Close Physician Gaps in Rural and Underserved Areas By Leveraging Global Talent Already in Colorado
Colorado faces a projected shortage of more than 2,400 physicians by 2030, alongside the growing shortage nationwide, particularly in rural and certain underserved urban communities. Meanwhile, as of 2017, there were an estimated 3,000 immigrants in Colorado with healthcare-related degrees in jobs that do not utilize their training, 2,000 of whom received their training outside the United States. Many immigrants, including physicians with extensive experience in their countries of origin, are unable to practice without policy changes and/or support in navigating licensing requirements. Colorado has already invested in solutions. HB22-1050, enacted in 2022, created two pathways for internationally trained physicians — a clinical readiness program (CRP) that prepares international medical graduates (IMGs) for U.S. residency and an expanded re-entry license for internationally trained physicians (ITPs) — individuals who have completed postgraduate training and hold a foreign medical license. The CRP has produced real results, including a 100% residency match rate, all in rural and underserved communities. But CRP grant funding is expiring, the re-entry pathway has not yet been utilized, and a critical third pathway — supervised provisional licensure — remains absent from Colorado statute despite having been enacted in 24 states and two territories.1 This memo calls on the incoming Governor to complete the architecture that HB22-1050 began and strengthen implementation of all three pathways through data assessment, interagency coordination, private funding, and outreach to ITPs and employers. Together, these actions can help close documented gaps in health services for communities with the greatest need. This is an opportunity for the Colorado government to deliver by maintaining rigorous physician standards while eliminating unnecessary barriers to practice.
Challenge and Opportunity
Colorado is entering a healthcare workforce crisis decades in the making, at a moment when the state’s capacity to respond through traditional pipelines is shrinking. Colorado faces an estimated shortfall of 2,400 physicians by 2030, consistent with national projections of a shortage of 86,000 physicians by 2036.2 The needs align with the state’s most vulnerable communities: rural counties, primary care, mental health, and obstetrics face the deepest gaps, with some eastern regions reporting ratios as high as 5,600 residents per primary care provider; and the vast majority of Colorado’s 64 counties contain at least one federally designated health professional shortage area. Colorado’s residency pipeline is insufficient to meet statewide needs.
Meanwhile, demand is accelerating, especially for older adults who require more care. For the first time, more Coloradans are over 60 than under 18, and by 2030, roughly 20 percent of the population will be 65 and over, with many living in the rural communities where physician access is most acute.
HB22-1050, enacted in 2022, established a framework for activating the state’s immigrant physician workforce by creating a program to help IMGs enter a U.S. residency and a pathway to gain licensure through a competency assessment. The bill envisioned that IMGs needing additional training and assistance, such as provided through a residency, could access the CRP program. Those that did not need additional training could access a streamlined path to full and unqualified licensure through the re-entry pathway. However, the bill did not provide a pathway for those who may benefit from additional supervision but who do not need a full residency. Since HB22-1050 became law, other states have enacted a provisional pathway for this purpose. This path does not lower standards — it creates a supervised, employment-linked route to demonstrate equivalency. It is the missing piece in Colorado’s framework to ensure pathways to licensure for all incoming international talent. It is also the piece with the most potential to scale, since it is employer-driven. (See Table 1.)
Navigation and Support — IMG Assistance Program. Threading across all three pathways listed above3 is the IMG Assistance Program, which connects individual IMGs to whichever pathway they are best positioned to enter through career coaching, credential evaluation, and USMLE preparation support. Without this connective tissue and support structure, even a broader set of pathways will be inaccessible to immigrants with underutilized healthcare credentials currently living in Colorado and even more in the region.
Research by More in Common found that healthcare workers are among the most broadly supported immigration categories among Americans across the political spectrum4. This proposal is a workforce competitiveness initiative: it addresses a documented shortage with a tested, supervised pathway. New policy that translates into lifesaving services for Colorado communities would be a clear win for the new governor.
Plan of Action
Recommendation 1. Commission an assessment of physician and policy gaps and crosswalk with information on international medical graduates in Colorado.
Colorado’s physician shortage data exists, but is incomplete for policymaking. Aggregate shortage statistics — doctor-to-patient ratios, HRSA Health Professional Shortage Area designations — tell us where gaps exist in general terms, but do not tell the incoming administration which specific locations and specialties face the most acute near-term hiring needs, or which segments of the IMG population in Colorado are closest to practice-readiness. Without this crosswalk, it is difficult to effectively target efforts to fill physician workforce gaps.
The incoming Governor should direct Colorado’s Department of Public Health & Environment (CDPHE) and Department of Labor & Employment (CDLE), in coordination with the Office of New Americans (ONA), the Colorado Rural Health Center, the Department of Health Care Policy and Financing (HCPF), and the Department of Regulatory Agencies (DORA) to publish a physician workforce gap assessment within 90 days. Building on existing data, the assessment should map shortage areas by county, specialty, and care setting; document unfilled physician positions by metrics such as time-to-fill and applicants-per-posting; and identify and prioritize rural and frontier counties with the most acute needs. Simultaneously, CDLE’s Global Talent Survey and other data sources should be used to produce an updated estimate of the IMG and ITP populations in Colorado, their degree of practice-readiness, and which licensing pathway — CRP, re-entry, or provisional — each segment is best positioned to enter.
The assessment should also analyze the ITP evaluation criteria for the provisional pathway, including by reviewing and building upon the existing evaluation criteria used in the re-entry pathway. Prior outreach generated interest in assisting Colorado to build out this specific pathway for ITPs (rather than having the same criteria used for evaluations of U.S.-trained doctors seeking re-entry), but the assessment plan should ground-truth the viability, costs, and potential scale.
This assessment will serve as the evidentiary backbone for the action plan and will allow the administration to set measurable targets and create a monitoring and evaluation framework: how many IMGs and ITPs to activate, in which specialties, and in which communities, over a defined timeline. The assessment should be conducted with input from health systems, rural hospital associations, the Colorado Medical Society, and others, and should be completed in time to inform the 2027 legislative session.
Recommendation 2. Build on HB22-1050 by amending Article 87 of the CO Revised Statutes to authorize the Colorado Medical Board to grant provisional licenses to qualified international medical graduates.
Colorado is one of fewer than half the states in the country that do not yet authorize a supervised provisional licensure pathway for ITPs. 24 states and two territories — including Arkansas, Illinois, Florida, Louisiana, Massachusetts, Washington, and Wisconsin — have enacted versions of this pathway, and the list is growing. Colorado’s current framework requires both IMGs and ITPs to either complete a U.S. residency program (highly competitive, with very few slots successfully allocated to them) or navigate the re-entry license, which has not yet been underutilized in part due to the high cost in time and dollars. The result is that many qualified physicians already living in Colorado cannot practice.5
The incoming Governor should work with legislative champions to amend HB22-1050 in the 2027 session to authorize the Colorado Medical Board to issue provisional licenses to qualified ITPs. To be eligible, an applicant would need to: hold a current or recently active foreign medical license in good standing; demonstrate substantially equivalent postgraduate training; hold ECFMG certification; have passed USMLE Steps 1 and 2; demonstrate English proficiency; and secure a full-time offer of employment from a sponsoring healthcare entity — including hospitals, Federally Qualified Health Centers (FQHCs), rural health clinics, or medical practices — that agrees to provide supervision and periodic competency evaluation. The provisional license would be valid for two to four years. Upon passing USMLE Step 3, receiving a positive evaluation from the supervising physician or medical director, and maintaining good standing, the license would convert to a full, unrestricted license.
A new provisional pathway would maintain current standards by ensuring strict eligibility criteria followed by an extended evaluation period — it creates supervised, assessment-based routes to demonstrate equivalency. The provisional license increases the pool of potential applicants because it allows physicians to earn income while practicing under supervision, while they work toward a full license. The bill should explicitly prioritize placement and retention in rural counties, primary care shortage areas, and/or facilities serving Medicaid populations, and also include guidance on supervision, employer eligibility, malpractice coverage, reporting, discipline, patient safety, and conversion to the full license. Placement in rural and underserved areas could be incentivized by prioritizing the assessment of provisional license applications for those with job offers in rural and underserved areas, among other measures.
Recommendation 3. Collaborate with healthcare employers, philanthropies, and impact investors to create revolving fund, loan, and scholarship programs that sustain alternative licensure pathways for physicians across all three pathways, with incentives for doctors to work in rural and underserved areas.
Given Colorado’s budget challenges and competing funding priorities, support for alternative pathways must be sustainable with philanthropic and private support, rather than relying on ongoing state appropriations. The CRP and IMG Assistance Program created by HB22-1050 were funded through state appropriations that are now expiring. Without a durable, privately capitalized financing mechanism, programs that have produced strong results will fail. The costs IMGs face on the path to licensure are substantial and prohibitive for many candidates: ECFMG certification, USMLE preparation and testing fees, credential evaluation, and living costs during non- or low-income training periods.
The Governor should direct a senior advisor (see Recommendation 5) to convene a working group in the first 90 days of the initiative, including health systems, rural hospitals, philanthropic funders, assessment providers, and impact investors, to design a revolving and loan fund structure. The blended-capital revolving fund — seeded with public and philanthropic dollars and replenished by loan repayments and employer contributions so it needs no recurring appropriations — should build on past lessons from successful models of State Revolving Funds and CDFIs, including the in-state precedent of the Denver Regional TOD Fund, and Minnesota’s grants for IMG residencies, which apply the concept directly to internationally trained physicians. The fund could include an allocation for grants and incentives for ITPs to serve in rural and underserved areas; where there are persistent physician gaps, incentives could also be offered to ITPs from other states who commit to working in an underserved area in Colorado for a specific term. The fund should draw on three primary sources of private and non-state capital.
Healthcare employer co-investment. Hospitals, health systems, rural health clinics, and FQHCs that hire ITPs through the provisional licensure pathway — and that currently spend significantly on temporary (locum tenens) coverage — are the natural anchor funders. The per-year cost of a locum tenens physician routinely exceeds $150,000; co-investment in the talent pipeline is substantially cheaper and produces a permanent hire rather than a temporary fill. Employers who place ITPs through the provisional licensure pathway should contribute a defined amount per placement back into the fund, creating a self-reinforcing cycle as the pipeline scales.
Philanthropic capital. Colorado philanthropies with missions aligned to health equity, workforce development, and immigrant integration are natural partners: the Colorado Health Foundation, the Denver Foundation, the Denver Health Foundation, the Rose Community Foundation, and national health funders such as the Milbank Memorial Fund and the Commonwealth Fund.
Impact investment and loan programs. Loan programs that allow individuals to finance their own path to licensure — with repayment structured around physician income once practicing — can support candidates who have the credential profile but lack upfront capital. Loan repayment and/or other financial incentives tied to rural or shortage-area service commitments can further align individual financial incentives with community needs.
A note on the Rural Health Transformation Program (RHTP). Colorado has secured up to $1 billion in federal RHTP funding over five years to strengthen health systems across the state’s 52 rural and frontier counties. While this initiative does not require RHTP funds, it can help Colorado meet the workforce goals RHTP is designed to achieve. The administration should engage the CO Department of Public Health and Environment to explore whether rural placement of ITPs can be recognized within Colorado’s RHTP implementation plan as a workforce strategy. This is not simply a funding ask: it is an opportunity to demonstrate to the Centers for Medicare and Medicaid Services that Colorado has an implementation-ready plan for activating the physician workforce in rural communities.
Recommendation 4. Launch employer outreach to build a pipeline of sponsoring institutions and connect IMGs and ITPs to available pathways.
A provisional licensure pathway is only as effective as the employer network ready to use it. The incoming administration should start building that network as soon as possible, so that willing sponsors are identified and the business case is established to support the bill and its implementation.
The Governor should direct a senior advisor (see Recommendation 5) to launch a targeted employer engagement campaign, working through the Colorado Hospital Association and the Colorado Rural Health Center as primary conveners. The campaign should identify health systems, rural hospitals, rural health clinics, and FQHCs willing to serve as sponsoring employers and make the business case directly; someone who becomes a permanent hire is substantially cheaper than a temporary physician and produces durable workforce gains. The shortage assessment commissioned under Recommendation 1 should drive targeting, concentrating outreach in the specialties and geographies where employer gaps are most acute.
In parallel, Colorado’s Office of New Americans, in partnership with stakeholders, should reach IMGs and ITPs through trusted community channels — immigrant-serving organizations, refugee resettlement networks, and professional associations — to map the eligible population and connect candidates to whichever pathway they are best positioned to enter.6 A single state-maintained landing page consolidating all pathway options, eligibility criteria, and contact points should be established to simplify navigation for both applicants and employers. Progress should be reported annually on the number of employer sponsors identified, individuals contacted, and candidates who entered each pathway.
Recommendation 5. Direct a senior advisor in the Governor’s office to sustain momentum through the 2027 legislative session and work with the legislature to create a statutory position in CDLE to coordinate longer-term implementation across agencies.
The four recommendations above require sustained coordination across at least five state agencies — CDPHE, CDLE, ONA, HCPF, and DORA/the Medical Board — as well as ongoing engagement with the legislature, health systems, immigrant-serving organizations, and philanthropic funders. Colorado’s current institutional arrangement has no single point of accountability for this work. Without a named senior official in the incoming Governor’s office with explicit responsibility for the health workforce (whose larger portfolio could be broader health or workforce issues), implementation could fragment across agencies and lose momentum.
The senior advisor should have explicit authority to coordinate across CDPHE, CDLE, ONA, HCPF, and DORA;7 convene the medical workforce coalition described above; and serve as the administration’s lead point of contact for legislative champions on the provisional licensure bill. The Governor and legislature should evaluate whether a more durable governance structure — a statutory position in CDLE that liaises with the Governor’s office, a permanent medical workforce function within CDPHE,8 and/or a statutory health workforce commission — is warranted to carry the initiative beyond a single administration.9
Conclusion
Colorado does not need to wait for the next generation of medical school graduates to begin closing its physician shortage. The workforce is already here — trained, experienced, and ready to serve the communities that need them most. The five recommendations in this memo build on the foundation Colorado established with HB22-1050, completing the architecture the legislature began with a provisional licensure pathway, a durable financing model, and the institutional leadership to drive it across the finish line.
The 2027 legislative session opens January 11. The incoming Governor has a narrow and favorable window to act — with cross-partisan support, a ready coalition, and peer states that have already proven the model works. A successful physician pathway also lays the groundwork for extending provisional licensure to nurses, behavioral health professionals, and others facing similar barriers. The race for talent is here and this initiative is a win that can jumpstart the Governor’s workforce leadership.
A new provisional pathway would maintain current standards by ensuring strict eligibility criteria followed by an extended evaluation period — it creates supervised, assessment-based routes to demonstrate equivalency. Candidates typically must hold ECFMG certification and pass the same U.S. Medical Licensing Examinations that U.S. graduates take. Under the proposed provisional pathway, a physician is required to pass USMLE Steps 1 and 2 and meet other strict eligibility criteria before they can be considered for a provisional license that allows them to practice under the supervision of a fully licensed physician in the state for two to four years. Only after the successful completion of this provisional practice and passing USMLE Step 3, the candidate may be eligible to convert their provisional license to an unrestricted license. The re-entry pathway requires a Colorado Medical Board competency assessment and is a direct pathway to full licensure, and the Clinical Readiness Program routes candidates through a full U.S. residency. In every case, the standard is the same one applied to domestically trained physicians; the pathway simply changes how competency is demonstrated.
These pathways are built to incentivize hiring in the areas with the most need through speed and financial benefits. In addition, employers have a business incentive to recruit and retain staff so they can meet their workforce needs, which are highest in rural and underserved urban areas. The evaluation framework in Recommendation 1 would monitor practice patterns to confirm that placed physicians are serving the high-need patients and communities the policy is intended to reach. For example, employers in underserved and rural areas made offers of employment to all eight graduates of the Clinical Readiness Program.
Yes — but with clear eyes about its role. The CRP has produced a 100% residency match rate, which makes it a proven, high-quality model worth sustaining. Its graduates emerge as fully residency-trained U.S. physicians, and the majority of individuals get placed within the state. However, its limitation is throughput and cost: it serves only about four participants per cohort, candidates must still complete a residency before practicing, and its state funding is expiring. The recommendation is to continue the CRP — ideally placing it on the durable, privately-capitalized financing footing described in Recommendation 3 rather than relying on expiring appropriations — while recognizing that it cannot close the shortage on its own. The provisional licensure pathway provides the scale that the CRP cannot.
In theory, the re-entry pathway is the most direct route to practice — it does not require a U.S. residency or a provisional license period — but it has gone essentially unused, so near-term expectations should be modest unless its barriers are addressed. Those barriers are identifiable: the roughly $9,500–12,500 cost of the competency assessment with an uncertain result, the time required to prep for the assessments, a lack of recent clinical hours for many candidates, and limited awareness of the pathway.
To make it viable, the state can (1) defray the assessment and preparation costs through the financing mechanism in Recommendation 3, (2) work with the Colorado Medical Board to clarify what evidence meets the competency standard so candidates better understand their likelihood of success of their ~$10,000+ investment, (3) raise awareness through the targeted outreach in Recommendation 4, and (4) help candidates bridge clinical-hours gaps. Done well, re-entry becomes a fast track for the most highly qualified internationally trained physicians, complementing — not duplicating — the provisional pathway.
The central rationale is activating the talent already living in Colorado. But eligibility for the pathways themselves should not be restricted to current Colorado residents. Provisional and re-entry pathways to licensure are credential-based, and limiting them to in-state residents would needlessly shrink the pool. The practical approach is to keep eligibility open while concentrating outreach and prioritization on the in-state pool. There is also a competitive dimension worth naming: as more states stand up these pathways, Colorado’s own internationally trained physicians become recruitment targets for other states — so a credible, well-supported Colorado pathway is partly about retaining the talent already here.
The shortage extends well beyond physicians, and is often even deeper for other healthcare professions — for example, nursing is the single largest category of underutilized immigrants with health degrees nationally and in Colorado. Every medical profession has its own requirements, pathway, and process. Therefore, understanding the barriers and processes for individual medical professions is necessary to design the best solutions. For instance, the specific barriers to licensing, recruitment, retention, etc. may differ across medical professions.
The recommendation is to start with physicians — where the gap is acute, the model is tested (24 states), and the licensing stakes are highest — and then extend any lessons learned for designing and implementing this pathway to other professions. Designing the physician pathway and its supporting infrastructure (financing, navigation, interagency coordination) with that expansion in mind means the state builds a platform rather than a one-off fix. It is also worth noting that internationally trained physicians complement, rather than compete with, the nurse practitioners and physician assistants already in the workforce — in many rural settings, a physician of record is what allows mid-level-staffed clinics to operate at all.
Colorado faces a projected shortage of more than 2,400 physicians by 2030, alongside the growing shortage nationwide, particularly in rural and certain underserved urban communities.
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