When Idaho Republican Rep. Raul Labrador walked out this month on a bipartisan group of U.S. House members trying to craft immigration reform legislation, he cited disagreements over health care, namely, whether immigrants should pay their own medical costs.
But the immigration bill now moving through the Senate includes health care provisions of a different kind - ones that could allow states to bring more foreign-born doctors to places chronically understaffed with medical providers. In Idaho, that's most of the state.
Foreign-doctor visas allow foreign-born and foreign-educated doctors and psychiatrists to work in places where American doctors won't. Doctors with the waiver agree to spend three years in those places, employed by hospitals or clinics.
The controversial bill includes several changes aimed at making the program easier to use and more flexible for employers, states and doctors.
To practice in the U.S., all doctors with foreign medical degrees - except Canadian degrees - must complete residency training in the U.S., according to the Association of American Medical Colleges.
The program has been a dud in Idaho. The state has 30 waivers to use each year. From 2005 to 2009, it used four. There was a mini-surge in 2011, when five international doctors came to Nampa, Blackfoot and Boise to work. Most of them are still practicing in those cities.
Dr. Muhammad Adnan is one of them. The 34-year-old internal medicine hospitalist (hospital-based physician) is from Pakistan, where he practiced for a while. He said he made good money, but he craved the training available in the U.S.
He went through the rigorous testing and requirements to come to the U.S. and started a residency in Michigan at a Trinity Health Hospital. While there, he learned of the Trinity-owned Saint Alphonsus Medical Center in Nampa.
"There was so much invested in me doing the residency program, I felt obligated to pay it back, and I thought maybe I should serve in an underserved area," he said.
He's now in his second year at the hospital, one of the few Idaho hospitals to take advantage of the waivers.
Saint Alphonsus supports the program "as one part of its overall physician recruitment plan to ensure that the communities we serve have an adequate supply of physicians and we can keep care as close to home as possible," said Steve Brown, chief medical officer for Saint Alphonsus Health System, in an emailed statement.
NOT AN INTERNATIONAL DESTINATION
Idaho is ranked last in the nation in states' share of doctors who attended international medical schools. Only 4 percent of doctors in Idaho - 115 of 2,873 active physicians in 2010 - were educated in other countries. The national average is 24 percent.
Primary care doctors - considered most important for rural areas - came to Idaho from at least 16 countries and made up 6 to 12 percent of the state's primary care doctors, according to an Idaho Department of Labor report last winter. The department found eight foreign-educated psychiatrists in Idaho.
Idaho also has the lowest share - 1.6 percent - of residents and fellows who were educated outside of North America.
The lack of international graduates could be explained by culture, history and the high number of U.S.-educated applicants competing for a small number of Idaho residency slots, according to Ted Epperly, who leads the Family Medicine Residency of Idaho.
Until it passed a new rule in 2008, the Idaho Board of Medicine would not license anyone educated at unaccredited international schools. The new rule gives those doctors a pathway to licensure if they can prove they are highly qualified.
That was a "show-stopper for many of those people, that Idaho wouldn't even recognize your school," Epperly said.
Residency programs often determine where a doctor will practice. And Epperly's program is dominated by U.S.-educated doctors. The program considers international applicants, but so many American doctors apply that they end up winning spots, he said.
He said it's possible the foreign-doctor visas could stem the worsening physician shortage in Idaho.
"We need more workforce in the state, there's no question about that," he said.
He's just not convinced Idaho will lure - and keep - that many doctors from around the globe.
The places in Idaho named by the federal government as underserved - qualifying them for the waivers - also tend to be rural areas. They may be unattractive for doctors from non-English speaking countries, Epperly said.
The "cultural differences can sometimes not be the best fit for rural Idaho," he said.
Adnan said Idaho's lack of residency spots for international doctors is probably the main barrier. He works in Nampa, so it's a stretch to say he's in a rural setting. And he finds that, aside from the occasional question about his religion and nationality, his patients in Idaho don't seem to care where he's from.
Not that it would matter. His job is to listen to patients, not worry about their cultural differences.
"If you cannot cross that barrier of your ego, then I don't think you'll be able to fly anywhere," he said.
Audrey Dutton: 377-6448, Twitter: @IDS_Audrey