In another blow to a floundering nursing home workforce shortage, the State Department last month froze green card processes for international nurses.
According to a bulletin from the federal office, only green card petitions filed earlier than June 2022 will proceed to the interview stage – all others will be paused indefinitely. Clif Porter, SVP of government relations with AHCA/NCAL, said the backlog of international nurses was synonymous with a backlog of seniors seeking to receive care in nursing homes across the country.
“At a time when the Administration plans to propose a federal staffing mandate for nursing homes, Washington should not simultaneously create barriers to recruit the nurses we so urgently need,” Porter said when the news was first announced.
Skilled Nursing News sat down with Porter to discuss what the association has been doing since the news broke to work around yet another roadblock for SNF operators.
This conversation has been edited for length and clarity.
Skilled Nursing News: Why did the State Department freeze green cards for international nurses when they know the industry faces workforce shortages?
Clif Porter: I think it’s the classic situation where you have certain standardized rules that are in place, and unfortunately, those rules sometimes impact the area that you really don’t want to be impacted. We’re in a situation where we’ve got what you call retrogression occurring, which essentially means that the demand for immigrant visas has exceeded the supply, so they more or less moved the date to limit the applicants.
So it’s a matter of catching up with applications?
They didn’t create the rule to negatively impact us, but unfortunately it has. And based on the shortage that we’ve had, in our sector, in health care writ large, there’s been a lot of work at trying to get more international nurses within our borders.You got all these different health care organizations working to get nurses from other countries to come here. Once all that begins to happen, you get to a place where you exceed these thresholds and a freeze occurs. That’s basically what we’re dealing with. I don’t view it necessarily as an action per se, that the administration did to specifically hinder our efforts, I think it’s something that has been in place and it needs to be changed to be consistent with the times.
How much of a setback will this be?
It’s really hard to say. There are 5,000 nurses or so that are waiting to have their visas processed to come to the country. We don’t have that number divvied up by sector of health care so it’s hard for me to say how many of those 5,000 were long-term care specific. Some are for sure. There has been a significant effort and will continue to be to increase foreign nurses in our sector. Obviously, this rule inhibits our ability to do that effectively.
Why is the visa freeze such a blow to the nursing home industry, and to the United States?
It’s such a multifaceted challenge. It’s really, really tough. We basically have a very similar education crisis for nurses, RNs in particular, described as related to the access problems.
That’s why this visa issue is so important.
Education bottlenecks play a role in the staffing crisis too?
University programs can only allocate a certain number of people at a time because you need professors that provide a certain amount of clinical time to train the nurse. Unfortunately, there’s a shortage of these particular professionals. As a result, the access to the programs are significantly restricted to much smaller classes – you’re training far fewer people than you probably could based on demand. People want to go to nursing school, that want to get in, but they don’t get in. You may have 150 that are academically qualified to be in the program, but you can’t take them because you don’t have the space. And you don’t have the instructors to teach them. That creates capacity limits which restricts the number of graduate nurses. Getting nurses even domestically is problematic and has its own challenges that we’ve got to fix.
Does there seem to be conflicting messages, with the Biden administration calling for a staffing mandate and the State Department freezing visas?
Conflicting for sure. We’ve got to start thinking across silos. Unfortunately, decisions are made in silos and there’s not always the necessary thoughts of what the downstream implications are. HHS and CMS are all under one agency. You start looking at the State Department and that’s where things can get very convoluted. It’s our hope that we can get the two agencies connected.
Do you see policy continuing in this direction, even as the workforce shortage persists?
For now, yes, it will continue. We’re going to have to do our work – elevating the issue, which we are doing and will continue to do, to advocate along with other health care organizations. The issue is, having to wait to get your visa outside of the country. It’s not the most efficient way to address it. We’re not necessarily saying there shouldn’t be a process, there should be, but why not have them come to the country and start working and wait [to get their visa] versus having them wait outside of the country. That’s the problem we have. Other categories of workers, more technological type workers, have the ability based on their visa process to come into the country and wait on their visa. As a result, they get to work while they’re waiting for the paperwork to go through. In the case of nurses, that’s not the case.
You said in an AHCA statement that the backlog of international nurses was synonymous with a backlog of seniors awaiting care. Anything more you’d like to say on the visa freeze and access issues?
It’s a critical issue. And it’s something that people aren’t thinking about. Capacity is a real issue. We don’t have a bed capacity issue, meaning that we have the necessary resources, and capacity and licensure to meet the needs of seniors and other folks who need our health care in America. The problem is, we don’t have enough staff to meet those needs.
How does that translate to access issues?
You have a couple of things happening. First is closures, particularly in rural markets. Kansas is one state that has been particularly impacted, Montana is another. When you look at rural America in particular, what ultimately happens is that you have a situation where you don’t have enough staff, or you’re pretty hard pressed anyway, you had the pandemic which further put pressure on your staffing levels and then you really don’t have a way out.
What have rural providers had to do in these cases?
As a result, you have to close a wing. Once you close a wing, it’s just a matter of time before you run out of resources, and then the whole operation is at risk. That’s the capacity issue that ultimately leads to closures in our settings, specifically in long-term care. But there’s an upstream of that – and that’s something that folks often miss. If I’ve closed a wing, that’s that many less beds that are available for hospital to discharge patients to, therefore those patients sit inappropriately in a hospital bed, taking up hospital capacity. As a result, folks that need elective surgeries or other types of procedures, that can wait, wait. And they often will have their access impeded, because you have beds occupied by patients that otherwise should be out.
What are the workarounds or contingency plans since this avenue to get immigrant nurses has been somewhat blocked?
Unfortunately we deal with agency staff to fill the gap. That system, that unsustainable model just doesn’t work. It worked for a minute – but that’s at an extremely high cost and it’s really just a temporary solution. So this is a real problem. In my opinion, [immigration processes] can be pretty easily fixed. These categories would change to where you are allowed to bring the nurse here and they still go through the immigration process as they should, and the steps that are needed, but they can actually be here working while they’re working through that process. That would help significantly. It doesn’t feel like a heavy lift.
What needs to happen to get everyone on the same page?
It’s a matter of really trying to work with all of the different agencies, elevating the issue, collaborating with the hospital association or other associations, and then going [to Congress] collectively, articulating the story, and then more importantly, magnifying when closures and the consequences of not fitting this happen.
That’s happening now?
We’re doing a lot of that, making sure that policymakers understand exactly what’s going on in the marketplace. And the good news is members of Congress are definitely getting sensitized to this and are starting to elevate, make noise. I think we just have to continue the pressure, and continue articulating our message and continue to be aggressive so that we can push through the bureaucracy – ultimately, then, the rules change. It’s every facet of the legislature, it’s the administration, it’s the State Department. It’s a variety of agencies. But not everybody understands the problem. We have got to get good minds focused on fixing it.
Will immigration policy ever end up more in line with what the industry needs?
I will say that, as a country, particularly from a policy perspective, everybody was really working hard together in real time to try to solve these problems [early in the pandemic.] We’ve got to start thinking about our recovery from the pandemic in the same way. The urgency around solving some of the what are called consequential problems from the pandemic aren’t necessarily held to the same level of urgency. I’m hopeful that we start thinking about this, apply the same principles we did in the midst of the crisis on recovering from the crisis, and ultimately build an infrastructure for the future.
