Why are we holding immigrants back?
By: Josh T. Smith
Tags: Public Health, Dentistry, Immigration, Policy

Imagine you are born outside of the United States. You work hard, get an education, and work in a well-paying job. After 10 years of experience, you decide you want to move to the United States. You would like to keep working in the same field you’ve been in for years, but you are not sure of the necessary steps to have your foreign license recognized within the United States. Even though you are fluent in English you can’t find clear answers. And the state laws differ, so a solution for one place doesn’t apply to another. Amid the uncertainty, you decide to make the move, only to learn you won’t be able to work in your field, despite your past decade gaining expertise working in the industry. However, you still need to make ends meet, so you start working one of the first jobs you find as a taxi driver until you can sort out the requirements for returning to your trade.

For many immigrants educated outside of the US, this is their reality. Of the 4 million foreign-educated immigrants in the labor force, 1.2 million are either underutilized (working in low-skilled jobs) or unemployed. Recent research suggests that occupational licensing laws — laws that control who can work in certain trades — increase the likelihood of immigrants being overeducated by between two and four percent. This is due to a mix of factors. For example, immigrants struggle to work in licensed trades because of poor English proficiency, unclear hiring expectations or hiring processes, or simply not having a professional network to rely on. A major barrier is the ambiguity in having foreign credentials recognized, whether it is a formal degree or just training or experience. There are significant costs in having those credentials recognized within the United States.

For some occupations, these barriers make sense. Occupational licensing laws create standards that are meant to promote public health and safety. These standards include requirements like licensing fees, education requirements, a set number of practice hours, or competency tests. Licensing laws are simply meant to prevent people without relevant training from offering root canals or wiring the electrical components in your home.

But these state-level laws often make it unnecessarily difficult for immigrants to navigate earning a license or having their foreign credentials recognized. These barriers create lower licensing rates among immigrants. Immigrants are about 34 percent less likely to work in licensed fields. And the same barriers explain immigrants’ tendency to be over-educated for the fields they work in.

Smart licensing policy can promote health and consumer safety benefits while creating a clear path towards the inclusion of foreign workers. Research shows many workers already have the relevant education or skills but are simply stymied by the complicated process. Policymakers should be considering three broad questions when shaping licensing policy:

Is requiring a license to work in the trade the best option, or are alternative policies, like certification or insurance, better for consumers? What, if any, pathway to licensure for immigrants exists? Is information about this pathway available and widely accessible?

The best way to get immigrants into a field might be to replace the requirement for a license with some other type of consumer protection, as many occupations are not licensed in all states, and licensing is the most restrictive form of consumer safety regulation. This is a convenient option as well since it requires only the removal of a license. This favors alternatives as simple as digital platform rankings or reviews, like Uber, Google Reviews, Yelp, or AirBnB use. Internet services like this make it easier than ever for consumers to learn about and avoid bad service providers.

Yet many occupations will remain licensed. And when the rubber hits the road in those fields, many states have not done enough to make their licensing processes clear for immigrants. State policymakers should reconsider their licensing laws and ensure that they are creating pathways towards integrating foreign workers with relevant education and training. Often that integration only requires opening the door.

How foreign dentists start working in the US

Dentistry is one example of a field where the consumer safety argument for licensing is stronger. Dentists remove teeth, drill into teeth, and administer anesthesia during certain procedures, making dentistry a field where serious harm can occur to consumers. Most states require that licensed dentists oversee patient care and most also require that assistants or therapists have their own licenses.

When a dentist trained outside of the US arrives here, what is the process for her to obtain a license? Overall, they are demanding requirements that can also be redundant because state licensing boards rarely recognize foreign credentials or degrees. To apply for a dental license, applicants must have graduated from an accredited dental university in the United States. The accreditation is managed by the American Dental Association’s (ADA) Commission on Dental Accreditation (CODA). Because CODA formally accredits only one foreign dental school, most foreign dentists must return to school if they want to practice in the United States. However, there is also an agreement between the United States and Canada to recognize licenses from accredited dental universities in the other country. Students from these Canadian schools, or the dental school directly accredited by CODA, can proceed to immediately apply for licenses in the United States just as students of US-based schools would.

Even where foreign experience is recognized, it usually only subtracts one or two years from US dental schools’ education requirements. Often foreign dentists must attend the last two, and sometimes three, years of an accredited US dental program before sitting for the licensing exams. According to the ADA’s survey, annual program costs range from $74,818.50 to $107.019.75 for non-residents. In addition to these costs, there are additional barriers and requirements for foreign students to receive student loans.

The American Dental Education Association (ADEA) provides information about general requirements and a central application platform foreign dentists can use to apply to many of the schools that have programs that accept foreign experience.

There are additional resources to help foreign-trained dentists along the pathway to working in the US. For the application process, The American Student Dental Association (ASDA) provides information on alternative routes to licensure, along with tips for the interview and skills tests. There are also private programs like The International Dentist Central (IDC) that charge for their services. The IDC is run by Dr. Alyssa Marshall, a foreign-trained dentist from South Korea who assists other foreign dentists in taking the required steps to work as a dentist in the United States.

Altogether, foreign dentists face a long path to working in the United States. That makes sense to some degree since dentistry is more dangerous than other licensed fields. But it might be asking too much. There’s a lot of room between an unregulated dental free-for-all and requiring dentists from outside of the country to go back to dental school in the United States. There’s room in licensing rules to better recognize the foreign experience or training that the dentist has. In August of 2019, the dental education program at King Abdulaziz University in the Kingdom of Saudi Arabia became the first internationally accredited dental university by CODA. That means students from this program can immediately apply for licenses within the United States. More state licensing boards and dental accreditation groups should be considering how to accredit international schools as a way to get immigrants already in the country working in dentistry (and other licensed fields).

A promising example is Minnesota. As of 2008, Minnesota is the only state that lets internationally-educated students sit for the same exams as dental students educated in the US. To qualify for this US-education exemption, Minnesota’s licensing board must deem the foreign training equivalent or better than CODA schools. They do this on a case-by-case basis evaluating the coursework of each foreign dentist, an interview, and examining three patient records.

Minnesota’s rules here are a positive step that other state licensing boards should emulate or improve on. If dentists trained outside the country can pass the same exams as native dentists, then there’s no reason to exclude them from the field or require redundant education. Making this the default pathway would simplify the path for foreign-trained dentists.

States should do more to help immigrants along the way

Dentistry is a useful example because much of the US suffers from a shortage of dental healthcare providers. It’s unclear how many foreign dentists already live in the US but are prevented from working in dentistry. However, recruiting foreign professionals will be a challenging task given the requirement that most foreign dentists go to US accredited programs.

Source: Does Occupational Licensing Impact Access to Dental Care? The Center for Growth and Opportunity at Utah State University, August 7, 2019.

Many licensed fields could benefit from implementing clearly defined pathways and widely accessible resources for potential immigrant workers. Since licensing is largely a state issue, each state needs to consider how best to revamp its policies.

For example, Michigan has a Licensing and Regulatory Affairs (LARA) website that includes detailed pathways for immigrants to obtain licenses in specific occupations. It acts as a central database for easy access to knowledge about different licensing pathways. Below is the flow chart provided on LARA’s website for a foreign dentist seeking to practice within the United States. LARA makes available information about pathways widely accessible and includes alternate pathways (including non-licensed alternatives) if the desired license requirements cannot be met.

Source: Michigan Office for New Americans and the Michigan Department of Licensing and Regulatory Affairs, July 2019.

In California, Governor Gavin Newsom recently signed a bill that asks boards within the Department of Consumer Affairs to expedite professional licensing applications for refugees, asylum seekers, or those with special immigrant visas. California’s law maintains rigorous requirements for professional licenses, but it also clearly outlines those expectations so that immigrants can understand and then meet them.

While adjustments to policies and programs that directly affect licensing are important, none of those changes would be possible without first understanding what prevents so many foreign-trained neighbors from practicing their desired trade within the US.

This year, in a bipartisan effort to understand why so many immigrants fail to find gainful employment based on their existing skill sets, US Congressmen John Katko (R-New York) and Ben McAdams (D-Utah) introduced the Improving Opportunities for New Americans Act of 2020. The act aims to identify current challenges and eliminate barriers that keep immigrants from reaching their potential. If passed, it will require the US Department of Labor to study how occupational licensing and other factors affect employment opportunities in the United States for immigrants and refugees with professional credentials obtained outside of the United States.

These federal and state-level reforms are exciting. Dentistry is one example, but immigrants are held back in many fields for reasons that don’t serve licensing’s consumer protection purpose. A promising first step would be for state licensing boards to consider how they recognize foreign credentials. Michigan and California are leading examples of how states can start putting the 1.2 million underemployed immigrants to work in skilled trades. That will make their rare and valuable skills more available to citizens across the country.

Jaslyn Stevens, one of CGO’s student research fellows, coauthored this essay.