Like many internationally trained physicians in the United States, it took years before Duncanville surgeon Anil Tibrewal could call Texas home.

Fifteen years of medical training to be exact. While the U.S. usually requires international medical graduates to complete a second medical residency in this country, Tibrewal completed three: one in India, another in England and the third in New York and Cleveland.

“I just thought about what is best for my family,” he said. In the end, his decision to move to the U.S. was worth it, and now he trains other surgeons in Dallas in addition to running a solo surgical practice for the past 16 years.

But starting this year, foreign-trained doctors like Tibrewal will no longer have to repeat their residency in the United States, where new grads receive hands-on training for up to seven years. Texas last year joined 17 other states by waiving the second residency requirement under a new law designed to bring more doctors more quickly into Texas cities and towns.

These “pathway” laws may seem a curious anomaly, running counter to the federal and state Republican push to keep immigrants without a clear path to working legally out of the United States. But for decades, foreign doctors have become a critical piece of U.S. health care, particularly in rural and underserved regions.

Texas has been facing a shortage of physicians, thanks to phenomenal population growth and an aging population of doctors nearing retirement. Of the 100,000 doctors licensed in Texas, about a fourth were trained outside the United States, matching the national ratio. It’s not clear how many of those are actually working as doctors. Still, the Texas Department of State Health Services predicts the state will see a shortage of 10,000 doctors by 2032, and Texas medical schools cannot make up that shortage.

“Current projections for medical education enrollment indicate that the state’s medical education system will not create a supply of physicians that will meet projected demand,” the state health department has concluded.

Enter House Bill 2038, known as the DOCTOR Act, from state Rep. Tom Oliverson, R-Cypress, an anesthesiologist who wanted to create an easier licensing pathway for military veterans and U.S. and foreign-born doctors who may have graduated but did not complete a residency program in the United States.

New rules, new medical license

Oliverson was not available to discuss his legislation, but according to his staff, the idea was not to lure more doctors from other countries but to attract foreign-trained doctors already living in the U.S. who have completed a medical residency in their own country.

“We talk every session about shortages in health care providers, particularly doctors in primary care,” Oliverson said last year in an episode of the Texas Public Policy Foundation’s The Layout podcast, adding that the shortages persist despite legislative attempts to correct it.

“Essentially, there are people out there who are willing to come practice medicine in our state who are capable of practicing,” he said. “These folks are all physicians. But they’re not able to practice here or the pathway ... is so difficult they chose not to practice here.”

Last month, the Texas Medical Board approved rules for a provisional medical license for doctors who fit the new HB 2038 category. Those rules, which go into effect this week, will allow foreign doctors who have completed a residency outside the United States — and who have a job offer in Texas — to be supervised by a licensed physician instead of completing that second medical residency to qualify for that provisional license. After four years, they will be eligible to apply for a regular Texas medical license.

To qualify for the program, they must have five years of experience working as a doctor before coming to the United States, be proficient in English, be in good standing to practice, free of disciplinary action and pass required parts of the U.S. licensing exam.

“I think it’s actually going to help physicians over here get into residency programs because now they’re not potentially going to be competing (for those slots) against foreign medical graduates,” said Dr. Sherif Zaafran, president of the Texas Medical Board. “So we’ve increased the denominator of physicians.”

In addition, the new law requires these provisionally licensed doctors to work another two years under supervision in health care deserts, typically more rural communities with too few doctors. Afterward, these doctors would qualify for a regular Texas medical license.

“This process allows for physicians to staff underserved areas in the pursuit of an unrestricted license, and also with the hope that some of them may set up permanent residence there,” Zaafran said.

Tibrewal and others hope it will help address the physician shortage.

“I think it’s overall a good thing,” Tibrewal said. “There is a shortage of doctors in the U.S., mostly in smaller areas. This helps bring qualified physicians to fill that gap. … If I had a choice, I mean, you know, definitely, it would have saved five years.”

H-1B visa fee hike hurting foreign doctor recruiting

Oliverson aims to attract foreign and military doctors who are already in the U.S. but working in other fields because they did not complete the required residency. Employers might prefer to hire those kinds of doctors over others still abroad to avoid paying the cost of an H-1B visa, the document foreign doctors use to work in the United States. President Donald Trump recently raised the cost to a whopping $100,000.

That executive order has thrown a new wrench into U.S. physician recruiting efforts, said Dallas immigration attorney Ann Badmus, who works with foreign doctors trying to work here. “I do see a little bit of a drop of the cases we typically have,” she said. “It’s too much uncertainty for some people.”

Zaafran acknowledged foreign doctor recruiting efforts have been caught in the crossfire of the H-1B visa price hike. “The executive order by President Trump, I believe per what they have been saying, was really mainly directed at high tech,” he said.

Still, some doctors like Dr. Jayesh Shah, an international medical graduate who works in San Antonio, worry the fee will hamper what has been a consistent flow of doctors, nurses and other health care workers to the United States. “Hopefully they will exempt health care workers.”

So far, business groups including the U.S. Chamber of Commerce have been unsuccessful in challenging the new fee in court.

Days before Christmas, a federal judge ruled in favor of the Trump administration. The Chamber of Commerce and the Association of American Universities had sued the Department of Homeland Security, arguing that only Congress, not the president, had the authority to impose the fee. The fee, their lawsuit argued, will impact hospitals and other businesses, resulting in job cuts and reduced services. That ruling has been appealed.

For years, Zaafran said, Texas-based employers have offered foreign doctors large signing bonuses.

If the higher visa fee remains in effect, he said he expects more recruiters offering to cover it. “I can foresee employment groups offering that $100,000 to be covered in return for a four-, five-, six-year commitment to see the return of the investment,” Zaafran said.

Dr. Avneesh Chhabra (CQ), a radiology professor at UT Southwestern Medical Center in Dallas believes the federal government will eventually back down on the visa fee hike because of the doctor shortage. But if that doesn’t happen, employers will eventually weigh the price of the visa against what an added health care provider can bring to a practice.

Chhabra welcomes the new law with a few caveats. “Right now there’s a shortage of doctors and we all know that and that is worsening,” he said. “I think it is a welcome move.”

His main concern is how well Texas employers will vet new doctors and their education credentials under this program. Chhabra, who trained in India and did residencies there and Philadelphia, said not all medical schools abroad are equal and that employers will need to scrutinize their candidates carefully.

Chhabra said he received a rigorous education both at school and during his residency there. “They train you like a real badass,” he said. But again, not all schools there, just like in the United States, are equal, he said.

“There has to be vetting,” he said.

Opportunity or cheap labor?

Not everyone believes there is a physician shortage in Texas. Dr. Ivan Melendez, who serves as the Hidalgo County medical authority, said what Texans are really struggling with is a way to pay for health care. Patients who need brain surgery aren’t waiting six months to see a neurosurgeon; they’re struggling with how to pay for that surgery, he said.

“The problem is not that people don’t have access to medical care,” he said. “It’s access to having the money to pay for health care.”

Zaafran of the Texas Medical Board has heard this argument before and disagrees.

“Insurance payments, Medicare and Medicaid cuts have all certainly been a factor in the economics of health care,” he said. “I don't believe it is the primary driver of our shortages.”

Melendez believes the intent of the new program is to attract more doctors who can be paid less by hospitals, medical practices and insurers, which as a result keeps their own costs down.

That’s not going to happen, insists Zaafran. “As far as these physicians being abused by decreased reimbursement or taken advantage of by hospitals, the board has put measures in place that helps minimize the chance of that happening,” he said. “Under this current mechanism, we are increasing the overall number with strict initial oversight to ensure no decrease in quality of care.”

This article first appeared on The Texas Tribune.