Abstract
This national survey study uses US Census Bureau data to estimate the proportion of non–US-born and noncitizen health care professionals in the United States in 2016.
National estimates of the proportion of current health care professionals, including physicians, who are non–US-born or noncitizens are unknown. These proportions may be significant. For example, non–US-born medical graduates comprise approximately one-fifth of practicing US physicians,1,2 and among non–US-born medical graduates who match into residency positions in the United States, approximately 60% are not US citizens.3 Using data from the US Census, this study estimated the proportion of non–US-born and noncitizen health care professionals in the United States in 2016.
Methods
The Harvard institutional review board waived review for this study. Analyses used data from the American Community Survey (ACS), an annual, nationally representative, US Census Bureau–administered survey of US households. The survey, which had a 94.7% response rate in 2016, is collected by mail, telephone, and personal-visit interviews and includes information on all household members.4
Individuals in self-reported health care occupations were included (for list of occupations, see Table 1) based on the US census classification scheme. Non–US-born individuals were defined as those who reported not being born in the United States or US territories and noncitizens were defined as those who were non–US-born who reported not being a US citizen (noncitizens were therefore a subset of non–US-born). First, the proportions of individuals in each health care occupation category who were non–US-born or noncitizens were calculated. Then the proportion of all and selected health care professionals by region of birth was calculated. ACS-provided replicate weights and the complex survey modules in Stata (StataCorp), version 14.2, were used to account for the complex survey design of the ACS.
Table 1. Percentage of US Health Care Professionals Who Were Non–US-Born or Noncitizens, by Health Care Occupation, 2016a.
| Health Care Occupation | No. of Health Care Professionals Surveyed, Unweighted | Health Care Professionals, Weighted % (95% CI) | |
|---|---|---|---|
| Non–US-Born | Noncitizensb | ||
| Medical and health service managers | 7709 | 14.0 (12.8-15.2) | 3.4 (2.7-4.1) |
| Psychologists | 2502 | 9.5 (8.0-11.0) | 2.0 (1.3-2.7) |
| Counselors (including mental health) | 9532 | 10.1 (9.4-10.9) | 3.2 (2.7-3.7) |
| Chiropractors | 627 | 10.8 (6.9-14.7) | 3.0 (1.4-4.6) |
| Dentists | 1975 | 23.7 (21.1-26.2) | 3.9 (2.8-5.0) |
| Dietitians and nutritionists | 1223 | 17.4 (14.7-20.1) | 7.7 (5.7-9.6) |
| Optometrists | 461 | 16.2 (11.3-21.0) | 1.9 (0.9-2.9) |
| Pharmacists | 3610 | 20.3 (18.8-21.7) | 3.7 (2.9-4.4) |
| Physicians | 10 607 | 29.1 (28.0-30.3) | 6.9 (6.3-7.5) |
| Physician assistants | 1080 | 12.7 (10.0-15.4) | 2.6 (1.2-4.0) |
| Podiatrists | 100 | 11.1 (1.9-20.2) | 0.0 (0.0-0.0) |
| Audiologists | 180 | 5.9 (2.3-9.4) | 1.9 (0.0-4.1) |
| Occupational therapists, physical therapists, and other therapistsc | 9234 | 12.5 (11.6-13.4) | 3.3 (2.9-3.8) |
| Veterinarians | 1008 | 7.3 (5.4-9.3) | 2.5 (1.4-3.6) |
| Registered nurses | 36 796 | 16.0 (15.5-16.6) | 3.3 (3.0-3.6) |
| Nurse anesthetists | 380 | 8.4 (4.8-12.1) | 1.6 (0.0-3.6) |
| Nurse practitioners and nurse midwives | 1875 | 10.7 (9.2-12.2) | 1.3 (0.8-1.8) |
| Health diagnosing and treating practitioners, all other | 372 | 31.1 (25.6-36.5) | 9.2 (5.6-12.8) |
| Health practitioner support technologists and technicians, health diagnosing and treating practitioner support technicians | 6749 | 12.8 (11.8-13.9) | 3.3 (2.7-3.9) |
| Licensed practical and licensed vocational nurses | 10 167 | 15.0 (14.2-15.9) | 4.0 (3.5-4.5) |
| Other health technologists, technicians, and health care practitionersd | 18 825 | 13.1 (12.5-13.6) | 3.2 (2.9-3.6) |
| Nursing, psychiatric, and home health aides | 22 463 | 23.1 (22.4-23.7) | 8.7 (8.2-9.2) |
| Occupational and physical therapy assistants and aides | 1448 | 9.0 (7.1-10.8) | 2.4 (1.5-3.3) |
| Dental assistants | 3235 | 16.5 (14.9-18.0) | 5.5 (4.6-6.4) |
| Medical assistants | 5307 | 17.3 (16.0-18.5) | 5.6 (4.8-6.3) |
| Other health care support occupationse | 6657 | 14.7 (13.6-15.8) | 5.5 (4.8-6.3) |
| Total | 164 122 | 16.6 (16.4-16.8) | 4.6 (4.4-4.7) |
Based on data from the US Census Bureau’s American Community Survey (ACS) in 2016. Estimates use ACS-provided replicate weights to account for the complex survey design and are nationally representative.
Noncitizen health care professionals were a subset of non–US-born health care professionals.
Other therapists include radiation therapists, recreational therapists, respiratory therapists, speech language pathologists, exercise physiologists, and other therapists.
Includes clinical laboratory technologists and technicians; dental hygienists; diagnostic related technologists and technicians; emergency medical technicians and paramedics; medical records and health information technicians; dispensing opticians; miscellaneous health technologists and technicians; medical, dental, and ophthalmic laboratory technicians; and other health care practitioners and technical occupations.
Includes massage therapists, medical transcriptionists, pharmacy aides, veterinary assistants, and laboratory animal caretakers, phlebotomists, medical equipment preparers, and other health care support workers.
Results
Our sample included 164 122 health care professionals (which represented 5.2% of the 3 156 487 household members surveyed in the ACS in 2016). Of all US health care professionals, 16.6% (95% CI, 16.4%-16.8%) were non–US-born and 4.6% (95% CI, 4.4%-4.7%) were noncitizens. Non–US-born health care professionals comprised a substantial proportion of several professions: dentists (23.7%; 95% CI, 21.1%-26.2%); pharmacists (20.3%; 95% CI, 18.8%-21.7%); physicians (29.1%; 95% CI, 28.0%-30.3%); registered nurses (16.0%; 95% CI, 15.5%-16.6%); and nursing, psychiatric, and home health aides (23.1%; 95% CI, 22.4%-23.7%) (Table 1). Noncitizens were also represented considerably among dietitians and nutritionists (7.7%; 95% CI, 5.7%-9.6%); physicians (6.9%; 95% CI, 6.3%-7.5%); nursing, psychiatric, and home health aides (8.7%; 95% CI, 8.2%-9.2%); medical assistants (5.6%; 95% CI, 4.8%-6.3%); and dental assistants (5.5%; 95% CI, 4.6%-6.4%) (Table 1). The majority of health care professionals not born in the United States emigrated from Asia (6.4%; 95% CI, 6.2%-6.5%) or Central America or the Caribbean (4.7%; 95% CI, 4.6%-4.8%) (Table 2). Nursing, psychiatric, and home health aides emigrated predominantly from Central America or the Caribbean (11.7%; 95% CI, 11.2%-12.2%).
Table 2. Distribution of Select US Health Care Professionals by Region of Birth, 2016a.
| Region of Birth | All Health Care Professionals | Select Health Care Professionals, Weighted % (95% CI) | |||||
|---|---|---|---|---|---|---|---|
| No. Surveyed, Unweightedb | Weighted % (95% CI) | Physicians and Surgeons | Dentists | Registered Nurses | Nursing, Psychiatric, and Home Health Aides | Pharmacists | |
| United States or US territory | 139 270 | 83.4 (83.1-83.6) | 70.9 (69.7-72.0) | 76.3 (73.7-78.8) | 84.0 (83.4-84.5) | 76.9 (76.2-77.5) | 79.7 (78.2-81.2) |
| Canada | 756 | 0.4 (0.4-0.5) | 1.1 (0.9-1.4) | 0.8 (0.4-1.4) | 0.6 (0.5-0.7) | 0.1 (0.1-0.2) | 0.5 (0.3-0.7) |
| Africa | 2094 | 1.7 (1.6-1.9) | 2.2 (1.9-2.6) | 1.4 (0.9-2.4) | 1.8 (1.6-2.0) | 3.4 (3.1-3.8) | 2.8 (2.1-3.7) |
| Asia | 10 247 | 6.4 (6.2-6.5) | 17.7 (16.7-18.6) | 14.1 (12.2-16.3) | 7.8 (7.4-8.3) | 4.4 (4.1-4.8) | 12.2 (11.0-13.6) |
| Australia or Pacific Islands | 127 | 0.1 (0.1-0.1) | 0.1 (0.0-0.2) | 0.0 (0.0-0.4) | 0.1 (0.1-0.1) | 0.1 (0.0-0.1) | 0.1 (0.0-0.3) |
| Europe | 3660 | 2.3 (2.2-2.4) | 4.2 (3.7-4.7) | 2.9 (2.1-4.0) | 2.2 (2.0-2.4) | 1.9 (1.6-2.2) | 2.5 (2.0-3.2) |
| Mexico and Central America or Caribbean | 6384 | 4.7 (4.6-4.8) | 2.5 (2.1-3.0) | 2.5 (1.7-3.6) | 2.8 (2.6-3.1) | 11.7 (11.2-12.2) | 1.4 (1.1-1.9) |
| South America | 1577 | 1.0 (1.0-1.1) | 1.5 (1.2-1.8) | 2.0 (1.2-3.1) | 0.8 (0.6-0.9) | 1.5 (1.3-1.7) | 0.7 (0.4-1.1) |
Based on data from the US Census Bureau’s American Community Survey (ACS) in 2016. Estimates use ACS-provided replicate weights to account for the complex survey design and are nationally representative.
The numbers surveyed for all health care professionals do not sum to 164 122 because there are 7 health care professionals for whom birthplace was unknown.
Discussion
In a nationally representative sample, non–US-born individuals and noncitizens comprised a significant proportion of many health care professions in 2016. These proportions were notable not only among physicians, on which previously conducted studies have focused,1 but also among the majority of other health care occupations that are important for patient care. As the US population ages, there will be an increased need for many health care professionals, particularly those who provide personal care like home health care aides, a large proportion of whom are currently non–US-born. Limitations of this study include reliance on survey-reported occupation, the possibility of underreporting of non-citizenship by certain subgroups, which has been documented previously with the ACS, and lack of detailed physician specialty information.5
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
- 1.Khullar D, Blumenthal DM, Olenski AR, Jena AB. US immigration policy and American medical research: the scientific contributions of foreign medical graduates. Ann Intern Med. 2017;167(8):584-586. doi: 10.7326/M17-1304 [DOI] [PubMed] [Google Scholar]
- 2.Pinsky WW. The importance of international medical graduates in the United States. Ann Intern Med. 2017;166(11):840-841. doi: 10.7326/M17-0505 [DOI] [PubMed] [Google Scholar]
- 3.Educational Commission for Foreign Medical Graduates ECFMG fact card: summary data related to ECFMG certification. https://www.ecfmg.org/forms/factcard.pdf. Accessed July 24, 2018.
- 4.US Census Bureau American Community Survey (ACS): methodology. https://www.census.gov/programs-surveys/acs/methodology.html. Accessed October 23, 2018.
- 5.Van Hook J, Bachmeier JD. How well does the American Community Survey count naturalized citizens? Demogr Res. 2013;29(1):1-32. doi: 10.4054/DemRes.2013.29.1 [DOI] [PMC free article] [PubMed] [Google Scholar]