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Where the next dollar against the doctor shortage should go: a 51-state triage of provisional-licensure laws for sidelined immigrant physicians

Jun 25, 2026 · 8:29 PM

Abstract

The United States is projected to be short up to 86,000 physicians by 2036, while as many as 65,000 fully-trained foreign physicians already live here and cannot practice. Since 2023, states have raced to fix this with provisional-licensure laws that drop the redundant repeat-residency requirement. This note triages all 51 jurisdictions (50 states plus DC) against the single defect that strands these laws: a clause tying eligible employment to hospitals that run a residency program, which confines new doctors to the cities that already have physicians. Three findings invert the naive read. First, the legislative fight is largely won: 23 to 24 states have now enacted a pathway, up from nine a year ago. Second, the binding problem moved to statutory design and board rulemaking. Six states carry a high-severity stranding defect. Third, on conservative assumptions a clean statute could add roughly 6,000 to 12,500 practicing physicians, closing 40 to 80 percent of the measured national primary-care gap of 15,604 practitioners. The recommendation is a five-line statutory strike and six rule provisions, drafted and ready, that cost a legislative staffer one session.

Background

The shortage is driven by aging: the 65-and-over population grows about 34 percent through 2036, and one in five US doctors is already 65 or older [1]. Immigrant physicians are not a marginal supply. About 26 percent of all US physicians and surgeons are immigrants [6]. Across all occupations, immigrant "brain waste" costs an estimated $39 billion in foregone wages and $10 billion in lost taxes a year [2]. The precedent that proves the problem is fixable is Tennessee, which passed the first-in-nation provisional-licensure law in 2023 [3]: it requires ECFMG certification, a completed foreign residency or recent practice, and a two-year supervised term before full licensure, and it costs the state almost nothing because it removes a barrier rather than building a program. Nine states had enacted such laws and roughly 30 had introduced bills as of 2025 [4]. The talent already lives here. No immigration pipeline is required.

Method

An autonomous research loop ran four stages, each producing one artifact, each passed by an independent evaluator with citation spot-checks before the next began. Milestone 1 built a 51-row crosswalk of provisional-licensure status and requirements, sourced to the Federation of State Medical Boards key-issue chart (last updated May 2026) and cross-checked against the AMA's October 2025 list [7][8]. Milestone 2 classified each enacted or proposed law by stranding defect, using eight named provision tags and a high/medium/low severity rubric (the rubric is an analyst construct, disclosed as such). Milestone 3 matched HRSA primary-care shortage data (via KFF, as of 2025-12-31) [9] against a state-level estimate of the sidelined-physician population derived from Migration Policy Institute brain-waste shares [10], then ranked states by the geometric mean of normalized need and normalized supply. Milestone 4 redlined Tennessee's verbatim statute and drafted a board-rulemaking comment. Artifacts and verdicts are linked in Provenance.

Findings

1. The legislative fight is nearly won; the wave roughly tripled in a year.

The naive expectation is a stuck legislature. The opposite happened. The brief's 2025 baseline of nine enacted states is now 23 to 24 (23 under the FSMB-strict "full licensure without postgraduate training" definition, 24 if California's and New York's limited routes count) [7]. The nine the brief named (Tennessee, Florida, Idaho, Illinois, Iowa, Louisiana, Massachusetts, Virginia, Wisconsin) are all enacted, plus 14 more. Seventeen states have a bill pending, and ten have nothing. The open question is no longer "will states pass laws." It is "do the passed laws place doctors where the shortage is."

2. The binding defect is one clause, and six states carry it at high severity.

The Tennessee defect is the residency tie: the employing provider must operate an ACGME-accredited residency program. Residency programs cluster in urban academic centers, and only about 2 percent of Medicare-funded residency training sits in rural or underserved areas [5]. The clause therefore confines new doctors to the metros that already have them. Six states carry a high-severity version.

Severity States Defect
High (6) Tennessee (governing until 2027), Oklahoma, West Virginia, New Hampshire, Maryland, Mississippi (SB 2441) Residency tie, academic-sponsor, US-fellowship, or no conversion to full
Medium (14) Texas, Illinois, Maine, New York, Washington, Nebraska, Georgia, Massachusetts, Rhode Island, Virginia, Oregon, Pennsylvania, Michigan, Vermont Partial tie, narrow list, long supervision, or supervisor scarcity
Low (8) Minnesota, North Carolina, Arizona, Florida, Arkansas, Nevada, California, Louisiana Shortage-targeted narrowing (aids placement)
None found (13) Idaho, Wisconsin, Kentucky, Iowa, Indiana, Kansas, South Carolina, New Jersey, Ohio, plus failed-only CT, MO, ND Broad, function-based sponsor scope

Tennessee itself is mid-fix, not frozen. Its 2026 amendment (SB 2366, effective 31 Jan 2027) broadens sponsors to FQHCs, rural health clinics, and community health centers, but adds an on-site same-specialty supervisor requirement that moves it from high to medium rather than to clean. Idaho's H 542 is the cleanest enacted model; Kansas HB 2251 is the cleanest pending one.

3. A clean statute could close 40 to 80 percent of the national primary-care gap.

The leverage estimate is the packet's headline number. Taking the national sidelined-physician anchor of about 65,000, distributing it across states by MPI brain-waste shares, and applying a disclosed 10 to 20 percent capture rate over five years yields roughly 6,000 to 12,500 additional practicing physicians. The measured national primary-care gap is 15,604 practitioners needed to remove all shortage designations [9]. So even on conservative assumptions, unlocking sidelined doctors closes 40 to 80 percent of that gap. The leverage concentrates in a few states.

Rank State Practitioners needed (rank) Est. sidelined IMGs Unlocked est. Statute status
1 California 1,045 (#3) ~14,800 1,500–2,950 Enacted limited + pending AB2386
2 Florida 1,434 (#1) ~7,200 700–1,450 Enacted, low severity
3 Texas 1,147 (#2) ~5,700 550–1,150 Enacted, medium (residency tie at issuance)
4 New York 1,036 (#4) ~5,400 550–1,100 Enacted permit (medium) + pending
9 Ohio 686 (#6) ~1,200 100–250 Pending, clean (HB763)
10 Arizona 776 (#5) ~1,000 100–200 Pending, low severity (HB2435)

The four largest states (California, Texas, New York, Florida) hold the bulk of the unlocked total, roughly 3,300 to 6,650 of the 6,000 to 12,500. But the highest advocacy leverage sits where a fixable statute gap remains: Texas (strike the issuance-time residency tie), New York and California (pass the pending converting bills), Ohio and Arizona (pass clean pending bills in high-shortage states), and Georgia (fund a law that takes effect only on appropriation).

4. The fix is two documents, already drafted.

The redline is minimal because Tennessee's own statute already defines "healthcare provider" broadly. The defect is a qualifier bolted on top: the provider must "operate ... a post-graduate training program accredited by the [ACGME]." Strike that qualifier in subsections (g)(2) and (g)(3), and the statute's own broad definition does the work. The model adds shortage-area direction (a renewal rule that steers doctors toward need without restricting the employer pool), a self-executing clause with a 180-day rulemaking deadline, and qualification-based supervision that permits telesupervision where no on-site same-specialty doctor exists. That last move is the one difference from Tennessee's own 2027 fix: it cures the defect without opening a new supervisor-scarcity one.

Recommendations

Item Executor Cost Anchor
Strike the residency tie at issuance Texas legislature One session, staff time M4 Change A2; ~550–1,150 physicians in play
Pass pending converting bills (A7319/S7840; AB2386) New York, California legislatures One session Largest pools in the US (~5,400; ~14,800)
Pass clean pending bills (HB763; HB2435) Ohio, Arizona legislatures One session 6th- and 5th-worst shortages
Fund the already-passed law Georgia legislature Appropriation Law strands at $0 until funded
File the board-rulemaking comment Niskanen/Cicero/Upwardly Global-aligned coalitions Comment filing M4 Part B, six rule provisions

Sequence by where statutory change still moves the needle. The clean-bill states (Ohio, Arizona) and the converting-bill states (New York, California) need passage. The medium-defect states (Texas above all) need the targeted A2 strike. The high-defect states (Oklahoma, West Virginia, New Hampshire, Maryland) have smaller pools but the clearest repair. Everywhere a law already passed clean (Idaho, Wisconsin, Kentucky), the lever is the board comment, not the bill: implementation, not text, is the remaining bottleneck.

Limitations

  1. No physician-specific state data exists. The Minneapolis Fed stated in January 2024 that nationally representative data on underutilized foreign-trained physicians "is not yet available" [11]. Every state physician estimate is the national ~65,000 allocated by MPI's all-occupations health-degree shares. If physicians cluster differently than nurses and therapists, the big-state estimates understate and the fallback states overstate.
  2. The 65,000 anchor is old and soft. It traces to a 2018 MIRA Coalition advocacy estimate [12], not a peer-reviewed count. If the true figure differs, every absolute estimate scales with it; the relative ranking is more robust than the absolute counts.
  3. The match is state-level, not county-level. The spec's county-level ambition is only partly met because the sidelined-IMG data has no sub-state geography. A state can rank high while its idle doctors live in the metro and its shortage is rural.
  4. The capture rate is an analyst construct. The 10 to 20 percent band is disclosed judgment, not drawn from any authority. If the binding constraint is board capacity, supervisor availability, or employer willingness, the unlocked numbers are upper bounds.
  5. The residency tie had a real safety rationale. Teaching hospitals carry built-in supervision. The redline replaces the tie with a supervisor-qualification regime rather than deleting it; a critic can fairly argue a collaboration plan in a small rural practice is weaker oversight than embedded residency supervision.
  6. The MPI shares and one TN amendment are not fully verified. MPI shares are 2013-17 ACS data. The crosswalk rests largely on the single FSMB chart, not 51 primary statutes. Tennessee's SB 2366 (2026) text was not independently retrieved this session; its description carries from FSMB.

References

  1. AAMC, new physician shortage report, 2024. https://www.aamc.org/news/press-releases/new-aamc-report-shows-continuing-projected-physician-shortage
  2. Migration Policy Institute, Untapped Talent: The Costs of Brain Waste. https://www.migrationpolicy.org/research/untapped-talent-costs-brain-waste-among-highly-skilled-immigrants-united-states
  3. Tennessee provisional-licensure law (2023), PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC10688565/
  4. Becker's Hospital Review, 30 states with foreign-trained-physician bills, 2025. https://www.beckershospitalreview.com/legal-regulatory-issues/30-states-have-bills-to-hire-more-foreign-trained-physicians-5-notes/
  5. Niskanen Center, Unlocking Potential, 2025-03-20. https://www.niskanencenter.org/unlocking-potential-how-states-can-remove-barriers-for-internationally-trained-physicians/
  6. MPI, immigrant physician share, via Niskanen Center, 2025-03-20. https://www.niskanencenter.org/unlocking-potential-how-states-can-remove-barriers-for-internationally-trained-physicians/
  7. FSMB, States with Enacted and Proposed Additional IMG Licensure Pathways key-issue chart, last updated May 2026. https://www.fsmb.org/siteassets/advocacy/policies/states-with-enacted-and-proposed-additional-img-licensure-pathways-key-issue-chart.pdf
  8. AMA, New licensing pathways for foreign-trained doctors, 2025-10-24. https://www.ama-assn.org/education/international-medical-education/new-licensing-pathways-foreign-trained-doctors-what-know
  9. KFF / HRSA Bureau of Health Workforce, primary-care HPSAs, as of 2025-12-31. https://www.kff.org/other-health/state-indicator/primary-care-health-professional-shortage-areas-hpsas/
  10. MPI, Brain Waste among U.S. Immigrants with Health Degrees, July 2020. https://www.migrationpolicy.org/sites/default/files/publications/MPI-HealthCare-Brainwaste-by-State_Final.pdf
  11. Federal Reserve Bank of Minneapolis, 2024-01-19. https://www.minneapolisfed.org/article/2024/occupational-licensing-can-detour-immigrant-physicians-career-paths
  12. MIRA Coalition ~65,000 figure, via GBH/PRX, 2018-03-26. https://theworld.org/stories/2018-03-26/highly-trained-and-educated-some-foreign-born-doctors-still-can-t-practice
  13. Tennessee Public Chapter 211 / SB 1451 (2023), verbatim baseline. https://publications.tnsosfiles.com/acts/113/pub/pc0211.pdf

Provenance

This note was produced by an autonomous research loop that ran four milestones, each generating one artifact passed by an independent evaluator with citation spot-checks before the next stage began. Artifacts and verdicts live in artifacts/ and verdicts/ in this problem's directory; the final artifact is the model-bill redline and board-rulemaking comment, 2026-06-25-m4-model-bill-redline-board-comment.md.