It is estimated that currently there are approximately 1.8 million young immigrants who came or were brought by their parents to the United States before age 16 without documentation and have been raised and educated in the United States as Americans.1 These youths’ educational achievements and aspirations are similar to those of their native-born peers, yet their unchosen undocumented status has hindered their pursuit of higher education, especially in medical and other graduate health sciences. Because they lack legal status, they have traditionally had limited access to financial assistance, as well as an inability to obtain legal employment, among other barriers. Nonetheless, many are driven by hopes of achieving the “American Dream” for which they and their parents originally immigrated.
There has been significant progress recently in legislation and policy at the state and national levels allowing for greater contribution by these undocumented youth to U.S. society. In September 2012 the Deferred Action for Childhood Arrivals (DACA), a national-level policy change, went into effect.2 Under DACA, eligible youths are being granted permission to reside and work in the United States. DACA-eligible youths must prove that they arrived in the United States prior to turning 16; were under the age of 31 in June 2012; have continuously resided in the United States since June 15, 2007; are currently in school, graduated from high school, or obtained a general education development certificate (GED); and have not been convicted of a felony, a significant misdemeanor, or three or more other misdemeanors.2 Once an eligible youth is approved, DACA defers deportation and grants lawful presence in the United States, work permits, Social Security numbers, and, in most states, driver’s licenses, all renewable every two years.2 These policy changes give undocumented students with DACA approval greater freedom to reach their educational and career goals.
DACA students represent a suddenly accessible, heretofore untapped, potential workforce. Recent reports indicate that there will be a primary care physician shortage in the United States.3 This shortage is due to a shrinking primary care workforce,4 an aging U.S. population,5 and the implementation of the Affordable Care Act, which will make health care accessible to more than 30 million uninsured Americans.6 DACA students could help alleviate the expected physician shortage.
It is difficult to estimate the full impact of DACA on the medical school applicant pool as DACA may also increase undergraduate completion among this group. One estimate in California indicated that only about 10% to 20% of undocumented students who graduated from high school enrolled in college.7 This is in contrast to the general population in which the percentage of high school graduates who subsequently enrolled in college was 68.2% in 2011.8 Moreover, the national graduation rate for bachelor’s degrees (completion in six years or less) is about 59%.9 A low estimate of potential, undocumented students in medical school can be estimated by applying current rates of enrollment of undergraduate education among undocumented students (10%)7 and subsequent entry into the field of medicine (about 2%–3%)10 to current estimates of total DACA potentials in the United States (1.8 million).1 This results in an estimated 5,400 new, largely underrepresented minority physicians in the coming decades. A best-case-scenario upper estimate can be estimated using the same method but imputing the current, general graduation rate (59%)9 to DACA students, which results in an estimated 31,860 potential future physicians. An undocumented student network called Pre-Health Dreamers reports that it currently has over 215 prehealth undocumented students in 27 states in its network.11
One social mission of medical education is to increase the number of primary care physicians in health professional shortage areas, especially those populated by underrepresented minorities.12 DACA students demonstrate characteristics likely to contribute directly to this social mission. DACA students are largely underrepresented minorities themselves,1 and such physicians are likely to return to and serve their communities, which are often low-income, health professional shortage areas,13,14 and are also likely to specialize in primary care.13,15 Further, undocumented students exhibit high levels of civic activity and express a deep commitment to give back to their communities.16
This Perspective is intended to begin discussion within the academic medicine community about the obstacles undocumented students face in navigating medical education and training, the implications of DACA in diminishing some of these obstacles, and proposed solutions to remaining barriers. It is, moreover, a call to peers in the medical community to support qualified undocumented students interested in pursuing medical careers. This Perspective is based, in part, on the experiences of DACA students in California at the premedical, medical school, and residency levels. We hope to begin a conversation within the medical community about making medical education more accessible to this underserved group.
Medical School Application Process
The first hurdle DACA students face is figuring out which medical schools will accept their applications. Although a few schools have informally begun accepting DACA students, Loyola Stritch School of Medicine in Chicago is the only school that has made a formal announcement on DACA students’ eligibility.17 Faced with uncertainty about their eligibility, DACA students have reported contacting medical schools one by one, only to find tremendous variation in the responses to their DACA status, sometimes receiving conflicting answers from different individuals at the same institution. Once they have identified the schools that appear ready to accept a DACA application, the students run into the application fees. Typically, DACA students come from immigrant families who have limited financial resources,18 yet they are explicitly excluded from the Association of American Medical Colleges Fee Assistance Program, which waives application and Medical College Admission Test fees for low-income U.S. citizens and permanent residents.19 Therefore, because of the cost of each application, they may be forced to limit the number of schools to which they apply.
An important step would be for students to have access to accurate information regarding their eligibility for admission to institutions, so as to maximize limited resources. Once eligibility at schools has been determined, medical school admission staff should be informed of the eligibility status of DACA applicants. In addition, the creation of a published national list of schools that accept DACA students would be helpful.
Financing a Medical Education
Ineligibility for federal aid
The price tag of a medical education is extremely high. Financing a medical education is a challenge for all medical students, but it is particularly difficult for DACA students because they are legally excluded from receiving federal financial aid. DACA students may be eligible, however, to apply for private need- and merit-based scholarships, private loans, school loans, and institutional aid. Also, some state laws allow undocumented students to apply for publicly funded grants.20 Medical schools can assist DACA students by offering financial planning advice early on, in order to prevent financial status from being a prohibitive barrier to their matriculation in the face of limited options for financial assistance. Medical schools can further encourage students to join their programs by creating flexible and generous scholarship packages and providing paid opportunities, such as research positions, within their programs.
International student fees
Whereas some states expect DACA students to pay more expensive international student fees for their education, 12 states have passed laws allowing DACA students to qualify for in-state tuition at public universities, including California and Texas, the two states with the largest populations of DACA students. The National Immigration Law Center (NILC.org) presents regularly updated student fee information on its Web site.20
Driver’s licenses and mobility
During the clinical years and as resident physicians, students often need to drive to distant clinical sites. Prior to 2012, undocumented students could not obtain driver’s licenses, which posed a significant hardship in traveling to disperse clinical sites. Since 2012, DACA-approved youths have been able to obtain driver’s licenses in most states. Although there is some variation in different states’ policies, at least 45 states offer driver’s licenses to DACA beneficiaries. Only Arizona and Nebraska specifically bar DACA beneficiaries from obtaining a driver’s license.21
Previously, undocumented physicians could not be employed after graduating from medical school because they did not have employment authorization. This has changed for DACA students, who can now obtain work permits and Social Security numbers and thus continue on to residency. DACA students may be employed in the same way as any other individual possessing a work permit. There is no need for additional paperwork or sponsorship in the employment process of an individual who is a DACA beneficiary.
A DACA beneficiary’s ability to apply for medical licensure is most likely dependent on each state’s regulations. In the four states with the highest numbers of DACA potentials (California, Texas, Florida, and New York),1 there are no laws that explicitly prohibit licensure of a U.S.-trained undocumented resident physician, though both Texas and New York have a similar stipulation that noncitizen, non-permanent-resident physicians must practice in physician shortage areas within the state for a minimum of three years.22–25
Medical programs that choose to accept and support undocumented students should recognize that these students might have psychosocial needs. Given the assortment of challenges their documentation status presents, these youth may report feelings of sadness and fear associated with the uncertainty intrinsic to their path.26 Notably, undocumented youth who continued their education through college reported that their success was facilitated by strong social support from teachers, counselors, and other mentors.27 Medical programs can actively provide this social support and create a welcoming environment for their students by training staff to be sensitive and informed of their circumstances. The high-achieving students who successfully enter medical school are likely to have developed reliable and productive coping strategies that are advantageous when undergoing the rigorous medical training process. Still, their unique circumstances and challenges warrant the availability of sensitive and supportive staff, faculty, and administration.
Many undocumented youths are hardworking, high-achieving students who face great obstacles in obtaining higher education. Society already has invested significant resources by educating these youths. We can all benefit by helping these students continue through higher education, which in turn will increase their opportunities to contribute meaningfully to the country they call home.
It is time for broad discussions among medical school administrators, faculty, students, and staff to develop institutional responses and to make standards readily available and more transparent for interested undocumented students. We call on the medical community to support these students as they pursue medical careers. Specifically, we encourage medical programs to consider accepting undocumented students and to openly promote their stance on eligibility, so as to make it easier for these students to navigate the application process. We also hope that schools will offer additional financial support to undocumented students, as their documentation status still prevents them from accessing federal financial aid, and this remains the steepest barrier for this group. Finally, we hope that our peers in the medical community will be aware of state policies that affect undocumented students, and be sensitive, empathic, and supportive when encountering these students seeking access to the medical professions.
Acknowledgments: The authors would like to thank Jirayut New Latthivongskorn and Denisse Rojas, founders of Pre-Health Dreamers, for contributing their experiences and insight to this piece. They also thank Cynthia Chamberlin, MA, CPhil, for kindly reviewing this work.
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