Medicare patients lean on doctors born ex-US

Clinical takeaway: Nearly half of physicians board-certified in internal medicine and its subspecialties were born outside the US, and their patients are more often disadvantaged. Immigration policy is not just a personal workplace issue, it also reaches patient access. 

Immigration policy changes since mid-2025, such as travel bans covering 39 countries, expanded visa vetting, and a $100,000 H-1B fee since blocked in court, have reached the physician workforce. Residency applications and hiring have already been disrupted. But what those changes put at risk for patients depends on where foreign-born physicians actually practice and whom they treat. 

Internal medicine is the largest physician specialty in the US, and residency positions have outnumbered US medical school graduates for years. International medical graduates have filled much of that gap, concentrating in primary care and in areas with documented shortages. Their role in the internal medicine subspecialties, and the characteristics of the patients they treat, have not been described in detail. A new census of physicians certified in internal medicine by the American Board of Internal Medicine (ABIM) since 1990, linked to a full year of traditional Medicare claims, addresses both. 

Physicians born outside the US accounted for 47.2% of the 249,679 physicians board-certified in internal medicine or one of its subspecialties in the 2026 workforce, split between 36.1% who graduated from foreign medical schools and 11.1% who trained in the US. 

Their patients were more often disadvantaged. In 2024, these physicians treated 22.5 million traditional Medicare beneficiaries. Compared with patients of US-born US medical school graduates, patients of foreign-born international medical graduates were more likely to be dually eligible for Medicare and Medicaid (20.9% vs 11.7%), Black (9.5% vs 7.0%), Latino (6.6% vs 3.9%), and living in a high-poverty ZIP code (19.8% vs 15.9%). Among physicians one to three years out of training, 55.4% of patients lived in an underserved location, against 42.4% for US-born graduates. 

Dependence was deepest where the aging population puts the most demand: more than half of internal medicine-certified geriatricians, nephrologists, and sleep medicine physicians were foreign-born international medical graduates, and every internal medicine subspecialty examined was at least 27%. 

The workforce estimate drew on certification records for all physicians initially certified in internal medicine by ABIM between 1990 and 2025, with inactive, retired, and deceased physicians removed. Of those, 178,782 were matched to 2024 traditional Medicare claims to describe the patients they treated. Physicians still in fellowship or certified in 2024-2025 were excluded from the patient analysis, as were beneficiaries younger than 65 years. 

The concentration in early-career internists is what makes this operational rather than theoretical. Physicians one to three years out of internal medicine training see the most underserved patients, and that window is governed by the Conrad 30 waiver program, which allows physicians on J-1 training visas to stay in the US after residency rather than return home, provided they spend three years practicing in a shortage area. The arrangement supplying underserved coverage is the same arrangement immigration policy governs. 

"In many underserved communities, physicians born outside the U.S. care for patients with complex medical conditions and limited access to care," said co-author Alicia Fernandez, MD, professor of medicine at the University of California, San Francisco, and an internist at Zuckerberg San Francisco General Hospital and Trauma Center. "They play a central role in providing consistent, ongoing care for these patients and are an important part of how America must think about healthcare workforce planning as we face physician shortages in numerous disciplines." 

Source: Meille, et al. (2026 Aug 12) JAMA. Non-US-Born Physicians in the US Internal Medicine Workforce