Why North Carolina’s House Bill 67 is a Dangerous Misstep for Patient Safety and Rural Healthcare

North Carolina’s House Bill 67 (Session Law 2025-37), (Summary provided as appendix) which introduces the “internationally-trained physician employee license,” aims to alleviate physician shortages in rural areas by allowing foreign-trained doctors to practice with reduced oversight. While the goal of improving healthcare access is noble, this legislation is a flawed and risky approach that fails to address the root causes of physician shortages, threatens patient safety, and opens the door to fraud. Below, I outline why HB 67 is a dangerous band-aid that completely sidesteps the deeper issues driving North Carolina’s healthcare crisis.

A Gateway to Fraud

The bill tasks the North Carolina Medical Board with verifying foreign credentials, including a current or recently expired (within five years) medical license from another country, 130 weeks of medical education, and competency through exams or certifications. However, enforcing these stipulations is a logistical nightmare. Cheating on standardized testing exams is rampant in some countries, with documented cases of fraud undermining testing integrity. Verifying the authenticity of foreign licenses and educational records is a daunting task, especially when language barriers and varying standards come into play. Just last week, a nurse in the U.S. was caught practicing without a license for years, exposing gaps in domestic oversight. If we can’t effectively police credentials at home, how can we trust the Board to scrutinize what’s happening abroad? This creates a real risk that unqualified or fraudulent physicians could infiltrate North Carolina’s healthcare system, endangering patients, particularly in vulnerable rural communities.

Bypassing U.S. Residency

Lowering the Bar for Licensure HB 67 allows internationally-trained physicians to obtain a full, unrestricted license after just four years of practice in North Carolina, without completing a U.S. residency training program—the cornerstone of ensuring clinical competence in the American healthcare system. Currently, the only pathway to full licensure for foreign-trained physicians is through a U.S. residency, which provides rigorous, standardized training under close supervision. By contrast, HB 67 permits competency to be demonstrated through foreign exams, specialty certifications, or alternative assessments, none of which guarantee equivalence to U.S. standards. This shortcut risks allowing physicians with inadequate training to practice independently, potentially compromising patient care. The bill’s fast-track to full licensure after four years further exacerbates this concern, as it legitimizes practitioners who may not be fully prepared for the complexities of the U.S. healthcare environment.

Failing to Address the Root Causes of Physician Shortages

The physician shortage in rural North Carolina is a pressing issue, but HB 67 is a superficial fix that ignores the underlying drivers of this crisis. The bill assumes that bringing in foreign-trained doctors will fill gaps in rural hospitals and practices, but it does nothing to address the regulatory suffocation and systemic pressures that have decimated private independent practices. Over decades, government policies and healthcare reforms have pushed for vertical integration, turning physicians into cogs in large, corporate healthcare networks. Excessive regulations, reimbursement cuts, and administrative burdens have made it nearly impossible for independent practices to survive, particularly in rural areas where patient volumes are low and resources are scarce. This has driven physicians to urban centers or salaried positions within hospital systems, leaving rural communities underserved. HB 67’s reliance on foreign-trained physicians does not reverse this trend. Instead, it perpetuates a system that prioritizes short-term staffing over rebuilding a sustainable framework for independent practice. By failing to address the regulatory and economic barriers that deter physicians from practicing in rural areas, the bill ensures that the shortage problem will persist, even if temporary gaps are filled.

A Temporary Fix with Long-Term Risks

Proponents of HB 67 argue it will bolster healthcare access in rural counties with populations under 500 people per square mile. However, the bill’s structure offers no guarantee that these physicians will stay. After four years, when they qualify for a full license, nothing prevents them from leaving rural practices for urban areas or other states with better pay and working conditions. This undermines the bill’s purpose and leaves rural communities back at square one.

Opening the Door to Fraudulent Physicians

The combination of lax enforcement and a fast-tracked licensure pathway creates a perfect storm for fraudulent physicians to exploit. The bill’s reliance on foreign documentation—difficult to verify and susceptible to falsification—raises the specter of unqualified practitioners gaining access to North Carolina’s healthcare system. Once they get here, there is a requirement for a licensed supervising physician to be present, but again, who enforces the level of supervision? Its easy to imagine a scenario where a stay at home physician is listed as the “supervising” physician but is doing anything but. Does the supervising physician have to review each chart? Sign each chart? Be present for the physical exam? I have no idea, and regardless of what legislators may say they will do, there is no good way to enforce their rules.

And once these physicians secure a full license after four years, they would have the same privileges as U.S.-trained doctors, with no additional safeguards to protect patients. The recent case of an unlicensed nurse practicing undetected for years underscores the real-world consequences of weak oversight. HB 67’s provisions could amplify this risk, allowing fraudulent or underqualified physicians to harm patients, particularly in rural areas where oversight is already stretched thin.

Hardly a Free Market

Some proponents of the bill point to Austrian economists von Mises and Hayek who were generally against the restriction of movement of labor, correctly pointing out this was often done to protect domestic groups from competition. But this is a simplistic argument that overlooks the root cause of physician shortages in America. There are certainly enough interest in medical school to more than meet the U.S. supply needs. In the 2024-2025 academic year, ~ 51,000 applied for 23,000 medical school seats. And this is demand despite the fact it requires 13-16 years of training after high school and $300,000-$400,000 to become a physician in the United States.

Fixing shortages here by facilitating easier entry for non-U.S. physicians simply allows a very distorted market to keep limping along. The market that would earn the support of Mises/Hayek would streamline and accelerate pathways for domestic citizens to become doctors, remove the many licensing hurdles current physicians place and addressing the significant attrition of U.S. physicians from the current market due to burdensome regulations that control the practice of medicine today. Instead, allowing unrestricted immigration to fill the artificial shortage created by the State serves as a backdoor for health systems to exploit cheaper international labor that are all about prioritizing health system profits over equitable opportunity for U.S. citizens. This approach just disincentivizes domestic talent development and perpetuates a rigged system that favors a bad bandaid over meaningful internal reform.

A Call for Real Solutions

North Carolina’s rural healthcare crisis demands action, but House Bill 67 is a dangerous misstep that prioritizes expediency over quality and safety. Instead of lowering standards and risking fraud, the state should tackle the root causes of physician shortages: dismantle the regulatory barriers that suffocate independent practices, reverse the trend toward vertical integration, and invest in sustainable solutions like more accelerated paths for smart U.S. citizens to become physicians, expanding U.S. residency programs and offering incentives for physicians to commit long-term to rural areas. Incentivizing long-term commitment to underserved areas could easily occur through some combination of loan forgiveness, tax breaks, and most importantly, regulatory relief for rural practices (google Direct Primary Care!), rather than relying on transient cheap foreign labor. By fostering an environment where local doctors can thrive, North Carolina can build a resilient healthcare system that serves all its residents. Patient safety and quality care must remain the priority. HB 67’s shortcuts threaten both, while failing to address the systemic issues driving physicians away from rural practice. It’s time to reject this flawed approach and demand policies that empower independent physicians, strengthen oversight, and ensure lasting solutions for North Carolina’s (and the nation’s) healthcare challenges.

Anish Koka is a Cardiologist in Philadelphia. He writes on health policy, and can be found on X @anish_koka , as well a podcast called The Doctor’s Lounge that’s available on most of your favorite podcast platforms.