By Arielle Zionts for KFF Health News.
Broadcast version by Zamone Perez for Virginia News Connection reporting for the KFF Health News-Public News Service Collaboration

A growing number of states have made it easier for doctors who trained in other countries to get medical licenses, a shift supporters say could ease physician shortages in rural areas.

The changes involve residency programs — the supervised, hands-on training experience that doctors must complete after graduating medical school. Until recently, every state required physicians who completed a residency or similar training abroad to repeat the process in the U.S. before obtaining a full medical license.

Since 2023, at least nine states have dropped this requirement for some doctors with international training, according to the Federation of State Medical Boards. More than a dozen other states are considering similar legislation.

About 26% of doctors who practice in the U.S. were born elsewhere, according to the Migration Policy Institute. They need federal visas to live in the U.S., plus state licenses to practice medicine.

Proponents of the new laws say qualified doctors shouldn’t have to spend years completing a second residency training. Opponents worry about patient safety and doubt the licensing change will ease the doctor shortage.

Lawmakers in Republican- and Democratic-leaning states have approved the idea at a time when many other immigration-related programs are under attack. They include Florida, Iowa, Idaho, Illinois, Louisiana, Massachusetts, Tennessee, Virginia, and Wisconsin.

President Donald Trump has defended a federal visa program that many foreign doctors rely on, but they could still be hampered by his broad efforts to tighten immigration rules.

Supporters of the new licensing laws include Zalmai Afzali, an internal medicine doctor who finished medical school and a residency program in Afghanistan before fleeing the Taliban and coming to the U.S. in 2001.

He said most physicians trained elsewhere would be happy to work in rural or other underserved areas.

“I would go anywhere as long as they let me work,” said Afzali, who now treats patients who live in rural areas and small cities in northeastern Virginia. “I missed being a physician. I missed what I did.”

It took Afzali 12 years to obtain copies of his diploma and transcript, study for exams, and finish a three-year U.S.-based residency program before he could be fully licensed to practice as a doctor in his new country.

But a commission of national health organizations questions whether loosening residency requirements for foreign-trained doctors would ease the shortage. Doctors in these programs could still face licensing and employment barriers, it wrote in a report that makes recommendations without taking a stance on such legislation.

Erin Fraher, a health policy professor at the University of North Carolina who advises the commission and studies the issue, said lawmakers who support the changes predict they will boost the rural health workforce. But it’s unclear whether that will happen, she said, because the programs are just getting started.

“I think the potential is there, but we need to see how this pans out,” Fraher said.

Afzali struggled to support his family while trying to get his medical license. His jobs included working at a department store for $7.25 an hour and administering chemotherapy for $20 an hour. Afzali said nurse practitioners at the latter job had less training than him but earned nearly four times as much.

“I do not know how I did it,” he said. “I mean, you get really depressed.”

Many of the state bills to ease residency requirements have been based on model legislation from the Cicero Institute, a conservative think tank that sent representatives to testify to legislatures after proposing such programs in 2020.

The new pathways are open only to internationally trained physicians who meet certain conditions. Common requirements include working as a physician for several years after graduating from a medical school and residency program with similar rigor to those found in the U.S. They also must pass the standard three-part exam that all physicians take to become licensed in the U.S.

Those who qualify are granted a restricted license to practice, and most states require them to do so under supervision of another physician. They can receive full licensure after several years.

About 10 of the laws or bills also require the doctors to work for several years in a rural or underserved area.

But states without this requirement, such as Tennessee, may not see an impact in rural areas, researchers from Harvard Medical School and Rand Corp. argued in the New England Journal of Medicine. In addition to including that condition, states could offer incentives to rural hospitals that agree to hire doctors from the new training pathways, they wrote.

Lawmakers, physicians, and health organizations that oppose the changes say there are better ways to safely increase the number of rural doctors.

Barbara Parker is a registered nurse and former Republican lawmaker in Arizona, where the legislature is considering a bill for at least the fourth year in a row.

“It’s a really poor answer to the doctor shortage,” said Parker, who voted against the legislation last year.

Parker said making it easier for foreign-trained physicians to practice in the U.S. would unethically poach doctors from countries with greater health care needs. And she said she doubts that all international residencies are on par with those in the U.S. and worries that granting licenses to physicians who trained in them could lead to poor care for patients.

She is also concerned that hospitals are trying to save money by recruiting internationally trained doctors over those trained in the U.S. The former often will accept lower pay, Parker said.

“This is driven by corporate greed,” she said.

Parker said better ways to increase the number of rural doctors include raising pay, expanding loan repayment programs for those who practice in rural areas, and creating accelerated training for nurse practitioners and physician assistants who want to become doctors.

The advisory commission — recently formed by the Federation of State Medical Boards, the Accreditation Council for Graduate Medical Education, and Intealth, a nonprofit that evaluates international medical schools and their graduates — published its recommendations to help lawmakers and medical boards make sure these new pathways are safe and effective.

The commission and Fraher said state medical boards should collect data on the new rules, such as how many doctors participate, what their specialties are, and where they work once they gain their full licenses. The results could be compared with other methods of easing the rural doctor shortage, such as adding residency programs at rural hospitals.

“What is the benefit of this particular pathway relative to other levers that they have?” Fraher said.

The commission noted that while state medical boards can rely on an outside organization that evaluates the strength of foreign medical schools, there isn’t a similar rating for residency programs. Such an effort is expected to launch in mid-2025, the commission said.

The group also said states should require supervising physicians to evaluate participants before they’re granted a full license.

Afzali, the physician from Afghanistan, said some internationally trained primary care doctors have more training than their U.S. counterparts, because they had to practice procedures that are done only by specialists in the U.S.

But he agreed with the commission’s recommendation that states require doctors who did residencies abroad to have supervision while they hold a provisional license. That would help ensure patient safety while also helping the physicians adjust to cultural differences and learn the technical side of the U.S. health system, such as billing and electronic health records, the commission wrote.

Fraher noted that doctors in programs with supervision requirements need to find an experienced colleague with the time and interest in providing this oversight at a health facility willing to hire them.

The commission pointed out other potential hurdles, such as malpractice insurers possibly declining to cover physicians who obtain state licenses without completing a U.S. residency. The commission and the American Board of Medical Specialties also pointed to the issue of specialty certification, which is managed by national organizations that have their own residency requirements.

Physicians who aren’t eligible to take board exams could lose out on employment opportunities, and patients might have concerns about their qualifications, the board wrote. But it said a majority of its member boards would consider certifying these doctors if states added requirements it recommended.

Lawmakers’ plans to use these new licensing pathways to increase the number of rural doctors will require the foreign-trained doctors to navigate all these obstacles and unknowns, Fraher said.

“There’s a lot of things that need to happen to make this a reality,” she said.


Arielle Zionts wrote this story for KFF Health News.


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New documents obtained through a Freedom of Information Act lawsuit showed how U.S. Immigration and Customs Enforcement plans to expand immigrant detention centers in Colorado.

Centers are planned for Hudson and La Junta, and Colorado Springs and Walsenburg would each get two facilities, all run by private firms.

Tim Macdonald, legal director for the ACLU of Colorado, said ICE should not be outsourcing centers to for-profit companies such as GEO Group, which runs a facility in Aurora with a history of civil rights abuses and lack of medical care.

"That's a terrible model," Macdonald contended. "We should not put profits on the backs of immigrants, it creates an incentive to detain more innocent men, women and children."

Macdonald pointed to a 2019 report documenting abuse, neglect and even death at GEO's Aurora detention center. In 2024, the family of Melvin Mendoza filed a wrongful-death lawsuit against the facility for failing to diagnose and treat a blood clot in Mendoza's leg. GEO did not respond to questions about the Mendoza suit but said by email they are proud of their 40 years of work with ICE and strictly comply with ICE detention standards.

President Donald Trump campaigned on the promise of mass deportations and as of last week more than 56,000 people have been detained, according to a Transactional Records Access Clearinghouse analysis of ICE data, which also found more than 70% of people being detained have no criminal record. Macdonald noted Trump also promised to prioritize deporting violent criminals.

"We know that's not happening," Macdonald pointed out. "They are detaining and removing grandmothers, pregnant women. In fact the evidence is that most of the people they are detaining and deporting have no criminal record whatsoever."

The new GOP tax and spending law includes $170 billion for immigration enforcement and $45 billion, an amount larger than the entire federal prison system's budget, is earmarked for expanding detention centers to hold more than 100,000 people per day.


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No matter their legal status, Albuquerque wants immigrants to feel safe in New Mexico's largest city and has unveiled a new executive order to make it happen.

Tim Keller, mayor of Albuquerque, said the order clarifies and strengthens city policies against fraud and impersonators, including directing police to go after anyone pretending to be an ICE agent. Keller stressed policy enhancements underscore the city's dedication to uphold the rights and dignity of community members and defend them from intimidation.

"Whether it is ICE agents popping out of vans wearing masks rounding up people who are not even immigrants, who are Native Americans, who are legally here in the city, whether it's McDonald's or it's Walmart," Keller outlined. "This has nothing to do with immigration policy; this is more like terror."

Over the weekend, the head of ICE said he will continue allowing the controversial practice of his officers wearing masks over their faces during their arrest raids. Keller noted there are 20,000 immigrants in the city who annually contribute more than $5 billion in economic activity.

Fabiola Landeros, community organizer of immigration for the nonprofit El Centro, first got in touch with the immigrant workers' rights group when her brother was deported. She said the Trump administration's mass deportation policy is creating fear, chaos and suffering, affecting families, public safety and health, the educational system and the economy.

"ICE is disappearing people," Landeros pointed out. "Imagine feeling afraid every time you leave your home, that you will be disappeared, separated from your children, or that you could be held in a detention center in a country that you're not from. This is against our collective values."

Data show at least 16% of the city's small businesses are run by immigrants. On Sunday, about 300 protesters gathered to demonstrate outside an Albuquerque Walmart where earlier this month ICE agents tased a man they were attempting to arrest.


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By Claudia Boyd-Barrett for KFF Health News.
Broadcast version by Suzanne Potter for California News Service reporting for the KFF Health News-Public News Service Collaboration

For months, Maria, 55, a caregiver to older adults in California’s Orange County, has been trying not to smile.

If she opens her mouth too wide, she worries, people will see her chipped, plaque-covered front teeth. An immigrant without legal status, Maria doesn’t have health or dental insurance. When her teeth start to throb, she swallows pain pills. Last summer, a dentist said it would cost $2,400 to fix her teeth. That’s more than she can afford.

“It’s so expensive,” said Maria, who often works 12-hour days lifting clients in and out of bed and helping them with hygiene, medication management, and housework. “I need money for my kids, for my rent, for transport, for food. Sometimes, there’s nothing left for me.”

KFF Health News connected with Maria through an advocacy organization for immigrant workers. Fearing deportation, she asked that only her first name be used.

Maria is among what the federal government estimates are 2.6 million immigrants living in California without legal status. The state had gradually sought to bring these immigrants into its Medicaid program, known as Medi-Cal. But now, facing a state enrollment freeze, low-income California residents in the U.S. without legal permission — along with the providers and community workers that help them — are anxiously weighing the benefits of pushing forward with Medi-Cal applications against the risks of discovery and deportation by the federal government.

Seeking to close a projected $12 billion budget deficit, California Gov. Gavin Newsom, a Democrat, signed a balanced state budget on June 27 that will end new Medi-Cal enrollment in January 2026 for those over 19 without legal status.

Meanwhile, federal immigration raids — which appear to have targeted at least one health clinic in the state — are already making some people afraid to seek medical care, say immigrant advocates and health providers. And the recent news that Trump administration officials are sharing Medicaid enrollee data, including immigration status, with deportation authorities is expected to further erode trust in the program.

U.S. Department of Health and Human Services spokesperson Andrew Nixon said the agency, which oversees the Centers for Medicare & Medicaid Services, had the legal authority to share the data to address “unprecedented systemic neglect under the Biden-Harris administration that allowed illegal immigrants to exploit Medicaid while millions of Americans struggle to access care, particularly in states like California.”

Further complicating matters, the Trump administration has threatened to withhold funds from states that provide health coverage to people without legal status. Currently, about 1.6 million people in the country without authorization are enrolled in Medi-Cal.

In 2016, California began opening Medi-Cal to low-income people lacking legal status, starting with children, then gradually expanded it to young people, older adults, and — in January 2024 — those ages 26 to 49. The state Department of Health Care Services, which oversees Medi-Cal, partnered with community health clinics to help get eligible people enrolled.

It’s too early to tell what impact the latest state and federal developments are having on enrollment numbers, since data is available only through March. But many health care providers and advocates said they expect a chilling effect on immigrant enrollment.

Seciah Aquino is executive director of the Latino Coalition for a Healthy California, which supports community health workers — also called promotores — who help spread awareness about Medi-Cal’s expansion to adults lacking legal status. Just over half of public health insurance recipients in California are Latino, compared with just 30% of Medicaid enrollees nationwide.

Aquino said her coalition will tell promotores to disclose data-sharing risks so community members can make informed decisions. 

“They take it very personally that advice that they provided to a fellow community member could now hurt them,” Aquino said.

Newsom condemned the data sharing, calling the move “legally dubious,” while U.S. Sens. Adam Schiff and Alex Padilla, both Democrats, have demanded that the Department of Homeland Security destroy any data shared.

California’s Department of Health Care Services announced June 13 that it is seeking more information from the federal government. The agency said it submitted monthly reports to CMS with demographic and eligibility information, including name and address, as required by law.

Medicaid enrollee data from Illinois, Washington state, and Washington, D.C., was also reportedly shared with DHS. Jamie Munks, a spokesperson for the Illinois Department of Healthcare and Family Services, the state’s Medicaid agency, said the department was “deeply concerned” by the news and that the data was regularly passed along to CMS with the understanding that it was protected.

In Sacramento, Democratic lawmakers found themselves in the uncomfortable position of rolling back health benefits for low-income residents with unsatisfactory immigration status, including people without legal status, people who’ve held green cards for under five years, and some others who are in the process of applying for legal status or have statuses meant to protect them from deportation. In addition to the Medi-Cal enrollment freeze for immigrants 19 and older in the country without authorization, all enrolled residents with unsatisfactory immigration status from 19 to 59 years old will be charged $30 monthly premiums starting in July 2027.

“What I’m hearing on the ground is folks are telling me they’re going to have a really hard time making these premium payments,” said Carlos Alarcon, health and public benefits policy analyst with the California Immigrant Policy Center, an advocacy group. “The reality is most people already have limited budgets.”

The legislature rejected a proposal from the governor to bar immigrants with unsatisfactory immigration status from receiving long-term nursing home and in-home care through Medi-Cal but went along with eliminating dental benefits starting in July 2026.

Health care providers said that without Medi-Cal coverage, many immigrants will be forced to seek emergency care, which is more expensive for taxpayers than preventive and primary-level care. Sepideh Taghvaei, chief dental officer at Santa Cruz County’s Dientes Community Dental Care, saw this play out in 2009 when the state cut adult Medi-Cal dental benefits. Patients came in with swollen faces and excruciating pain, with conditions so advanced that they required hospital treatment. “It’s not cost-effective,” she said.

State Sen. Roger Niello, a Republican who serves as vice chair of the Senate budget committee, said he believes California shouldn’t be funding Medi-Cal for people who lack legal status, particularly given the state’s fiscal challenges. He also said he worries that coverage of people in the country without authorization could encourage others to move to California.

“If we maintain that expense to the noncitizen,” he said, “we’re going to have to cut someplace else, and that’s undoubtedly going to affect citizens.”

Californians, too, are going through a change of heart. In a May poll conducted by the Public Policy Institute of California, 58% of adults opposed the benefit.

For Maria, shifting health care policies have left her feeling paralyzed. Since she arrived here five years ago, the caregiver’s focus has been on earning money to support her three children, whom she left with her parents in her home country, she said.

Maria didn’t learn she might be eligible for Medi-Cal until earlier this year and hadn’t yet found time to complete the paperwork. After a friend told her that the state could freeze enrollment in January, she began rushing to finish the sign-up process. But then she learned that Medi-Cal data had been shared with immigration authorities.

“Disappointed and scared” was how she described her reaction.

Suddenly, she said, enrolling in Medi-Cal doesn’t seem like a good idea.


Claudia Boyd-Barrett wrote this story for KFF Health News.


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