How immigration issues may impact the physician workforce


Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.



AMA Chief Experience Officer Todd Unger speaks with AMA General Counsel Brian Vandenberg, AMA Trustee and medical student of University of California Irvine School of Medicine Sarah Mae Smith, and resident of Brigham and Women's Hospital, DACA recipient Dalia G. Larios, MD, on updates regarding COVID-19 including the Deferred Action for Childhood Arrivals program, commonly known as DACA, and related immigration issues that could impact the physician workforce during COVID-19.

Learn more at the AMA COVID-19 resource center.

Unger: Hello, this is the American Medical Association's COVID-19 update. Today, we're discussing the Deferred Action for Childhood Arrivals program, commonly known as DACA, and related immigration issues that could impact the physician workforce during COVID-19. I'm joined today by Dr. Dalia G. Larios, a resident at Brigham and Women's Hospital and a DACA recipient in Boston, Sarah Mae Smith, a medical student at the University of California, Irvine School of Medicine and an AMA trustee in Anaheim, California, and Brian Vandenberg, AMA general council in Chicago. I'm Todd Unger, AMA's chief experience officer in Chicago.

The DACA program and related immigration issues have surfaced during COVID-19, especially as they pertain to much needed health care workers. Mr. Vandenberg, can you briefly explain the issues surrounding the DACA program, in particular, right now?

Vandenberg: Sure. Thanks, Todd. Thanks for having me. The DACA program, I think as most people understand now, is a program which provides deportation protection for roughly 700,000 undocumented. These are individuals who were brought to the United States as children, grew up here and now potentially face deportation in the absence of this program. So the issue that exists today is whether a Trump administration decision to terminate this program, which would expose these individuals to potential deportation, is valid, and this issue is before the Supreme Court today. The timing of this is particularly important because of the pandemic that we face today because 30 some thousand DACA recipients are health care workers, many of whom, like Dr. Larios, are on the front lines of the COVID-19 pandemic.

Unger: Dr. Larios, will you comment on that?

Dr. Larios: Yes. Thank you so much, Todd, again for having us. Brian, I think a lot of your comments are spot on in terms of really the effect this pandemic is having on DACA recipients. We know that we're in an incredibly dire situation from this virus, and it's placing a huge spotlight on the medical community. Something that cannot be ignored within this community are the contributions from immigrants and DACA recipients, in particular, given that about 30,000 of them, as you mentioned, are part of this field.

Also something that's really notable during this pandemic is the fact that it's disproportionately affecting communities of color and Latinx communities. So now more than ever, we really need a diverse medical workforce. We need doctors that are able to speak different languages and that can really care for the needs that we're seeing. So I think that this is a time where having everyone on board, especially also with a shortage of physicians, is really crucial.

Unger: Ms. Smith, you and the student section of the AMA are very passionate about this. Can you talk a little bit about why you're so passionate and what you're working on?

Smith: Thank you, Todd, and also thank you, Dr. Larios. I have such tremendous respect and appreciation for your work and your experiences. As you noted, Todd, medical students were really at the forefront of bringing this issue to the American Medical Association in 2016 when I was the section delegate for the Medical Student Section. We brought forward a resolution directing the AMA to issue a statement in support of U.S. health care professionals who are Deferred Action for Childhood Arrivals recipients. Since then, the AMA has been a strong advocate on the legislative front in terms of trying to permanently enshrine the protections under the DACA program into law and more recently in the judicial realm defending the program as well.

When we were having these early discussions, some of my medical student colleagues with DACA spoke about the stability and the safety that the program offered them and how it had empowered them to pursue careers in medicine. I know it's certainly hard enough to be a medical student in these uncertain times without having the specter of the Supreme Court potentially ending these protections lurking.

Unger: Mr. Vandenberg, why is this issue particularly important right now?

Vandenberg: Well, I think there's an interesting timing issue in that, number one, it just so happens that this is a hot button issue sitting before the Supreme Court with a decision potentially coming down in a matter of days, probably within the next month. With that as the backdrop, which has been a case that's been in play for quite some time, having this case considered in the context of a global pandemic, where the very recipients of the DACA program are among the heroes that are helping us manage through it, provides a really unique point of view.

In fact, it's one of the things that we highlighted to the Supreme Court in our amicus brief with 30 or so other organizations, to really call attention to the contributions that DACA recipients have had on society in general but particularly in the health care space, highlighting the many physicians, nurses, other health care workers who are providing needed contributions at a point in time when there is a significant shortage of physicians and other health care workers.

The pandemic that we're facing today just punctuates that issue. Interestingly, in our brief which was filed in the fall, among the things we tried to highlight in terms of the reliance of society and the health care system on DACA recipients, we highlighted the potential of a pandemic, somewhat prophetic. We didn't know this was coming certainly, but it's pretty interesting in hindsight that that was one of the points that we made to demonstrate the significant need for Dreamers in society, but health care in particular.

Unger: Ms. Smith, any other comments on the shortage that we're seeing right now in physicians, especially in rural areas with underserved populations?

Smith: Well, we certainly had a significant physician shortage even before the pandemic, as was noted with the Association of American Medical Colleges projecting a shortage of up to 122,000 physicians by 2032, and certainly this pandemic is only exacerbating that. Rescinding DACA and the corresponding work authorizations for these health care professionals would reduce our nation's health care capacity at a time we can really ill afford it.

As Dr. Larios noted, this is especially true since many DACA physicians and medical students are from backgrounds underrepresented in medicine. We know that underrepresented minority physicians are more likely to practice in underserved areas, which are among those being the hardest hit by this pandemic, and especially to practice culturally-competent care to best serve those populations. Disrupting the ability of physicians with DACA status to serve their patients is really the last thing we need right now.

Unger: Dr. Larios, this—I'm sorry. Go ahead, Brian.

Vandenberg: I was just going to pile on there for a moment because there's an interesting development in the Supreme Court case on the heels of the pandemic. The briefing on briefs was completed some months ago, but on the heels of the pandemic, the Supreme Court, in a somewhat unusual move, allowed a recent filing within the past month on behalf of the 27,000 or so health care workers who are DACA recipients to really highlight this unique point in time and to ask the court to block the proposed termination in view of the pandemic. So interesting development really playing out in real time here.

Unger: Dr. Larios, this is obviously a lot of uncertainty for you, the pandemic, the DACA status. Can you talk to us a little bit about how does this feel for you personally? What's it like to practice with that level of uncertainty?

Dr. Larios: No, it's definitely a lot to have on your mind as a provider during this time. In the hospital, something that I told myself is you're just to focus on your patients, focus on serving them and providing the best care that you can. I find that when I do that, my anxiety and all these thoughts and uncertainty sort of tend to fade for that time and allow me to really do my work as a doctor. It's really when I come home and things sort of calm down and settle down that I'm reminded that I'm in such a vulnerable position and that my job could disappear at any time. Sometimes I worry will I be able to do this in six months? Will I be able to do this in a year?

The thought of not being able to continue being a doctor, to continue serving the populations that I've worked so hard to understand, to be able to care for is really sad. It's something that really sort of hits me at my core because I think so much of being, for me, a doctor is being able to give back, and the thought of not having that is really saddening.

I also think more broadly about our DACA recipients in other areas that are so essential during this time. Certainly, we've talked about the spotlight in medicine, but we have DACA recipients who are teachers who are keeping our educational system continuing during this time. We have DACA recipients who are researchers working in labs to find therapies for this virus, to find vaccines. All of those things are just as important and are so crucial during this time. So I think not just about the impact on myself and what I will lose, but also what we lose as a country.

Vandenberg: There's something that I'll highlight there that Dalia hit on. It's easy to think about this in terms of the impact on the individual DACA recipients and how it changes their lives, and that's important. But one of the things that we highlighted in our brief and that's really one of the fundamental legal issues in this case has to do with the notion of serious reliance interests. That's a legal concept that essentially says that an administrative rule like this cannot be changed without the serious reliance interests being adequately considered.

Here, you've got not only the reliance on DACA in terms of the individuals impacted, but it extends much further, health centers, hospitals rely on DACA students. The patients rely on DACA students. The public does. So all in all, there's an extensive reliance on DACA recipients in many facets of society, but in health care particular where one of the fundamental tenants is "Do no harm." If we strip this population of caregivers out of the system, that's pretty significant harm, and we point that out to the court. We hope that they consider that.

Unger: Well, given the importance of that, Mr. Vandenberg, Ms. Smith, can you comment on what the AMA is doing in terms of DACA and other immigration-related issues that affect physicians?

Smith: Well, in terms of supporting the DACA program, this past week the AMA sent a letter to the Vice-president as well as our congressional leaders, with over 70 other health care organizations also recognizing the importance of this, urging them to maintain work authorization for those with DACA status during this public health emergency. This really follows on and echoes the amicus brief we filed in that Supreme Court case challenging the DACA program that Brian mentioned.

Regarding other immigration issues, we've also been advocating around the conditions in immigrant detention centers, which is not a new issue for the AMA. We've been advocating for improved humanitarian standards for those in immigration detention for some time, but the COVID-19 pandemic has really leaped there and exacerbated the dangers to those in these detention facilities.

As such, we recently urged the Department of Homeland Security and the Office of the Inspector General to investigate reports that pregnant women seeking asylum here in the United States have been denied timely access to health care by U.S. Customs and Border Protection agents, recommending that CPB refrained from detaining pregnant women during the pandemic and assess whether its oversight and disciplinary mechanisms are sufficient to ensure that officials are held accountable. This is recognizing that the health of the mother and the child in these instances should be the first priority of CPB agents and timely access to health care for pregnant women is a human right.

Vandenberg: Yeah, I think what Sarah Mae highlights is AMA has an advocacy role in multiple facets, certainly from a regulatory standpoint but also the judicial advocacy side. Those are very complimentary tools that work together. Separate and apart from our role in the judicial advocacy side in the DACA lawsuit before the Supreme Court, we're involved in a multitude of other immigration-related issues, including the public charge rule, a variety of other things that have to do with conditions at the southern border. There's been no shortage of immigration-related issues of late, and we've been very active both in the courts and in the legislatures and the executive branch working to find a solution that ensures that people are cared for, irrespective of their ability to pay, irrespective of the circumstances of their presence in the United States. This is basic health care script of politics script of financial considerations but with the individual first and foremost.

Unger: Well, Dr. Larios, I just want to thank you for all of your service during the COVID-19 pandemic and the uncertainty that surrounds DACA right now. Thank you also, Mr. Vandenberg and Ms. Smith, for being here today and sharing your perspectives. That's it for today's COVID-19 update. We'll be back tomorrow with another segment.

For updated resources in the meantime, go to the AMA COVID-19 resource area at Thanks for being with us here today. Take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.