The United States is about to learn the hard way what happens when an entire generation of nurses retires without enough new clinicians to fill their shoes at the bedside.
As a result, hospitals in the same country that performed the first successful kidney transplant and pioneered anesthesia and heart rhythm restoration will have no choice but to ration care.
That’s the only way to describe what happened to an Alabama man who was turned away from 43 different hospitals across three different states before ultimately dying of a cardiac emergency 200 miles from home because no nearby system had an available intensive care bed it could staff. A spokesman for one hospital said the man “needed medical services that were not available.”
And it’s what happened to expecting mothers in Idaho earlier this year when the only hospital in the 8,000-person city of Emmett said it had become “unsustainably expensive to recruit and retain a full team of high-quality, broad-spectrum nurses to work.” That followed an earlier decision by an upstate New York facility to pause its maternity services after struggling to recruit enough replacements to offset staff resignations and retirements. The terrifying reality is that providers in every corner of the country have closed beds, units, and even entire facilities over an inability to adequately staff bedsides.
A nurse old enough to retire today has only known the U.S. health care system in a nursing shortage, but they’ll tell you it’s never been more challenging. It’s a crisis in five parts, including increased demand for care by an aging population and workforce, restraints that hinder nurses from practicing at the top of their licenses, lingering burnout from the pandemic, an inability to educate enough new nurses, and a recently throttled pipeline of qualified international talent.
To fill the gap in care left by retirements and burnout, federal economists calculate that the U.S. health care system will need to add at least 200,000 new nurses every year through 2026. We’ll be lucky to get half that. One workforce study predicted a shortage of more than 450,000 bedside nurses within the next two years. And as providers grapple with this desperate reality, a zero-sum race to the bottom will emerge in which suburban and urban hospitals raid already overburdened rural systems and long-term care facilities for talent.
Nursing schools reject tens of thousands of applicants every school year. It’s not because these would-be nurses failed to meet admission criteria—it’s largely because the schools don’t have enough nurse educators to train them. As limited instruction capacity squeezes the number of new matriculating nurses, hospitals have increasingly relied on foreign-educated nurses, who’ve grown to represent roughly 15% of the U.S. nursing workforce.
Employment-based health care immigration is a complex labyrinth of rules and regulations that doesn’t make it easy or fast for an international nurse to emigrate and begin treating American patients. Under current law, international nurses compete for the same limited number of employment-based green cards within an enormous pool of applicants that include IT workers, lawyers, engineers, and architects. Unlike those other workers, nurses do not qualify for temporary visas. So, while many computer engineers from other countries apply for green cards after moving to the U.S. and working under an H1-B visa, nurses must complete the immigration process entirely overseas.
Under the best conditions, that’s a multi-year process in which the nurse has passed English language and licensure exams, established a sterling overseas clinical record, and secured a job offer that has been demonstrated not to harm U.S. workers. Now, that timeline will grow significantly, thanks to a recent visa freeze instituted by the U.S. State Department.
The State Department tightly monitors the number of employment-based green cards issued against the remaining number for the fiscal year, which is set by Congress and has been untouched since 1990. Post-pandemic resurgent demand for this category recently forced State to issue a notice of visa retrogression, an immigration term of art that refers to eligibility backdating when demand exceeds equilibrium. As a result, any nurse who became eligible for their green card after June 1, 2022—which amounts to thousands of nurses who have been winding through the system for upwards of two years—is ineligible to enter the country until the backlog has cleared. In practical terms, American hospitals won’t be get the nurses they’ve been counting on any time soon.
Despite the urgency to get more nurses to the bedside, the State Department and the White House have zero discretion. The responsibility falls to Congress, which reserves the authority to issue visas and allocate them for specific immigrant preference categories. Each year, processing issues and other inefficiencies across various government agencies involved result in thousands of issued visas going unused. Health care advocates have begun pressing Congress to recapture some of these allocated-but-untouched green cards for the express use of immigrant nurses. There’s precedent: Congress did just that in 2000 and 2005.
More recently, one bipartisan proposal introduced last Congress, the Healthcare Workforce Resilience Act, would have set aside tens of thousands of these mothballing visas for nurses and doctors. But it didn’t pass, and a new version has yet to be reintroduced. According to the nonpartisan Congressional Research Service, there are roughly 220,000 employment-based visas that were available for recapture as of 2021.
The state of nursing in America is dire, and we’re doing nothing to correct it. Every young American who wants to be a nurse should be encouraged but we deny them a spot in school. Every qualified international nurse who wants to bring their skills and passion to this country should be greeted with open arms but are instead slow-walked through a senseless bureaucratic queue. It doesn’t make any sense.
The nursing shortage isn’t a red-vs-blue, rural-vs-urban issue. It’s not about the southern U.S. border or the gridlock that defines D.C. It’s about a pregnant mother getting the care she and her baby deserve. It’s about the heart attack patient not being turned away because the emergency room doesn’t have the nurses to treat him. This is a whole-of-America crisis and we need a whole-of-government response, including a sensible loosening of licensing requirements, prioritize positive patient outcomes by modernizing the responsibilities and standards of nursing, supporting expanded educational opportunities, and enabling lawful employment-based immigration.
America’s nursing shortage is a malignant tumor and you can’t ignore cancer; you’ve got to cut it out. Policymakers need to treat this crisis with the urgency it deserves—if we can’t heal our ailing health care system, we can’t heal our patients who need care most.
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