Colleges and universities often educate students who are among the millions of “undocumented” or “unauthorized” immigrants in the United States, and a significant and growing number of states recognize these students as residents eligible for in-state tuition at public universities.1,2 These young people are sometimes called “Dreamers” because they fit the profile described by long-proposed, but as-yet-not-passed, federal legislation commonly called the DREAM Act (Development, Relief, and Education of Alien Minors).3 Typical Dreamer students were born outside the United States; most were brought to the United States at a young age by parents who lacked proper immigration documentation or who originally arrived with a recognized lawful status but overstayed their visas. Thus, although they are officially or legally undocumented immigrants, Dreamers have been raised in the United States and are usually fully acculturated. Because they are raised by immigrant parents, they are typically bilingual and bicultural. The United States may be the only country Dreamers know firsthand because they have been educated within U.S. borders and have lived much, often most, of their lives in the United States. For all intents and purposes, the main difference between Dreamer students and their citizen peers is that the latter have always had access to an assigned Social Security Number (SSN).
Some Dreamer students who have excelled academically at the undergraduate (baccalaureate) level are now seeking advanced graduate and professional training, including medical school admission.4,5 Until quite recently, there were substantial, perhaps impenetrable, barriers hindering these talented students from becoming practicing physicians. Although the DREAM Act has never become law, the creation of the Deferred Action for Childhood Arrivals program (DACA)6 makes medical training, licensure, and medical practice feasible.
Medical schools should welcome applications from Dreamers and assist qualified Dreamer applicants in successfully matriculating. Qualified Dreamer applicants have a strong claim, based on ethical and social justice principles, to be considered for admission and matriculation into medical school in the United States. The same principles that inform medical schools’ efforts to build diverse student bodies counsel physician educators and admissions counselors to include this unique population in their institutions and thereby benefit the communities which these future physicians would serve.
Why Admit Dreamers?
The Loyola University Chicago Stritch School of Medicine recently (2012) changed its eligibility requirements to clarify that it will consider the applications of “Dreamers” who meet normal criteria for admission.7 The admissions Web page indicates that applicants “must be U.S. citizens or hold a permanent resident visa or be eligible for the Deferred Action for Childhood Arrivals (DACA) process of the U.S. Citizenship and Immigration Services at the time of application.”7(emphasis added) We believe that this is the first clear public statement by a U.S. medical school indicating its intent to invite a subgroup of Dreamers to apply for admission on the basis of their merit and as U.S.—not international—students.
Why did Loyola University Chicago Stritch School of Medicine adopt this merit-based policy? Why should other medical schools welcome applications from Dreamers of DACA status? We believe that three main ethical principles and policy considerations support their eligibility. First, a belief in equality, perhaps the fundamental value in contemporary democratic society, means that these potential applicants must be considered—just like others—on their merits. Second, the medical profession’s duty of beneficence, the obligation to help patients, means that medical schools cannot turn away a significant pool of diverse talent in developing the physician workforce. Third, and related to beneficence, the value of social justice requires that medical schools seek to produce a physician workforce that better serves those communities that have been traditionally underserved, such as ethnic minorities and recent immigrants. Herein, we examine each in turn.
First, medical schools have a duty not to discriminate by denying applicants for arbitrary reasons. All people—all potential applicants—must be treated equally, the same, unless a relevant reason to treat them differently can be identified. With the conferral of DACA status, a Dreamer can no longer be denied admission on the grounds that he or she cannot lawfully practice medicine in the United States. There is no longer any categorical legal barrier barring these applicants’ practice of medicine. DACA status includes an Employment Authorization Document (EAD) and enables the Dreamer to apply for an SSN. A medical school graduate of DACA status is, thereby, authorized to work in the United States and will be able to secure licensure in most states.8 Thus, to deny these applicants because of their immigration status is simply to practice arbitrary discrimination against a particular group of people.
Some might argue that DACA status has been created by the executive branch of government and could change with future chief executives. They claim that the potential impermanence of the status makes accepting Dreamers imprudent; however, public policy and laws are always subject to change, and institutions cannot discriminate on the basis of hypothetical future scenarios.9 To continue to wait for further legislative action is to continue to deny opportunity to a population who can meet all the legal requirements.
Second, these Dreamers represent a very valuable resource whose development as part of the physician workforce is entailed by the medical profession’s duties of beneficence to all patients and of social justice for underserved populations. Large numbers of patients, including many ethnic minorities and recent immigrants, lack access to physicians, and those who do have access are not always served well. The duty of beneficence requires medical educators to seek and develop the talent of as many qualified trainees as possible. To exclude a particular population of possible physicians is to ignore their contributions, to narrow the potential of the future physician workforce, and, potentially, to neglect the needs of future patients. Further, the medical profession’s duty to help patients—that is, to be beneficent—requires that physicians and physician educators foster a diverse physician workforce.
The ethical obligation to train the best potential workforce pulled from all of the best candidates intersects with the social justice value that requires medical schools to form physicians who have the capacity and skills, including cultural awareness and competence, to provide all patients with high-quality, compassionate care. Medical schools should seek to produce physicians who aspire to serve communities that have been traditionally underserved, such as ethnic minorities and recent immigrants. Dreamer students represent a very valuable resource in achieving the diversity necessary to meet the health care needs of contemporary U.S. society. As articulated in the vision statement of the Association of American Medical Colleges (AAMC), a diverse physician workforce is important because physicians who share the culture and background of underserved minority populations produce more positive results in terms of patient outcomes, satisfaction, and access.10 Medical schools also seek to increase the cultural competency, sensitivity, and humility of all those they educate. A diverse student body promotes cultural competency and understanding in the educational environment as students learn from each other.11 Further, graduates who identify as being from underserved minorities are themselves more likely to treat racial and ethnic minority patients, and they are more likely to set up practice in typically underserved communities.12,13 It is perhaps the nation’s need for a diverse physician workforce that most recommends the consideration of applicants with DACA status to medical schools.
A Changing Society and Health Care Landscape
Given the changing demographics in contemporary U.S. society, the need to develop a diverse, culturally competent workforce is especially acute. The United States is an increasingly diverse nation. So-called ethnic “minorities” constitute the fastest-growing part of the population and, in fact, account for approximately 90% of all population growth in the United States.14 U.S.-born Latinos make up a disproportionate share of this growth. Some estimates indicate that within the foreseeable future (e.g., before the second half of this century), current racial and ethnic minorities (not foreign born) will make up the majority population of the United States.15
Perhaps even more relevant to our present purposes, the changing demography of the United States includes a large recent immigrant population. The United States is home to approximately 40 million foreign-born residents.16 In addition, an estimated 11 million undocumented immigrants reside within its borders.16 Large numbers of these immigrants have lived in the United States for many years. The rise of the undocumented population has also coincided with growing numbers of families of “mixed” immigration status: Some family members with citizen or permanent resident status reside lawfully in the United States, whereas others lack the documentation that would allow them legal U.S. residence. These families often lack access to health care, and as they acculturate, they become part of a population that is subject to significant health disparities.17 In addition, access to care is limited for immigrants and ethnic minorities such as Latinos because they are uninsured at disproportionately high rates.17,18,19 Undocumented immigrants—and significant numbers of recent lawful immigrants—will largely remain uninsured after the implementation of the Affordable Care Act.17
This brief overview of the ethnic diversity and changing demographics in the United States suggests the need for a more diverse physician workforce. Medical schools have a duty, based in the principles of beneficence and social justice, to work to increase the ethnic and cultural diversity of the physician workforce so as to meet the needs of the evolving population. This workforce must also be equipped to serve immigrant communities. Such a workforce should include physicians who share ethnic and cultural ties with patients and who have insight into the life experience of immigrant populations. This understanding and familiarity is important from a cultural sensitivity and health outcomes point of view because patients who relate to their physicians have better outcomes and higher compliance.11 Even more important, these shared qualities and life experiences may imbue the physician workforce with an inclination to serve populations left behind by health insurance reform. Dreamers represent a potentially valuable resource in achieving this goal.
Who Are Dreamers of DACA Status?
According to a Brookings Institution analysis of DACA applications, 900,000 Dreamers are believed to be eligible for DACA status, and, as of June 2013, more than half a million have applied for this status.20 To be eligible for DACA status, the applicant must be between the ages of 16 and 31 years old; must have arrived in the United States prior to the age of 16; must have resided continuously in this country for at least 5 years; must be currently enrolled in school, have completed high school, or have obtained a GED; must have no serious criminal involvement; and must be able to prove he or she was in the United States on June 15, 2012. Notably, because of the minimum age, a subset of the population without documentation will likely age into eligibility in the coming years.21 The group of persons eligible for DACA includes many ethnicities, but Latinos constitute a supermajority of this population. Almost 75% of DACA applicants were born in Mexico; Central Americans constitute about 10% of the applicant pool, and another 7% are originally from South America. The remaining DACA-eligible population includes approximately 4% from Asian nations, 2% of Caribbean origins, and 2% from other nations.20 Of particular note is that the distribution of DACA applicants by state mirrors the settlement patterns of immigrants in the United States generally.20 In other words, DACA applicants are from the concentrated immigrant communities that we hope medical school graduates will serve after training.
We believe that Dreamers of DACA status hold the greatest potential to ameliorate the shortage of practicing physicians and medical students of Latino origin. Currently, only about 3% of practicing physicians in the United States are Latino. Medical schools have made some strides in this regard, as Latino matriculants constitute more than 8% of recent classes nationally.22 Nevertheless, these numbers continue to represent a troubling disparity because 17% of the U.S. population is Latino.23 Additionally, as we have noted above, the need to improve Latino representation in the physician workforce is all the more acute because this ethnic group is a fast-growing part of the U.S. population.15
Whereas eligibility for DACA status requires only 5 years in the United States, 72% of all DACA applicants have lived in the United States for more than 10 years.20 These medical school applicants should not be considered international students. They bear a much greater resemblance to U.S. citizens and permanent residents than they do to international students. As mentioned above, persons who are granted DACA status were usually brought to the United States more than 10 years ago before the age of 16, and they have completed significant portions, usually most, of their education in this nation. In other words, they have spent formative years, acculturating to life in the United States, making it their home. Dreamers are from immigrant communities; they are part of the fabric of these communities in the United States; they are not members of communities in other countries.
Dreamers and DACA: Removal of Barriers to Licensing and Residency
Logistical barriers facing Dreamers who wish to apply to medical school have always been surprisingly few in number. A common myth is that a valid SSN is required to complete the process. There are accepted substitutes for an SSN for most steps. For instance, applicants can complete the American Medical College Application Service (AMCAS) process with an AAMC-issued ID number. (This is important to note as Dreamers can apply to medical school concurrent with applying for DACA status. They need not await the conferral of DACA status and the actual securing of an SSN.) In general, the main barrier in applying to medical school has been the fact that medical schools have implicitly excluded Dreamers through their policies. Many medical schools have restricted eligibility to persons with particular immigration statuses (i.e., only U.S. citizens or permanent residents), and some medical schools have accepted a limited number of international students. None of these categories fit Dreamers. Until recently, however, medical schools have had good justification for maintaining these restrictive policies.
Before the creation of the DACA process, access to residency programs and licensure presented insurmountable obstacles for Dreamers who wished to practice medicine. Any Dreamer who graduated from medical school would have been unable to secure either a work authorization or an SSN from the federal government. Without these, a medical school graduate generally could not secure a license from the state medical board and, therefore, could not enter a residency program in that state. This situation was unequivocal in most states, but there were some minor exceptions; for instance, in Illinois, medical school graduates could apply to a residency program using an AAMC ID number—just as they had for the AMCAS process. The state would then issue a temporary license for up to three years. This exception accommodated foreign medical school graduates entering U.S. residency programs who were in the process of applying for an SSN. Through such a program, Dreamers might have been able to complete a short residency, but they would have then been unable to renew their licenses. Even if such a physician could have completed the residency within three years, he or she would no longer have a license to practice medicine. Because there was no path to a sustainable medical practice for undocumented physicians, medical schools tended to maintain policies that excluded Dreamers from even applying.
DACA status removes this long-standing barrier to securing and maintaining a residency slot and a medical license. The conferral of DACA status comes with what is colloquially known as a “work permit,” formally known as an EAD. When a U.S. resident has an EAD, he or she can apply to the Social Security Administration for an SSN. Medical school graduates who have DACA status, therefore, will be eligible to gain a state license to practice medicine and thereby enter a residency training program. As long as their deferred action status is renewed every two years, they can continue to practice medicine.
Financing Medical Education
The burden of paying for medical school currently poses the most significant challenge to developing Dreamer physicians. Even with DACA status, Dreamers are ineligible for the federally guaranteed student loans available to U.S.-citizen medical students who need financial aid. Thus, a medical school would need to commit to providing significant financial aid for any successful Dreamer matriculants. Although options, because of state regulations, may be more limited for public medical schools, private medical schools can choose to invest large amounts of their scholarship resources to cover the tuition and living expenses of Dreamer students as justified by need and merit. Questions of fairness are likely to arise by such a policy—whether in place at a public or private institution.
Two ethical principles are appropriate for guiding the development of a specific approach to financial aid. On one hand, the principle of equality counsels that all students should be treated the same. We noted earlier that this principle compels medical schools to consider the applications of Dreamers of DACA status on the applicants’ merits. However, as identical treatment is not always possible in all respects, the principle of equity suggests that students may be treated somewhat differently if such treatment results in equivalent outcomes. In the case of Dreamers, the principle of equity implies that a school can apply significant amounts of its resources to offset the lack of access that these students have to public resources. In addition, the principle of equality challenges medical schools to both (1) develop options that are similar to and not disproportionately better than those available to other students, and (2) as far as possible, secure additional resources to offset the needs of Dreamers so as not to implicitly penalize the students who are U.S. citizens or residents.
Although we believe that both equality and equity are important, the principle of equity must have a kind of prima facie priority. The situation and circumstances of Dreamers have combined to deny these potential physicians opportunities equal to those of their citizen peers. Equity counsels medical schools to try to offset Dreamers’ disadvantages. An overemphasis on equality will likely further deny them opportunity as it would prevent any differing treatment. Equity recognizes that under the status quo, Dreamers are currently being treated differently, and this different treatment may require compensatory action. But, medical schools must not disregard equality altogether because the perception of equality fosters cohesiveness in the institution and helps medical students to relate to their peers from different backgrounds. The belief that others are benefiting from special treatment, especially if such treatment is happening at one’s own expense, can be destructive to the environment.
The principle of equality should motivate medical school officials to vigorously seek additional financial resources that might flow from benefactors and/or state-related agencies astutely aware both of the financial needs of Dreamers and of the importance of investing in their medical education. The needs of these students and the opportunity available to develop this untapped pool of talent can inspire significant donations and proposals for novel programs at the local and state level. We believe that procuring new sources of aid for those ineligible for federally guaranteed student loans and other established funds is an obvious good. Further, tapping new funding sources also respects the principle of equality in that it prevents the pitting of the interests of students from one group against those of another. Although the principle of equity allows medical schools to justify using disproportionate scholarship resources for those who have no access to loans—even if the practice results in slightly larger loan burdens to other students (who have such access)—the principle of equality implies that it is far better if this deficit can be avoided.
Some medical schools administer their own loan programs for students. Such existing or similar newly created loan programs may be applied to Dreamer students. Providing loans that are comparable to those available to the other students (via, for example, federally guaranteed loans) would allow for distinguishing between these two groups of recipients but would not result in different treatment; in other words, a new loan program for Dreamers that does not disrupt other funding sources would be equitable. In addition, some states have means to provide loans through state-related agencies to foster investment in the professional workforce of the state. Occasionally, such financiers work with public health agencies to create loan programs to encourage physicians to practice in underserved areas.24 Working with these agencies to design similar loan programs for Dreamers promotes equity and respects equality by not removing resources from students who are born or naturalized U.S. citizens.25 And, of course, such loans are ideal because they help develop this pool of diverse talent, which would, in turn, directly enhance the good of the community.
The Next Steps for Medical Schools
Obtaining a comprehensive history of the interactions of Dreamer students with medical schools has proven to be very difficult; however, we have anecdotal evidence, including accounts from student activist groups and medical school administrators, indicating that thus far, in recent years, there have been very few U.S. medical schools that have successfully graduated a Dreamer who has gone on to become a practicing physician in the United States. Through DACA, medical schools now have a viable path to undertake the development of Dreamers as part of their talent pool. Making Dreamers eligible for admission strengthens the applicant pool of any school. We believe that because such students have not had access to medical schools, collectively they are likely to represent a group of highly qualified applicants with an abundance of stifled demand.
The principles of social justice have great merit. Social justice is not charity. Social justice means enabling the participation of all—Dreamers, recent immigrants, minority populations, U.S. citizens—in the life and opportunities of the community to the extent possible. Social justice is the positive obligation that goes beyond nondiscrimination to offset the effects of historical and cultural exclusion. Enabling qualified Dreamers to become physicians is therefore an ethical obligation of the medical education community. The medical education community must remove barriers as far as possible and provide appropriate support structures to offset challenges specific to these students. In turn, these students will help the medical profession to serve underserved populations and will contribute to the cultural awareness and competence of their peers. This will foster a more widespread capacity across the medical profession to serve varied patient populations. We believe that removing barriers for Dreamers entails two actions by medical schools.
First, we believe that schools should recognize DACA-eligible Dreamers as a separate group or category of applicants rather than seek to fit them under the category of “international student” as some have sought to do, or—worse—exclude them from applying at all. As we noted above, DACA status is more accurate and does not reify the fiction that these students are foreigners. They are desirable applicants precisely because they are long-standing members of our U.S. communities who have had particular and rich cultural experiences. Furthermore, at some medical schools, international student status may also limit the kinds of financial aid for which the students are eligible. Thus, it is best to recognize the Dreamers precisely as who they are with the strengths they bring.
Second, as we noted earlier, social justice implies a duty of equality and equity toward these students. Most obviously, schools must seek to offset the limitations of their student loan eligibility. Equality prohibits placing arbitrary obstacles such as restrictive school admissions policies in the path of Dreamers. Moreover, medical schools must also assess the social support services that might benefit these students. Our preliminary discussions with Dreamer applicants and our experiences heretofore with the Dreamers in our summer pipeline program suggest that their experiences and needs are quite varied. Some have led active lives, involved themselves in their wider communities, and traveled much while others have lived “in the shadows,” staying close to home and operating primarily within the informal economies in which their families have sustained themselves. For this latter group, successful matriculation into a medical school environment that is possibly quite far from home and removed from familiar social networks may require deliberate mentoring and supplementary social support systems. Schools should not leave the securing of supportive resources to chance or to the ingenuity of the student.
Finally, both the medical and medical education communities have a duty to advocate a permanent immigration status for Dreamer students as they progress toward their future practices. The DACA program is a creation of a particular presidential administration and is subject to change with the inauguration of a new chief executive of the United States. Our duty to serve the communities our institutions serve requires that we steward the resources available to us including the talent of Dreamers. It is time to make the dream a reality.