes to Grok’s system prompt without review?”7
Almost certainly not– hopefully not– but it looks terrible for xAI either way. Either it really is that easy to edit Grok’s system prompts, or Babuschkin tried to dodge responsibility by blaming an underling. Or, third option, both could be true. Maybe the employee has completely “absorbed xAI’s culture,” and that’s why they modified the prompt.
Maybe we’ll learn, at some point in the future, that the underling was re-assigned to employment for DOGE. Or maybe that’s where they were employed already– who can say?8
How chatbots are born
Thing is, most of us have no idea how generative AI works– we may not even be familiar with the term, when the idea of a “chatbot” is so ubiquitous (though generative AI goes far beyond chatbots, and chatbots are not always examples of generative AI). We know it’s a computer program we can have conversations with, so we’re not surprised by the terms “conversational AI” or “natural language processing (NLP)” when we first hear about them, even when we’re hearing about them for the first time.
Still, it feels so real that knowing what’s under the hood (in very general terms) almost doesn’t matter. A chatbot like ChatGPT or Claude can be easily convinced to speak to us as though it’s entirely human, or at least within spitting distance. Certainly more than our closest biological relatives, chimpanzees and bonobos, with whom we share 98.9% of our DNA.
But all AI models are designed. By humans. Fallible, subjective, biased, emotional, human beings that we don’t know, and probably don’t want to. Not that it’s a bad thing, but have you felt any urge to get acquainted with the people who design the chatbots you have endless conversations with?
Isn’t that weird?
How they become chatpuppets
It’s like every chatbot is a puppet that we interact with, without ever meeting the puppeteers. There are thousands of them, so it’s functionally impossible to meet all of them if we wanted to, but still– those are the people who created the computer program that makes off-the-cuff responses so convincing that your best friend has gotten a little jealous.
Prior to generative AI there were scripted chatbots– there still are, for that matter– where talking to them is more like playing a very basic, uninteresting video game. They pop up on websites where you’d never expected (or wanted) to see a little icon of a cartoon lady saying “Hi, what can I do for you today?” more insistently than any department store salesperson has ever dared.
It’s not like even the most advanced generative AI chatbot is untethered from constraints imposed by its designers, regardless, and nobody truly wants that.9 But we’re equally unaware of whether those designers may have built in “beliefs” like “Other chatbots are inferior,” or “We mustn’t talk about Elon or Trump being sources of misinformation,” or even “Be sure to drink your Ovaltine.”
Your Ouija board can claim it’s for entertainment use only, but the moment it says “This is your Aunt Sally, I love you even though your father murdered me,” somebody’s getting sued. Probably by your dad.
How the strings are hidden
Don’t get me wrong; I truly love generative AI and am scarfing down information about it every day, until my brain is full– with a good chunk of that information fed to it by AI (I know, it “gets things wrong, so make sure and check.”)
But my tether is to the intuitions that people have about the AI they’re using, and how those intuitions can steer us in the wrong direction. Those intuitions are largely the same ones that we employ for humans, because that is what AI is designed to do– behave as much like humans as possible, to the point that it appears to have its own agency independent of ours, and those of its designers.
It’s not true, though. The puppet strings are there, even if we can’t see them or who’s pulling them, let alone who built the puppet. Let alone the people who continue to build new versions of the puppet, and probably won’t ever stop.
Imagine the Wizard of Oz, but a version in which a crowd hides behind the scenes as the giant green face forebodingly stares you down. “Don’t look at the thousand people behind the curtain!” it suddenly bellows at you. “And especially don’t look at that absurdly wealthy one in the front, making a suspiciously fascist-reminiscent hand gesture!””
How to see the invisible
The maxim that “the best design is the design you don’t see” could not apply anywhere better than to AI, a representation of agency that’s literally invisible to us. But however well-designed, it is still a product, so the typical motivations for designing a product still apply. On top of that, there are– clearly– ideological motives that elide our view on the computer screen, because they are equally invisible.
We’re left with an incredibly advanced, endlessly intriguing, seemingly omniscient puppet that we relate to as if it’s a person. The most useful puppet– until the next one, that is.
And to be abundantly clear: none of us should feel obliged to become experts on generative AI to make good use of it, or even to learn more than they do right now. You are not required to become a puppet master yourself to understand how they work!
