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BISMARCK, N.D. — The leaders of Sanford Medical Center had waited all summer to learn the fate of the 59 nurses planning to move across the world to their isolated state capital. The reinforcements from the Philippines, Kenya and Nigeria would allow the hospital to expand its heart unit and staff a new wing. Costly temporary nurses would go. The scramble to fill shifts would finally be over.

But by the time the hospital’s department heads gathered in a conference room this fall to hear the latest development, the news already had spread. The nurses were delayed — again.

“We’re projecting no arrivals until the first quarter of 2025 or later,” Wendy Kopp, the chief of nursing and clinical services, told the solemn room.

Days before the early morning meeting in September, the State Department had announced that it would issue the type of work visas that the nurses needed only to those who had applied before December 2021. That would exclude dozens of new hires critical to Sanford’s efforts to replenish its depleted bedside staff during its biggest workforce crisis in years. The nurses were left adrift with no immediate path to the United States.

It was one more gut punch from a broken immigration system untouched by Congress for 33 years and largely operating on a framework dating to 1965. As a record surge of unauthorized migrants enters the United States through its southern border, stoking political divisions and straining resources, the troubled system for those eligible to come here legally has buckled in the background. Congress splintered over the issue again this month, as Republicans resisted calls from the Biden administration for more aid to Ukraine unless it comes with more-stringent border policies.

Since Congress last updated the number of new arrivals the country will admit each year — a tiny fraction of whom are allowed to come in permanently to work — the economy is more than twice as large. But despite growing demand to help fill 8.7 million <a href="https://urldefense.com/v3/__https://www.bls.gov/jlt/__;!!M9LbjjnYNg9jBDflsQ!FvxlMfgpj67RNifF41uvFFWVovqCAWRBx6GM2oPo9U89TvCQwwhqCHIZlgW-9nIXisp_eEb9292fwZYy8SQgaw$" target=_blank>open jobs</a> with skilled and unskilled foreign-born workers, strict quotas keep out millions of qualified immigrants every year. Demand was so high this year that the State Department was forced to restrict many types of visas, including — for the first time in years — those for nurses.

Getting a coveted pass to enter the United States means waiting in backlogs for years in a neglected bureaucracy of overlapping, resource-starved federal agencies. There are record delays at an obscure Labor Department office, a backed-up processing queue at a Homeland Security agency so overburdened that it has wasted thousands of untouched green card applications, and years-long waits for final interviews at some U.S. consulates.

“The legal immigration system is collapsing under its own weight,” said Theresa Cardinal Brown, a former federal immigration official who is now a senior policy adviser on the issue at the Bipartisan Policy Center in Washington.

The visas are blocked, year after year, by what David Bier, an immigration expert at the Cato Institute, calls “an almost insurmountable barrier of bureaucratic red tape.”<a href="https://www.cato.org/blog/family-employment-green-card-backlog-exceeds-9-million" target=_blank> </a>

Melina Mara

The Bismarck hospital’s stalled pursuit of foreign-born nurses underscores how the legal immigration system is failing a vital U.S. industry. Thousands of well-qualified workers overseas are ready to recharge a field decimated by pandemic burnout and retirements at a time when baby boomers are experiencing increasing health problems. But most can’t get here, even with a well-funded employer like Sanford spending millions — including $5,000 in immigration-related fees for each nurse — and employing a small army of immigration experts.

<a href="https://www.washingtonpost.com/elections/candidates/joe-biden-2024/" target="_blank" class="contextual_link">President Biden</a>, shortly after winning office, pledged to reopen the country to <a href="https://www.washingtonpost.com/politics/2020/12/02/biden-visas-legal-immigration/" target=_blank>more immigrants</a>, reversing Trump administration policies that had slowed the flow of refugees, Muslims and others from overseas. Among Biden’s priorities was whittling away backlogs in the system.

But almost three years later, a Washington Post review of the federal agencies responsible for issuing immigrant visas found that bureaucratic delays remain a systemic issue, the result of staffing and budget shortfalls that worsened during the Trump era; a reliance on paper files; and long-outmoded rules.

White House spokesman Angelo Fernández Hernández put the onus on Congress, saying in an email that since taking office, Biden has repeatedly called on lawmakers to pass “comprehensive immigration reform.”

“Absent Congressional action, this Administration has led the largest expansion of lawful pathways in decades,” Fernández Hernández said. “We continue to work to find efficiencies and improvements across government to ensure employers and immigrants can effectively navigate the laws in place.”

As illegal immigration roils U.S. politics, the nation’s failing system for legal immigration has received less notice. This story examines how post-pandemic failures in federal agencies and congressional inaction have fueled a growing crisis for the U.S. economy.

Only Congress can expand legal immigration. But year after year, legislation that would lift caps for work and family visas and other categories goes nowhere. Most Republican lawmakers have hardened in their view that border measures to stop the flow of illegal crossings must come ahead of any expansion of legal immigration. So far, Democratic opposition to many of those efforts — as the party tries to balance the humane treatment of migrants with the reduction of illegal immigration — has led to an impasse that has stretched for decades.

In North Dakota, population 780,000, where the nursing shortage is compounded by an <a href="https://www.bls.gov/eag/eag.nd.htm" target=_blank>unemployment rate </a>of just 1.9 percent, Republican Sen. Kevin Cramer finds himself at odds with his party on raising the level of legal immigration.

“We’re at a point now where some of my very best right-wing friends, they just can’t even bring up legal immigration solutions,” said Cramer, who in November introduced a <a href="https://www.congress.gov/bill/118th-congress/senate-bill/3211" target=_blank>bill</a> with Sen. Richard J. Durbin (D-Ill.) that would allow more nurses into the country. “The angst of illegal immigration has spilled over to the other side.”

In Bismarck, hospital leaders are now left to reassess the level of care they can provide, as they wait for the State Department’s backlog to clear so that the long-delayed immigrants can enter the country, joining 12o other nurses who’ve come from abroad in the past 16 months.

“We know these individuals have a dream to come to the U.S.,” said Erica DeBoer, chief nursing officer at the medical center’s parent network, Sanford Health. “Why are we putting so many barriers in their way?”

By the end of 2020, nine months into the <a href="https://www.washingtonpost.com/coronavirus/" target="_blank" class="contextual_link">coronavirus</a> pandemic, the Sanford network confronted a nursing crisis felt across the world.

Burnout, illness, and a vaccine mandate that had angered many employees had led thousands of registered nurses to quit and retire from the nonprofit system of hospitals, clinics and senior-care centers across North and South Dakota, Minnesota and Iowa. Turnover had hit 30 percent.

The need was everywhere. The government says the country must add 200,000 new nurses each year to replace up to 20 percent of the workforce. Nursing schools, facing a <a href="https://med.und.edu/about/publications/biennial-report/index.html" target=_blank>shortage </a>of instructors, can’t keep up, particularly in rural regions like North Dakota, where just half the nurses needed were graduating annually.

The only patches during the public health crisis were incentive pay for extra shifts; a program that trained nonclinical staff to care for patients; and traveling nurses, who work on temporary contracts, flying from hot spot to hot spot. But traveling nurses commanded more than three times the hourly rate of staff nurses — and lacked a loyalty to the hospital and the community.

Nurses from the Philippines had patched holes in the U.S. health-care system since the 1960s. But almost none had reached rural America. They certainly had not reached conservative North Dakota, where the population is 83 percent White and the Great Plains winter is unrelentingly frigid. “Oh my goodness, our temperature is not great,” DeBoer remembered thinking.

Across the country, demand for foreign-born nurses had tripled in the pandemic. Sanford expanded its team of immigration lawyers and hired a health-care staffing company, which by the spring of 2021 had begun to recruit 193 nurses to sign contracts to come to Bismarck, and hundreds of others for facilities across the region.

“Then it was hurry up and wait,” recalled Kopp, the nursing director in Bismarck.

The task confronting the 150-bed hospital was how to navigate a U.S. immigration system that has stayed the same even as the world has become more mobile.

Since passage of the Immigration Act of 1965 — which aimed in part to boost the U.S. labor market — the job market has expanded dramatically.

Congress amended the law in 1990, skewing visas away from unskilled jobs and boosting the cap for permanent workers to 140,000, most sponsored by U.S. employers.

But lawmakers kept a rule restricting a single country to 7 percent of the total employment-based green cards in a given year. For the Bismarck hospital, that meant nurses from populous nations like India would probably be out of the running; most Indians seeking visas must wait more than a decade to come.

For decades, foreign-born nurses had qualified for temporary visas that cleared a path for many of them to stay once they were here. But Congress let that program expire more than a decade ago.

With limited exceptions, nurses must now complete the immigration process entirely from abroad, with most competing for one of just 40,000 slots a year in a broad visa category known as EB-3, which grants permanent entry and a path to a green card. The category includes numerous occupations, including software developers, engineers, lawyers and home health aides. In recent years, U.S. employers have sponsored about twice as many visas as there are EB-3 slots available, and an applicant’s family members are also counted toward the cap. In most fiscal years, as few as 5,000 nurses make the cut.

Even when immigrants are not blocked by those annual green card limits, their path is long and expensive, as hospital leaders in Bismarck quickly learned.

Mara Correa for years had wanted to leave her native Philippines for a nursing job in America, where she could have better pay and work-life balance as she started a family. In Manila, her wages were a third of what she could earn in the United States.

Her sister’s home in Winnipeg, Manitoba — a seven-hour drive northeast of Bismarck — made Sanford an ideal place to work. She accepted an offer in 2021. “Compared to other countries, things are way better [for nurses] in the U.S.,” said Correa, 33.

But first, her application faced a tortuous path through the system for legal immigration. The queue began with the Labor Department’s Office of <a href="https://www.dol.gov/agencies/eta/foreign-labor" target=_blank>Foreign Labor Certification</a>, where a staff of 194 makes sure that American workers won’t be harmed by the hiring of foreign-born workers. It’s a convoluted process that took 199 days for immigrants in most professions at the end of 2020, Labor Department data shows.

Nurses and physical therapists have for decades circumvented that requirement because they fall into “shortage” professions. Labor has not identified a single new shortage occupation in more than 30 years.

But Correa still had to wait for the office to certify that pay for the immigrant nurses would not undercut local prevailing wages, a process that took more than three months, data shows.

In the past decade, applications for permanent visas for nurses and other professions have doubled, according to budget data. Congressional rules mandating quick turnarounds by Labor for some highly skilled workers — many headed for high-demand, temporary tech jobs — have left petitions for others, including nurses, at the bottom of the pile.

The certification office’s budget was flat during most of the Trump administration, then grew by roughly 10 percent over the two fiscal years that began in the fall of 2020. But current and former employees said the increase is not enough to address the accelerating demand. For decades, Congress has refused appeals from Labor to fund the office through fees.

Immigration experts blamed both parties and a weak constituency of foreign workers for neglect of the office.

“No matter who’s in charge … the unions on the liberal side or the restrictionists, all have the cultural view that having the Labor Department be friendly to immigrants is not a top priority,” said Leon Fresco, an immigration lawyer who oversaw immigration litigation for the Justice Department.

After receiving Labor’s sign-off, Correa’s visa petition moved to U.S. Citizenship and Immigration Services at Homeland Security, where a hiring freeze by the Trump administration had led to a “steep reduction” in career and contract staff, an agency report shows. The pandemic forced the department to close in-person work for three months.

For years, USCIS has done much of its business on paper, slowing the processing of applications. Several efforts to digitize operations have come up short.

“USCIS is a technological disaster,” said Sarah Peterson, a Minneapolis-based immigration lawyer, though she cited recent “small yet effective improvements," including online scheduling for local offices and fingerprinting appointments.

The agency derives 96 percent of its revenue from processing fees, which have not changed since 2016 despite a rise in requests for asylum and other forms of humanitarian protection. The Trump administration also added layers of scrutiny and verification for green card applications and other benefits, in what immigrant rights advocates describe as an effort to slow the process.

The pandemic closed many processing centers, adding to delays. By the end of the fiscal year that began in the fall of 2019, that meant 6.1 million pending applications had piled up at USCIS.

To break through the logjam, the Bismarck hospital, like a growing number of employers, paid for expedited processing — $2,500 for Correa and each of the other nurses. Without this premium, the bureaucracy would have added nine months to a year to their journeys, immigration advocates said.

Correa’s final step to a green card was an in-person interview at the consulate in Manila. To get in line, though, her case had to be processed at the National Visa Center in Portsmouth, N.H., a clearinghouse for all overseas requests. The center, operated largely by outside contractors, fell behind during the pandemic, when it stopped staffing phone lines to answer questions.

Once her documents were complete, Correa waited for the State Department to schedule an interview. U.S. consulates had lost staff to Trump-era departures and hiring freezes. Many closed for months at the start of the pandemic and reopened at different times with limited service. More than 565,000 visa applicants waited for interviews at the height of the public health crisis in July 2021, State Department data shows.

As of January, according to <a href="https://refugeerights.org/news-resources/nvcs-interview-scheduling-backlog-report-disclosed-a-way-to-learn-about-visa-interview-backlogs-at-consular-offices-around-the-world?preview=true" target="_blank">data</a> released to the International Refugee Assistance Project, it was projected to take an average of 801 business days at the consulate in Manila to schedule a face-to-face meeting for an immigrant visa, although applicants for EB-3 visas sometimes had a quicker path.

“You had all of the existing cases piling up as new cases were continually coming in, and offices were trying to address the growing backlog with essentially the same staffing levels they had before the pandemic hit,” said Charles Oppenheim, who retired in 2021 as chief of the department’s Immigrant Visa Control and Reporting Division and is now director of visa consulting for WR Immigration.

When Correa was finally called for her interview at the consulate in Manila, it took less than an hour, she said, with questions about her clinical experience and how she found the job with Sanford.

After 14 months, she reached Bismarck in August 2022 — the first nurse to arrive from abroad. She was quickly assigned to fill vacancies in the hospital’s acute dialysis unit. An additional 10 or so nurses followed each month, most from the Philippines, but also from Nepal, Nigeria and Kenya. One came from India. By early December, 117 nurses had started new lives in Bismarck.

The transition for Correa was bittersweet. She left two brothers, an extended family and her fiancé in the Philippines. “When I finally got the visa, oh my God, it was mixed emotions,” she recalled. “It was the start to fulfilling my dreams, but I left so many people behind.”

At the Bismarck hospital, the impact of the new arrivals was almost immediate.

The hospital’s reliance on traveling nurses plummeted, particularly among those who had staffed the small dialysis unit for acutely ill patients. Spouses of the foreign-born nurses took vacant jobs at the hospital and as aides in nearby nursing homes.

The new arrivals also picked up extra shifts. Patients and nurses alike were buoyed by the infusion of fresh energy. Back-to-back blizzards during Correa’s first winter — without all-weather tires on her car — made her wonder if she had made a mistake. But she eventually felt so welcomed by the hospital that she became the first nurse to join its council devoted to increasing diversity, equity and inclusion.

Aqeel Adnan Al-Mahdaly, 30, who works in the cardiology unit, said some nurses have opted instead to apply for jobs in other countries where it’s easier to immigrate. “It’s really hard to get to the U.S.,” he said, “because there are a lot of exams and the processing takes so long.”

Mary Schmidt, a cardiology nurse for 41 years under three hospital owners, remembered feeling nervous that patients would chafe at nurses who did not look like them.

“In North Dakota, you have a lot of older people who are very biased,” she said. “They don’t see a lot of people you see in New York City. But they’ve revived us.”

By late 2021, Bismarck’s turnover rate had begun to edge down. Still, hospital leaders decided to recruit an additional five dozen foreign-born nurses to fill open positions. They were scheduled to arrive in 2024 and 2025.

But they soon realized that the system had gotten even harder to navigate — Correa, despite the many delays, had been one of the lucky recruits. Key agencies involved in the complex bureaucracy of visa approvals were confronting even worse delays now.

The Labor Department, with an explosion in visa petitions, particularly for temporary skilled workers, was now taking an average of 207 days to certify them. It was taking eight months to ensure that prevailing wages were not being undercut.

USCIS was still falling behind, too. The agency’s ombudsman, in a <a href="https://www.dhs.gov/annual-report-congress" target=_blank>report</a> in June of this year, cited “significant backlogs and the problems resulting from them,” including inadequate funding and technological weaknesses that have been exacerbated by a flood of applications from Ukrainians, Afghans and others the Biden administration has granted humanitarian assistance.

The result was 8.9 million pending applications at the agency from April through June of 2023.

As of June, USCIS had 829,000 pending green card applications, almost triple the number 10 years ago, agency data shows.

Struggling against the bureaucracy, Sanford continued to pay $2,500 for premium processing at USCIS.

And then, in a way no one had anticipated, the system fully short-circuited.

The first sign of trouble came in April of this year, when the State Department’s monthly visa bulletin announced that available slots for the EB-3 visa and other employment and family categories were nearing numerical caps and country quotas — limits that the State Department, by law, cannot exceed.

By the fall, the agency had announced that anyone who became eligible for a green card after Dec. 1, 2021, could not enter the country — no matter how badly their employer might need them. Many of the foreign-born nurses hired by the Bismarck hospital in the second round had signed contracts after this date, meaning they couldn’t enter the United States under the new guidelines.

It’s not clear exactly what drove the worsening backlog in applications. But experts say demand may have spiked because for a short period the government was able to offer employers unused family visas that had languished during the pandemic. Now those extra visas have tapered off, and available slots have plummeted.

“What are we going to do for the next 18 months?” DJ Campbell, the hospital’s new human resources chief, remembered thinking. “It was very, very stressful.”

Among his biggest concerns was that Bismarck would lose the nurses to the Middle East and Europe. “If you can go to another country, are you going to wait another year for us or take that offer?” he said.

Adding to the anxiety was the start of construction early this fall on a 36-bed, three-floor addition to the hospital, scheduled for completion in January 2025. Would there be nurses to staff the new wing?

The delay was all the more infuriating as hospital staff watched the foreign-born nurses who had made it to Bismarck continue to thrive.

Tami Flemmer, the hospital’s senior director of risk management, hosts weekly Scripture readings with a group of 40 Filipinos in her basement. “They bring the best food,” she said. But the biggest payoff has been intangible. Strangers who flew across the world have revived morale on a staff whose pandemic weariness had lingered far beyond the worst days of the crisis.

“Our nurses are still coming out of that compassion fatigue and trauma,” said Kopp, the nursing director. The foreign-born nurses “are not coming out of that place. This has been their dream, whereas sometimes I think our nurses are trying to get by.”

On the morning Kopp told her colleagues that the 59 nurses from abroad would be delayed, the newest arrivals, eight women from the Philippines and one from Nepal, started their three-week cultural and professional orientation.

Wesleyan University, B.A. history

Lisa Rein covers federal agencies and the management of government in the Biden administration. At The Washington Post, she has written about the federal workforce; state politics and government in Annapolis, and in Richmond; local government in Fairfax County, Va.; and the redevelopment of Washington and its neighborhoods.

Lisa Rein

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A broken immigration system keeps workers out of jobs the U.S. needs to fill