Some commentators insist there is no real doctor shortage in the United States—or that the problem is mainly a shortage of training opportunities for Americans. In a 2022 congressional testimony submitted by Doctors Without Jobs, the problem was described as a training shortage with a call to prioritize U.S. citizens and lawful permanent residents for residency positions. A 2024 Heritage Foundation report makes a related but distinct argument: it acknowledges a physician shortage but says the main bottleneck is too few U.S. medical-school seats, and if there were more, then more residency positions can be filled with U.S. graduates rather than international medical graduates. These arguments disagree about where the bottleneck lies, but they share a broader claim: international medical graduates are evidence of a policy failure, and prioritizing American graduates would solve the problem.
The argument breaks down in three ways. First, it confuses who fills training positions with whether the country has enough training positions (both in medical school and in residency) and ultimately enough physicians to meet patients’ needs. Second, it understates the size of the shortage by measuring demand through the care people currently receive while ignoring future projections and ignoring those who delay or forgo care. Third, it assumes that international medical graduates (IMGs) are crowding U.S.-trained physicians out of the most competitive specialties, even though they are instead disproportionately represented in primary care and in rural and underserved communities where many U.S. graduates are less likely to practice.
Prioritizing Americans should mean prioritizing American patients’ access to care—not the nationality of the doctor who treats them. The scale of the problem is substantial: the AAMC projects a shortage of up to 86,000 physicians by 2036. That estimate may understate the country’s unmet need. If people who currently underuse care because of cost, distance, or other barriers began receiving treatment at rates closer to standard levels, the same AAMC analysis estimates a shortfall of roughly 117,100 to 202,800 physicians relative to current supply.
Reallocating existing residency positions from international graduates to American graduates would change who receives training, but it would not add doctors to the workforce or help close a shortage of that magnitude. Ending the shortage requires expanding the physician workforce and directing doctors toward the specialties and communities where patients face the greatest lack—not by excluding or otherwise constricting qualified professionals who are already helping fill those gaps.
For ordinary patients, the doctor shortage translates directly into longer waits, longer drives, narrower specialty access, and more conditions that spiral into emergencies because there simply aren’t enough doctors nearby. Misdiagnosing a structural problem as an immigration policy problem is dangerous because it keeps attention away from actual solutions that would help Americans, especially those at or below the median income.
About 81 percent of U.S. counties are “health-care deserts” of some kind, according to a 2025 GoodRx analysis. In these counties, a majority of residents lack adequate access to at least one of six services, including pharmacies, primary-care providers, hospitals, hospital beds, trauma centers, or community health centers. The problem of scarcity is not limited to rural areas; a 2025 AMN Healthcare survey of 15 major metropolitan areas found that new patients waited an average of 31 days for a physician appointment.
These burdens fall hardest on low-income patients because they have fewer ways to absorb scarcity: people with flexible work schedules and money for out-of-network care can travel or pay more, while people relying on Medicaid (which has a limited provider network), public transit, or hourly wages may have to miss work or postpone care. A 2024 Commonwealth Fund survey found that 41 percent of working-age adults who delayed care because of cost said their health problem worsened. Physician shortages therefore turn distance and waiting time into a financial and medical penalty borne most heavily by patients with the fewest alternatives.
When the physician shortage is framed primarily as a dispute over who receives training positions, policymakers can lose sight of the larger task: expanding the supply of doctors to meet patient demand. The resulting shortages are likely to be most acute in underserved specialties and high-need regions. Workforce planning should therefore focus not only on who enters training, but also on how many doctors the country needs and where they are most needed—especially in communities where middle- and lower-income patients receive care. Without that broader approach, policymakers can avoid investing in the supply side of care while measurable consequences such as delayed diagnoses and higher use of emergency departments accumulate in the background.
The First Mistake: Confusing Allocation With Capacity
To understand why the “foreigners are taking American spots” story is mistaken, it helps to start with understanding how residency works. Graduating from medical school is not enough to practice medicine independently in the United States. After graduation, physicians must complete residency, a period of supervised specialty training that usually lasts three years for fields like family medicine and longer for surgical specialties. Graduates must also pass the three-part United States Medical Licensing Examination (USMLE)—Step 1, Step 2 Clinical Knowledge, and Step 3—and meet any additional licensing requirements set by the state where they want to practice.
Each year, the National Resident Matching Program uses an algorithm to pair applicants and residency programs. Applicants rank the programs they want, programs rank the applicants they want, and the system matches people into available positions. The Match determines who gets which slot; it does not determine how many slots exist in the first place.
Moreover, the Balanced Budget Act of 1997 capped the number of residents most hospitals could count for Medicare funding, generally at their 1996 levels. That decision reflected projections of a physician surplus rather than a shortage, and it did not create a mechanism for funding to adjust as the population grew and aged. Since then, the U.S. population has grown from about 268 million in 1997 to nearly 342 million in 2025—an increase of roughly 28 percent—while the share of Americans age 65 and older rose from 12.4 percent in 2004 to 18 percent in 2024. The cap does not prevent hospitals from creating additional positions: in 2018, the Government Accountability Office found that 70 percent of teaching hospitals trained at least one resident above its Medicare cap, although Medicare still funded the large majority of residency positions. The AAMC has reported that hospitals were training more than 13,000 residents above their caps without federal support–roughly 9 percent of all residents.
Residents are less expensive than fully trained physicians and provide valuable clinical labor, but they cannot practice independently; each additional position requires attending supervision, faculty, clinical sites, accreditation, administrative support, and funding. Hospitals may add positions when doing so serves their own staffing or teaching needs, but they have less incentive to finance training whose benefits extend to the broader national workforce. This makes residency expansion particularly difficult for rural and community hospitals, which often have the greatest need but the fewest resources to support new programs.
That means the real bottleneck is funding and the number of total residency spots, not the nationality of the people in the applicant pool. If international medical graduates disappeared tomorrow, the number of funded residency positions would still be the same number, and the same number of doctors would come out the other end. The Match would simply allocate the same capped set of slots among a smaller pool of applicants.
Some U.S. graduates do go unmatched, but the number depends on which graduates are counted. In the 2025 Main Residency Match, 1,324 of 20,368 U.S. MD seniors—6.5 percent—and 619 of 8,392 U.S. DO seniors—7.4 percent—did not initially match to a first-year residency position. Most later found positions through the post-Match process known as the Supplemental Offer and Acceptance Program (SOAP): after both stages, 97.8 percent of U.S. MD seniors and 98.4 percent of U.S. DO seniors had secured positions. Even among graduates applying after their graduation year, roughly half of active U.S. MD and DO applicants matched to PGY-1 positions in 2025.
For the applicants that did not initially match, the reasons are not simply that international graduates took their places. According to the NRMP’s analysis, match outcomes are associated with the competitiveness of an applicant’s preferred specialty, the number of programs ranked, exam scores, and other qualifications. Some applicants rank only a narrow range of highly competitive programs, while others may be disadvantaged by their academic records or application materials. If international medical graduates disappeared, some positions might be filled by U.S. graduates who otherwise would have gone unmatched—but the number of residency positions would not increase. The result would be a change in who receives training, not an expansion of the physician workforce.
The Second Mistake: Pretending the Shortage Is Small
The physician shortage in the United States is a large structural shortfall that reflects aging patients, aging physicians, burnout, uneven specialty distribution, and decades of underinvestment in training capacity.
The Association of American Medical Colleges projects a physician shortage of up to 86,000 doctors by 2036 under baseline assumptions. More strikingly, the AAMC estimates that if populations that currently underuse care because of cost, distance, lack of access, or other barriers began using healthcare at rates more in accordance with standard treatment, the country would face a shortage of roughly 117,100 to 202,800 physicians relative to current supply.
That last point matters because it reveals how misleading current “observed demand” can be. A healthcare system can appear merely strained when, in reality, many people have already given up on getting timely care. They skip appointments, delay follow-up, or never establish stable primary care relationships at all. Measured demand therefore often understates medical need.
As a simple matter of supply and demand, why hasn’t the market solved this problem? Because health care is not a normal market. In a textbook market, a shortage raises prices, attracting new suppliers until supply catches up. But in medicine, both sides of that adjustment are distorted. On the demand side, people who cannot afford care, cannot travel, or cannot take time off work often disappear from the observed market: they do not make appointments, so their unmet need never appears as demand. The patient also does not have the power to negotiate. The doctor’s office tells patients what they owe, but does not set the price for most services. The cost of medical services involves negotiated contracts with commercial insurers or is established by a fee schedule set by Medicare or Medicaid. Patients therefore have only limited ways to respond: when possible, they can switch plans, search for other in-network providers, pay out of pocket, or accept the providers and waiting times available through their coverage. None of these options give patients meaningful leverage over price or access, while the options that offer the most flexibility—cash payment, out-of-network care, or traveling farther—are least available to low-income patients.
This helps explain why high spending and high physician incomes can coexist with severe shortages. A low-income community may have enormous unmet medical needs without generating enough financially visible demand to attract new providers. In health care, the people most harmed by scarcity are often the least able to make that harm and scarcity visible in the market economy.
The supply side is also unusually slow to respond. Even if the conditions for increased supply were perfect, a person would still need to complete medical school, pass the licensing exams, and undergo several years of supervised residency training in order to enter the workforce. Even when more physicians are available, they are not interchangeable. A cardiologist cannot fill a psychiatry shortage, and a doctor in Boston cannot serve a shortage area in Mississippi.
That is why addressing the shortage requires policy: expanding residency capacity, directing training and payment toward shortage areas, and creating supervised pathways for qualified international medical graduates.
Now compare that shortage to the scale of unmatched American graduates. Using the 2026 figure of roughly 2,000 unmatched U.S. graduates, the numbers still do not come close to solving the broader workforce problem. If the country is short around 200,000 physicians under a fuller-demand scenario, then even instantly turning every unmatched American graduate into a practicing doctor would leave a massive gap. And of course that thought experiment is unreal: not every unmatched graduate is permanently excluded (many reapply and get accepted), and not every unmatched graduate is suited for every specialty.
The Third Mistake: Misunderstanding Where Foreign Doctors Actually Work
International and U.S.-trained graduates do compete for some of the same residency positions, but they are not competing for one undifferentiated pool of identical jobs. U.S. graduates are concentrated in the most competitive specialties and institutions, while international graduates are disproportionately represented in primary care and in rural and underserved communities.
In the 2026 Main Residency Match, U.S. MD seniors matched at a rate of 93.5 percent, and U.S. DO seniors matched at 93.2 percent. By contrast, match rates for U.S. citizen international medical graduates were lower, at about 70 percent, and non‑U.S. citizen international medical graduates were lower still, at 56.4 percent. If the system truly preferred foreign graduates over American ones, those numbers would look very different.
These figures compare different applicant pools under different conditions. International graduates must complete additional ECFMG certification requirements, and many non-U.S. citizens also need visa sponsorship. The lower IMG match rates therefore reflect a more difficult and selective route into residency.
The specialties that attract the most prestige and the most intense competition–such as dermatology, neurological surgery, plastic surgery, orthopedic surgery, and otolaryngology–are already among the areas where the number of U.S. graduates is already much higher than international medical graduates.
International medical graduates are concentrated elsewhere: internal medicine, family medicine, pediatrics, psychiatry, pathology, rural hospitals, and high-need communities. Research on the physician workforce has repeatedly found that IMGs are more likely than U.S.-trained physicians to practice in underserved areas and to enter primary care fields in which the doctor shortage is most pressing.
Programs such as the Conrad 30 J-1 waiver allow states to request waivers for international medical graduates who agree to practice for at least three years in federally designated Health Professional Shortage Areas—such as rural communities, low-income urban neighborhoods, and public or nonprofit clinics serving populations with too few providers. The waiver removes the usual requirement that J-1 physicians return home for two years after training, allowing them to remain in the United States and work in these communities. In other words, federal policy recognizes that these locations have persistent difficulty recruiting physicians.
That is why cutting IMG participation would not produce a neat one-for-one substitution in which eager American doctors step into every vacated role. In many cases, the realistic alternative to an IMG physician is not an American replacement waiting in the wings, but a clinic with fewer doctors, a rural county with no local specialist, or a hospital under even more strain.
Far from protecting ordinary Americans, this kind of policy would make it harder for working-class and rural patients to see any doctor at all. It would mainly reduce care in the very communities that already bear the brunt of shortages.
Not Every Unmatched Graduate Has Been “Barred by Foreigners”
Part of the rhetoric around residency shortages relies on a hidden premise that anyone who finishes medical school is qualified to practice, wants to practice, and should automatically be guaranteed a residency slot–and that failure to match can only be explained by unfair exclusion. That premise is difficult to defend in any profession where the stakes are people’s health.
Residency programs are not just credentials; they are selecting future physicians for intense clinical environments. The residency selection committees weigh exam performance, clerkship evaluations, letters of recommendation, interviews, specialty fit, professionalism, and the program’s own institutional needs. Some applicants reapply and later match. Some change specialties. Some improve their applications. Some do not match because other applicants are simply stronger. At the end of the day, although the Match runs by an algorithm, it is merely a preference matching algorithm. The people in the hospitals still choose who they want to be their trainees and future colleagues. The NRMP does not report how many applicants were “unqualified.” Its data show associations between match outcomes and factors such as exam scores, specialty choice, and the number of programs ranked, but no causal breakdown of why each applicant failed to match.
That does not make the unmatched-student problem trivial. Failing to match can harm a career and leave a graduate with crushing debt. But it is still different from claiming that international doctors are the reason all of those people are shut out. Some U.S. applicants may lose particular positions to international graduates, but that individual displacement is not evidence that international physicians caused the national shortage or that excluding them would improve access to care.
It’s worth noting that a 100 percent match rate would also be an odd goal on its own terms. It would mean residency programs effectively lose the ability to reject candidates who raise real concerns about readiness, judgment, interpersonal skills, or specialty fit. No serious system responsible for training physicians should be forced into automatic acceptance of every graduate regardless of quality.
The Real Drivers of the Shortage Are Structural
Once the scapegoating frame is removed, the actual causes of the physician shortage come into focus. The first is demographic. The population is growing, and the population is aging. Older patients need more care, often across multiple specialties, while a large share of the physician workforce is itself nearing retirement age.
That growth will not continue forever. The Census Bureau projects that deaths will outnumber births by 2038; under its middle-immigration scenario, the total population would continue growing until roughly 2080 before peaking and declining. Any eventual decline could moderate demand in the long run, but it will not address the near-term shortage as the physician workforce is aging out of practice. AAMC workforce data show that 23.9 percent of active physicians were already 65 or older in 2024, while an AAMC retirement analysis places the median physician retirement age at roughly 67. The relevant question is therefore not simply whether the number of patients will eventually shrink, but whether enough physicians will remain available as current doctors retire or die.
The second is burnout and attrition. Multiple surveys since the pandemic have found substantial cuts in hours, early retirements, and serious levels of emotional exhaustion across medicine, particularly in already strained fields such as emergency medicine, family medicine, pediatrics, oncology, and obstetrics and gynecology.
The third is policy design. Federal funding rules constrain residency capacity, while state licensing rules can make it difficult for experienced foreign-trained doctors already living in the United States to practice at their level of training. Under current rules, many international graduates must repeat U.S. residency before practicing independently, so simply recruiting more doctors from abroad does not bypass the residency bottleneck. Some residency programs also impose time-since-graduation limits that can effectively screen out the most experienced international graduates from consideration, even when they have completed substantial postgraduate training abroad.
States should complement residency expansion with supervised, provisional licensing pathways for qualified international graduates who pass U.S. exams, complete credential checks, and demonstrate competence in practice. This would put physicians already in the country to work sooner.
The United States is not suffering because it has too many foreign doctors in medicine. It is suffering because it has too few total doctors. Residency slots are capped by funding, and new ones are not created by excluding foreigners. The doctor shortage is vastly larger than the number of unmatched American graduates, and international medical graduates are concentrated in the very specialties and communities where shortages are already most severe. Blaming foreign doctors is therefore not just bad politics or bad ethics. It is bad arithmetic. A country facing a genuine physician shortage cannot afford to confuse immigration scapegoating with workforce planning. The real solution is harder but also much clearer: expand training capacity, modernize licensure, and stop driving away the physicians who are already helping keep the system afloat.