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.
It’s infuriating that I have to defend this profoundly unjust yet unfairly maligned, rights-violating, prison gate-keeping, Hollerith-ass, bureaucratic government-enforced insult to human dignity in app form, but here we are.
On Inauguration Day, January 20th, one of the first things Trump did was cancel the CBP One app— an app developed by Customs and Border Protection used by undocumented immigrants to secure an appointment at the southern border of the United States and thereby enter the country legally– most likely after JD Vance told him that it’s an “open border wand” that turns illegal immigrants into legal ones.1
What was that Arthur C. Clarke quote? “Any sufficiently advanced technology is indistinguishable from magic”?
I wouldn’t call CBP One advanced technology per se, but Vance clearly thinks of it as magical– very handy, because then you don’t have to learn how it actually works.
As I have documented in detail, the app works in much the same way that any app used to navigate entry into/exit out of the country works. It’s been a legal mandate for the U.S. to record entry and exit from the country by foreign nationals, since 1996-ish. The CBP One app uses facial recognition technology (FRT), tested initially (for this purpose) on air passengers traveling through checkpoints on their way to a flight.
The way it works is that a traveler gets their photo taken (usually a passport photo), which is then converted to a template used to check their identity against future images taken of them while traveling into/out of the country.
The template can also be used to identify travelers from amongst a group, for example from a flight manifest, to determine whether the person in the photo is in that group– and if so, which one is them. The engine that drives this process is called the Traveler Verification Service, or TVS.
Or this same biometric (identification based on physical distinguishing characteristics) technology could be used to capture images of migrants in Central Mexico and submitted to CBP along with their biographical information.
Then the images and information would be compared to vast databases maintained by the DHS to search all encounters at the border since the beginning of time (effectively) and check whether the migrant in question was involved in any of them. The image is further used for a “liveness check,” aka to verify the migrant’s identity after the appointment has been secured, to ensure that they’re the same person who made the appointment.
Why am I making this comparison?
To show how the technology used in the CBP One app mirrors what was already in use for, and was even initially tested on, citizens of other countries visiting the U.S. by air.
To show how rigorous the comparison process is– to the point that when it’s used on Americans,2 they become concerned for their own privacy and how that data is gathered and used. As they should be, frankly.
To show how, therefore, the claims that CBP One is somehow being used to allow “otherwise impermissible,” “illegal,” or even “criminal” immigrants into the country are unmitigated codswallop.
In fact, this app was, until recently, effectively the only way to enter the country legally.3 Even for asylum seekers, who are not just permitted but required, under U.S.4 and international law, to be physically present within the United States to apply for asylum, and have been since 1967.
That hasn’t been acknowledged in America for an extremely long time, but nevertheless– as rights become further and further violated, it becomes increasingly important to remember what they are.
But let’s snap back to the present, where CBP One,5 or at least its scheduling functionality (has it been used for much else? Hard to say) was shut down as of January 20 at noon.
And now we have a new DHS-developed technology– a registry6 that immigrants staying in the country for 30 days or long will be required to sign up for, providing biometric data in the form of fingerprints, to facilitate their “mass self-deportation.” Because yes, that’s the goal, according to a DHS statement7 issued Tuesday.
Compelling mass self-deportation8 is a safer path for aliens and law enforcement, and saves U.S. taxpayer dollars, in addition to conserving valuable Customs and Border Protection (CBP) and Immigration and Customs Enforcement (ICE) resources needed to keep Americans safe.
Here’s the part that nearly gave me an aneurysm, from newly-installed Secretary of DHS Kristi Noem:9
We’re just going to start enforcing it to make sure [the undocumented immigrants] go back home, And when they want to be an American, then they can come and visit us again.
I have some questions for Ms. Noem.
What does she think migrants are here to do in the first place? Has she tried asking them if they want to be Americans?
Has she offered them a route to citizenship? Did she send the invitation to “come and visit us again” out on pretty stationary, with an enclosed coupon for Cracker Barrel?
How are they supposed to “come visit us again” after they’ve been “mass deported” back to the same countries they tried to escape due to imminent threat to their lives and well-being, and the only way to “come back to visit” legally has just been obliterated before their eyes?
Did she tell them the Cracker Barrel’s door is locked with a deadbolt?
Under this plan, the illegal aliens will no longer get a free pass into our country by lodging meritless claims in seeking asylum. Instead, migrants seeking asylum will have to present themselves lawfully at a port of entry. So they’re going to have to lawfully present themselves at a port of entry. Those who choose to break our laws and enter illegally will no longer be able to use meritless claims to gain automatic admission into our country. We will hold them — for a long time, if necessary.
Did he mean it?
Does he remember saying it?
Does it matter?
The First Lady broke immigration laws,11 as did the Co-President,12 but nobody’s demanding their fingerprints and encouraging them to “self-deport.”
And yet undocumented immigrants are forced to live in a tautology where they will be “illegal” no matter what they do, while the shining promise of existing in America legally isn’t just out of reach, but is dangled teasingly over their heads by the government of the same country with a mandate to welcome them in– the poor, the tired, the huddled masses yearning to breathe free. The people seeking a better life than they could have in the “shithole countries”13 (remember that?) from whence they came.
While I might consider the CBP One app to be a cruel joke, when it was first used to assist migrants, it was as a way for NGOs (non-governmental organizations) to locate those who had been forced into Mexico by the previous Trump administration as part of the so-called Migrant Protection Protocols, and bring them back to the border for a hearing. It was a tool used for collaboration between DHS and NGOs, to make sure that at least some of the migrants who have a right to enter the country were allowed to exercise it
It was a way to be slightly less gratuitously cruel to people, existing in a state of greater desperation than anyone in DHS personally could fathom, who just want to find safety and create a better life.
And now that’s gone, everything’s made up, and the law doesn’t matter.
But maybe I can spend the second half of this post saying something constructive. Some things that might actually help:
Stay informedand make good judgments. I know, I know, it’s a horrorshow that can be unbearable to watch/read/listen. But for example, it’s important to know when ICE isn’t going to raid your local church or school because they’re not allowed to raid “sensitive locations,” and you can avoid raising a panic unnecessarily. If you know when to be scared, and how much, that alleviates some of the “scared at 11, 24/7” feeling that will drive you into the ground.
Help out the organizations doing the work. I strongly recommend the Immigration Council, who are working their asses off to seek justice for migrants and deserve every dollar you care to donate. Sign up for a newsletter so you don’t have to keep wading through the shouting and rhetoric to learn what’s actually happening with immigration.
Show up for “sanctuary policies” at a city council meetings and anywhere in your community having discussions on that topic14 to learn what protections can be provided under those policies for migrants in your area. Remind people, if necessary, that sanctuary jurisdictions are in full compliance with federal law. Don’t let your local government and law enforcement get bullied into doing ICE’s dirty work.
Remind people of how immigration is supposed to work. How America is founded on immigration, and how it was once possible to just “show up” at Ellis Island, get checked out by a doctor, and saunter your way in. Show them this video of George H.W. Bush and Ronald Reagan arguing, in a debate at the League of Women Voters in 1980, about who had a more compassionate and reasonable policy for how to make migrants feel welcome in America, and watch their heads explode.
Find common ground
Find somebody you disagree with about immigration, sit down with them, and do this:
Make some choices about how it should work, if it were totally up to you. No basing arguments on facts not in evidence (also known as BSing), and no predictions.
Make your rules clear to each other. You don’t have to agree– you just need to fully understand where each other stands. When you reach the point of “I hear you saying this,” followed by “Yes, that’s exactly what I’m saying,” you’ve calibrated correctly.
Look up how it actually works. Look at how it’s handled elsewhere in the world, and how it’s been handled before.15
Look up what the conditions, the stats, etc., actually are. Learn about the countries and cultures that asylum seekers and refugees are emigrating from.
Go back to the rules you created earlier, and re-evaluate. Amend the rules accordingly. Takesies-backsies are not just allowed, but encouraged.
This is the hard part: Reconcile how things are with how you want them to be. Explain how doing things your way would make it better– not just better than the status quo, but better than what your partner has in mind.
This is a conversation about how to treat populations of other people who are not necessarily any more similar to each other than you are to that neighbor you hate for letting his dog poop in your yard. Probably a lot less, actually.
So as an added layer of difficulty, stimulate those empathy muscles and walk through all six steps with a hypothetical family in mind, rather than a faceless mass. Give them names, nationalities, motivations. Then imagine how they fare, according to your rules, the current rules, your partner’s rules, etc.
There is no possible way to say “Good luck with that” with the earnest intensity that I mean to put behind it. It’s going to sound dismissive no matter what. But with every fiber of my being, and every ounce of sincerity that is possible to convey, I nevertheless say: Good luck with that.
The U.S. is is bound by the 1951 Refugee Convention (through its adoption of the 1967 Protocol) and the Immigration and Nationality Act (INA), which explicitly allows anyone physically present in the U.S.—regardless of how they arrived—to apply for asylum. ↩︎
If you’re in the United States for reasons beyond your control– that is, you didn’t decide to come here on your own, pay for it on your own, and physically get yourself here on your own– you’re entitled to the rights and responsibilities of U.S. citizenship. Additionally, if you’re in custody of the U.S. in some way or another, the same goes. If it’s a bunch of Americans who are patrolling outside the cell where you’re spending day after day, year after year, even decade after decade, you deserve the kind of rights that every native-born American, living out his or her entire life on American soil, enjoys or should enjoy (and can sue if he/she doesn’t receive). Like, you know, the right to due process.
All right? Because that’s how a civilized country behaves.
A civilized country does not act as if people from other places are inhuman because they weren’t lucky enough to burst into existence in a hospital room on American soil or haven’t yet gotten the chance to complete the lengthy, tortuous, and utterly capricious experience of becoming a naturalized citizen.
A civilized country does not capture people and lock them up for years without charge or trial, regardless of where it found them or under what circumstances. It finds the time to actually figure out what they supposedly did to merit being locked away from anyone they know or even anyone who speaks their language, officially tells them what it is, and determines whether they’re guilty of it. Then releases or punishes them accordingly.
A civilized country remembers that the tired and huddled masses yearning to breathe free are going to want to breathe its free air so long as such a thing exists. It does not respond by vacuuming all of it out and providing oxygen tanks to a selected few favored people, so that the undesirables can properly suffocate. It does not whine “They hate us for our freedoms” and proceed to eliminate those freedoms so that there’s nothing left to hate.
And a civilized country would never be so cruel, so inhuman, so devoid of any shred of empathy, that it would fight to deny the ability of people who were brought here without any intention of their own, as children, to remain in that country instead of sending them packing to go live in a location and culture that’s alien to anything they’ve ever known.
