ROBERT SIEGEL, HOST:

And we turn now to the ongoing debate over immigration reform. One of the goals of reform, say advocates, is to get more skilled workers into the U.S. But just increasing the supply of professional visas isn't enough. Some disciplines, including medicine, also have tough state licensing requirements. And as Robert Smith of our Planet Money team reports, that can be a huge hurdle.

ROBERT SMITH, BYLINE: People around the world want the same thing from their doctors. First, do no harm. Second, could you take a look at this bump on my neck? I don't know - kind of feels funny.

See, the job's the same everywhere, but the pay is much higher in the United States.

DEAN BAKER: Our median pay for doctors is somewhere around 250,000 a year.

SMITH: Dean Baker is an economist with the Center for Economic and Policy Research.

BAKER: If you look to West Europe, median pay would be a bit over 100,000 a year. And you're very hard-pressed to say why our doctors should get so much more than doctors elsewhere in the world.

SMITH: Now, if we were talking about a product - if, say, T-shirts in America cost twice as much as in the rest of the world, we would just import more T-shirts, right? We would get them cheaper.

BAKER: Same thing with doctors. We should think of doctors the same way we think of the shirts; that, you know, if we can get doctors for lower cost from elsewhere in the world, then we could save enormous amounts of money.

SMITH: Now, the big difference, of course, is that a bad T-shirt won't kill you. A poorly trained doctor can. There are tests and training that we require before an international doctor can practice here. But these barriers can end up being pretty onerous. Take this guy.

DR. JOSHUA LANDY: My name's Joshua Landy, and I live in Toronto, Canada. I'm a physician.

SMITH: He's a critical care doc. If you go into the emergency room in Toronto and you can't breathe, Landy's the guy who can save you. So last year, Landy and his wife had to spend a year in the Bay Area. And Dr. Landy was thinking, while I'm there, I should get my license in the U.S., in California - you know, save some lives while I'm there.

LANDY: I thought the process would take about a month because that's similar to what I experienced in Canada.

SMITH: He was way off. There were tests and letters and a background check, fingerprinting. He had to pry his diplomas out of their frames in order to send in copies. After nine months of the California application process, Landy just gave up. His year in California was almost over.

LANDY: And we drove home.

SMITH: And doctors from Canada have it relatively easy. If you're a physician from other countries in the world, that process is guaranteed to take years even if you're already a doctor.

ALI FADIL: It is tough. You have to go back, like you're going backward.

SMITH: Ali Fadil is a first-year resident in Atlanta. He practiced medicine in Baghdad, and it's been grueling to start again in the United States. It took a year - and $6,000 - to prepare for a set of extensive exams, thousands of dollars more to apply for his residency training. And that training will take years more - more training, in fact, than a U.S.-educated doctor would be required to do.

FADIL: Believe me, it's not easy. If I had a chance to do something else other than medicine, I would have done it. It's a better life.

SMITH: Making international doctors jump through hoops is something of a tradition here. Now, the more stringent requirements are justified by safety concerns. Dr. Humayan Chaudhry is the president of the Federation of State Medical Boards, and he says there's just no way to judge the quality of medical training around the world.

DR. HUMAYAN CHAUDHRY: The process may be seen as perhaps cumbersome to practicing physicians. But once it's completed, the goal is at the end of the day, to protect the public. And that is absolutely the reason why all these safeguards are in place.

SMITH: The process is tough, and it can be confusing. Each state sets its own rules and standards. Dr. Chaudhry, though, says it doesn't deter doctors from coming here. Twenty-two percent of all the licensed doctors in the U.S. went to medical school outside the country. But economist Dean Baker argues that just because there are a lot of foreign doctors, doesn't mean that there shouldn't be even more. A lot of poor and rural areas in the U.S. have a doctor shortage, while qualified international doctors are waiting years to redo their training. Baker says that perhaps we can save some time here. Go to the medical schools in Mexico and Pakistan and India, and make sure the training is good enough the first time. Say to young wannabe doctors...

BAKER: Here's what you have to do. Here are the courses you have to take. Here's the test you have to pass. We could let them take them in India. You pass those tests, you get to come to the United States and work as a doctor- just like anyone who was trained in the United States.

SMITH: And Baker says the benefit isn't just for the foreign doctors. Imagine all the competition - doctors opening offices on every corner, driving the price of health care down. As they might say about T-shirts: If you can make sure the quality is the same, why pay more?

Robert Smith, NPR News, New York.

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