Across rural Minnesota, foreign-born doctors have been crucial in easing an acute shortage of physicians. But small-town hospitals, clinics and doctors’ offices could be strained if President Donald Trump’s immigration and travel ban prevails, according to state Attorney General Lori Swanson.

The ban is on hold and in legal limbo after a pair of dramatic court rulings. Swanson and her team of attorneys, who had joined Washington state to challenge Trump’s executive order banning travelers from seven predominantly Muslim countries, are still pursuing the lawsuit. On Friday, they detailed the effects that the order would have on families, companies, universities, hospitals and communities across the state.

Since Trump signed his order, Swanson’s office has been flooded with e-mails and phone calls. “We’re getting contacted by so many people — families who are separated by the ocean. Health care. Universities deprived of scientists who can’t come now. Corporations who are relying on people from some of these countries to help bring know-how to us,” Swanson said Friday. “It’s really quite broad.”

After the order was struck down by a federal appeals court on Thursday, Trump on Friday responded by saying he may revise the order or possibly appeal to the U.S. Supreme Court.

Swanson’s office has compiled more than a dozen sworn statements from those affected by the ban. Others from the academic and corporate worlds have confided in Swanson’s office but won’t go public, she said. “There’s fear and trepidation … that the president will tweet at them,” she said.

In addition to worries about immigrant families being torn apart and universities losing foreign students and researchers, statistics show that the ban could create havoc for those living in nursing homes and rural Minnesota, as well as those who rely on home health providers.

Foreign-born doctors and care workers have been instrumental in helping ease shortages in those areas. In Minnesota, “one out of five doctors were born in another country,” Swanson said. “That’s huge, and many of them are serving in rural parts of our state to deal with this crisis of not having enough primary care doctors.”

Minnesota has 121 federally designated areas that have a primary-care doctor shortage, 62 areas where there are not enough mental health care providers and 126 areas where there’s a dentist shortage.

The dearth of primary-care doctors is especially acute in rural and economically distressed urban areas, in part because many doctors are retiring and fewer medical students are choosing to go into primary care, Swanson said. In addition, those who leave rural communities to go to medical school aren’t returning to their hometowns.

“They incur 200 grand in loans and then they stay in the cities and they don’t move back,” Swanson said. “We have a dire shortage of primary-care doctors, and it’s going to get worse as the population continues to age.”

Even loan forgiveness programs used to entice newly minted doctors to rural areas haven’t solved the problem, she said.

To help fill those gaps, a federal program draws foreign-born doctors to these areas. Doctors who have a J-1 visa must leave the United States for two years after they complete their medical studies. But that requirement is waived if they agree to serve rural or underserved areas for three years.

“Under this program, rural areas obtain world-class physicians for three years,” according to an affidavit from Mark Schoenbaum, director of the Office of Rural Health and Primary Care at the Minnesota Department of Health. “Many of these physicians settle in rural areas with their families and remain there for their careers.”

‘Recruitment is crucial’

Trump’s travel ban executive order sparked concern, fear and confusion among some of these doctors. According to Swanson, 275 doctors in Minnesota are from the seven countries affected by the president’s order, the threat of which is keeping them from returning home for emergencies, funerals or visits to their family for fear they won’t be allowed back into the United States.

Schoenbaum said such concerns have dampened efforts to bring in more foreign-born doctors. “Recruitment is crucial for Minnesota’s rural hospitals,” he said in his sworn statement, part of the evidence compiled by Swanson’s office.

In some communities, a foreign-born doctor could be the entire medical staff, said Cindy Morrison, chief marketing officer for Sanford Health, which has 1,400 physicians serving in 300 communities in western Minnesota, North Dakota, South Dakota and northwestern Iowa. “They are critical for underserved areas,” she said.

The continued strain and possible worsening of the shortage could have ramifications not only for the physical health of those living in small rural communities but also for a town’s economy, Swanson said.

Minnesota has 79 “critical access hospitals” located primarily in rural communities. The federal government has designated them vital to meeting a community’s health care needs. Those hospitals sometimes are the largest employers in that town.

“To have a critical access hospital, you have to have physicians,” Swanson said. “And if this ban creates a chilling effect and we can’t recruit, we might have potential closures of some of these hospitals. That’s incredibly detrimental to those towns.”

Ripples in health care

Trump’s order also could add stress to those working in home health care and in nursing homes, Swanson said. According to statistics and statements gathered by her office, 5 to 8 percent of the state’s home health care workers are from the countries restricted by Trump’s executive order. “That’s 1,300 to 2,000 people,” she said. “That’s significant.”

About 3 to 5 percent of the nursing home workers are from those countries, Swanson said.

Kelly Thibert, president of the American Medical Student Association, said her organization is fielding calls and e-mails from medical students who live in countries affected by the travel restrictions on Somalia, Iran, Iraq, Libya, Syria, Sudan and Yemen as well as students outside those countries fearing a ban will be expanded.

A program that matches medical students with residencies has more than 42,000 registrants vying for 31,000 positions around the country. International students are concerned about their futures, she said.

“They wonder whether they will be able to complete their residency and finish all their requirements,” she said. “There’s uncertainty, an uneasiness. We work the majority of our lives to be educated to be doctors and then this comes up where you might not be able to fulfill your dream or goal of becoming a physician.”