State of Washington, et al., v. Trump., et al

Filing 194

MOTION for Leave to File Third Amended Complaint, filed by Plaintiffs Commonwealth of Massachusetts, State of California, State of Maryland, State of New York, State of Washington, Intervenor Plaintiff State of Oregon. (Attachments: # 1 Complaint 3rd Amended, # 2 Index of Exhibits, # 3 Index of Declarations, # 4 Exhibit A, # 5 Exhibit B, # 6 Exhibit C, # 7 Exhibit D, # 8 Exhibit E, # 9 Exhibit F, # 10 Exhibit G, # 11 Exhibit H, # 12 Exhibit I, # 13 Exhibit J, # 14 Exhibit K, # 15 Exhibit L, # 16 Exhibit M, # 17 Exhibit N, # 18 Decl of Joint Former National Security Officials, # 19 Decl of Nima Ala, # 20 2nd Decl of Rabyaah Althaibani, # 21 Decl of Alireza Ayoubi, # 22 Decl of Shervin Beygi, # 23 Decl of Bahareh Bina, # 24 Decl of Ethan Devenport, # 25 Decl of Yasaman Esmaili, # 26 Decl of Mahdi Hajiaghayi, # 27 Decl of Mojdeh Jalali Heravi, # 28 Decl of Vahid Jazayeri, # 29 Decl of Mohammad Shafiei Khadem, # 30 Decl of Ahmad Moghaddam, # 31 Decl of Younes Nouri, # 32 Decl of Proshat Parsimoghadam, # 33 Decl of Emad Soroush, # 34 Decl of Tannaz Sattari Tabrizi, # 35 Decl of Seyed Danial Vaezi, # 36 Decl of Banafsheh Samareh Abolhasani, # 37 Decl of Armin Alaghi, # 38 Decl of Pegah Jalali Asheghabadi, # 39 3rd Decl of Rovy Branon, # 40 5th Decl of Asif Chaudhry, # 41 Decl of Maryam Dadkhahan, # 42 Decl of Jason Detwiler, # 43 2nd Decl of David Eaton, # 44 Decl of Kiana Ehsani, # 45 Decl of Ali Farhadi, # 46 Decl of Hoda Farhadi, # 47 Decl of Maryam Fayazi, # 48 Decl of Mohammad Ghaedi, # 49 Decl of Anne Greenbaum, # 50 Decl of Hannaneh Hajishirzi, # 51 2nd Decl of Deirdre Heatwole, # 52 Decl of Parisa Hosseinzadeh, # 53 Decl of Adam Mokhalalati, # 54 Decl of Shima Nofallah, # 55 4th Decl of Jeffrey Riedinger, # 56 Decl of Solmaz Shakerifard, # 57 Decl of Khadijeh Sheikhan, # 58 Decl of Ali Shojaie, # 59 Decl of Hema Yoganarasimhan, # 60 2nd Decl of Kathy Oline, # 61 2nd Decl of Dave Soike, # 62 2nd Decl of Rita Zawaideh, # 63 2nd Decl of Mitra Akhtari, # 64 2nd Decl of Melanie de Leon, # 65 Decl of Payam Fotouhiyehpour, # 66 2nd Decl of Marc Overbeck, # 67 2nd Decl of Sana Parsian, # 68 Decl of Sahar Z. Zangenah, # 69 2nd Decl of Dennis Galvan, # 70 Proposed Order) Noting Date 10/16/2017, (Melody, Colleen)

SECOND
DECLARATION OF
MITRA AKHTARI

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The Honorable James L. Robart

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UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WASHINGTON

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STATE OF WASHINGTON; STATE
OF CALIFORNIA; STATE OF
MARYLAND; COMMONWEALTH
OF MASSACHUSETTS; STATE OF
NEW YORK; and STATE OF
OREGON,

CIVIL ACTION NO. 2:17-cv-00141-JLR

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Plaintiffs,
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v.
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DONALD TRUMP, in his official
capacity as President of the United
States; U.S. DEPARTMENT OF
HOMELAND SECURITY; ELAINE
C. DUKE, in her official capacity as
Acting Secretary of the Department of
Homeland Security; REX
TILLERSON, in his official capacity
as Secretary of State; and the UNITED
STATES OF AMERICA,
Defendants.

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Pursuant to 28 U.S.C. § 1746(2), I, Mitra Akhtari, hereby declare as follows:
1. I am a graduate of Harvard University's economics PhD program and received my B.A. in

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applied mathematics and economics from the University of California, Berkeley. My
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teaching and research fields are labor economics, political economy, development
economics, and public finance.

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2. At Harvard, I was an affiliate of the Weatherhead Center for International Affairs, the largest

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international science center within Harvard’s Faculty of Arts and Sciences. I was also

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ATTORNEY GENERAL OF NEW YORK
120 Broadway
New York, NY 10271-0332

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affiliated with the Institute for Quantitative Social Science, Harvard’s largest social science

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research center.

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3. I am currently working as a data scientist at Airbnb.

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4. I have personal knowledge of the facts set forth in this declaration, and I am competent to
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testify about them.

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5. I am one of the founding members of the Immigrant Doctors Project, as well as one of its

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researchers. The Project consists of ten economists and doctoral candidates in economics at

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Harvard, the Massachusetts Institute of Technology, and the University of Chicago.

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6. The Immigrant Doctors Project (“IDP”) was formed in February of 2017 to analyze the
impact of the President’s Executive Orders on the provision of health care in the United

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States.
7. I have reviewed the Proclamation titled “Enhancing Vetting Capabilities and Processes for

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Detecting Attempted Entry Into the United States by Terrorists or Other Public-Safety

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Threats,” issued by the President on September 24, 2017 (hereinafter, “the Third Executive

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Order”). I am aware that the Third Executive Order purports to bar entry into this country

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by nationals from Syria and North Korea, and restricts the issuance of certain visas to

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nationals of Chad, Libya, Iran, and Yemen (collectively, “designated countries”).
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8. IDP’s work shows that the Third Executive Order is likely to hurt the health of millions of

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Americans—including New Yorkers—who rely on physicians trained in the affected

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countries.

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9. The data underlying our results comes from Doximity, an online networking site for doctors.

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Doximity assembles data from a variety of sources, including the American Board of

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ATTORNEY GENERAL OF NEW YORK
120 Broadway
New York, NY 10271-0332

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Medical Specialties, specialty societies, state licensing boards, and collaborating hospitals

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and medical schools. Doximity data has been verified as being highly reliable and has been

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used in research published in leading peer-reviewed journals, such as the Journal of the
American Medical Association. 1

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10. The Doximity data also is comprehensive, covering 1,005,419 physicians—virtually all

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practicing physicians in the United States. (Every doctor assigned a National Provider

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Identifier by the Centers for Medicare and Medicaid Services is included.)

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11. To evaluate the impact of the Third Executive Order, IDP restricts its analysis to the subset
of observations in the Doximity data with both current zip code and country of medical
school information, leaving us with a final sample of 827,522 doctors.

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12. Doctors are classified as immigrants from one of the countries designated in the Third
Executive Order based on the country in which they attended medical school. Although this

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is not a perfect measure of national origin, it is a useful—and even conservative—estimate

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for the total number of affected doctors.

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13. We count approximately 7,000 doctors presently working in America who attended medical
school in one of the designated countries. There are two important reasons why this count

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likely understates the total number of affected doctors. First, the Doximity data covers
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1,005,419 physicians, but we restrict our analysis to the 827,522 physicians with both

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current zip code and country of medical school information. We do not adjust for the fact

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that 18% of doctors in the United States are excluded from our analysis. Second, we do

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See, e.g., Anumpam B. Jena, M.D., Ph.D. et al., Sex Differences in Academic Rank in US Medical Schools
in 2014, Journal of the Am. Med. Ass’n, 314(11):1149-1158 (Sept. 15, 2015).

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ATTORNEY GENERAL OF NEW YORK
120 Broadway
New York, NY 10271-0332

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not count citizens of designated countries who did their medical training in the United

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States or in other non-designated countries.

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14. While there may be some doctors who will be incorrectly included in our counts—for

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example, doctors who attended medical school in the designated countries, moved to the
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United States, and became naturalized U.S. citizens—the number of doctors who are

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among the 18% excluded from our sample or who trained in the United States likely

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exceeds the number incorrectly included in our count. We therefore believe that 7,000

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doctors is a conservative estimate of the total number of doctors directly affected by the

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Second Executive Order.
15. Doximity contains data on the address of a doctor’s practice. We group doctors based on

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the commuting zone of their practice address. Commuting zones are groups of adjacent
counties that have close economic ties; for instance, seven counties in the eastern part of
Massachusetts make up the Boston commuting zone.

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16. To estimate the number of appointments provided to patients each year by doctors from the

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designated countries, we multiply the number of doctors by 2,000. This estimate is based

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on research by Hannah Neprash, who finds that an average doctor serves just over 40

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appointments per week (40 appointments/week x 50 weeks worked = 2,000
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ATTORNEY GENERAL OF NEW YORK
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New York, NY 10271-0332

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appointments/year). 2 Estimates from other sources, such as the 2016 Survey of America’s

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Physicians, generate similar estimates.3

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17. We characterize commuting zones as having a shortage of doctors if the population of the

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commuting zone is more than 3,500 times the number of doctors with an internal medicine
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specialty in the commuting zone. This definition corresponds closely with one of the main

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criteria used in the federal Health Professional Shortage Area (HPSA) designation: whether

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the ratio of the population to primary care providers exceeds 3,500. Population information

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is obtained from the 2015 American Community Survey, conducted by the U.S. Census

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Bureau.
18. In New York State, approximately 500 doctors trained in the designated countries, including

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200 from Syria alone, offer 1.1 million medical appointments each year. In New York City,
there are about 300 doctors who trained in the designated countries; they offer about
600,000 appointments each year.

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19. There are 741 commuting zones in the United States. Three of New York’s commuting

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zones—Syracuse, Poughkeepsie, and Buffalo—are among the top 20 commuting zones in

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terms of the percentage of doctors who trained in the designated countries: the number of

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doctors trained in the designated countries is above average compared to the rest of the
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country:

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See Hannah T. Neprash, Better Late than Never? Physician Response to Schedule Disruptions (Nov.
15, 2016), available at http://scholar.harvard.edu/files/hannahneprash/files/neprash_jmp_november2016.pdf.
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See The Physicians Foundation, 2016 Survey of America’s Physicians: Practice Patterns &
Perspectives (Sept. 2016), available at
http://www.physiciansfoundation.org/uploads/default/Biennial_Physician_Survey_2016.pdf.

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ATTORNEY GENERAL OF NEW YORK
120 Broadway
New York, NY 10271-0332

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a. In Buffalo, doctors trained in the designated countries offer about 120,000
appointments each year.
b. In Syracuse, doctors who trained in the designated countries offer about 60,000

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appointments each year.
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c. In Poughkeepsie, doctors trained in the designated countries offer about 60,000
appointments each year.

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20. Even smaller commuting zones are affected by the Third Executive Order. For example, the

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city of Olean in Cattaraugus County in western New York is a medically underserved

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commuting zone. Although it has less than ten physicians from the designated countries, it
stands to lose as many as 20,000 appointments each year.

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21. In a rural and medically underserved area like Olean, the shortage of doctors can have a
devastating impact on the health of residents. Cardiology and neurology are two of the three

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specialties with the highest share of doctors from the designated countries. Proximity to

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cardiologists and neurologists is critical to the survival and recovery of patients suffering

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from heart attacks and strokes. In these cases, there is a short window—the so-called

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“golden hour”—during which immediate treatment can prevent permanent damage to the

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heart or brain. Longer drives to the nearest specialist mean higher rates of permanent
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ATTORNEY GENERAL OF NEW YORK
120 Broadway
New York, NY 10271-0332

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disability and death. 4 Beyond emergency situations, long distances can prevent patients

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from seeking routine, but essential care.5

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I declare under penalty of perjury that the foregoing is true and correct.

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Executed on this 11th day of October, 2017

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/s/_______
Mitra Akhtari

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A 2002 survey found that increased distances from medical care in rural areas contributed to higher
fatalities from car accidents. See U.S. Dep’t of Agriculture, Health Care Status and Health Care Access of Farm
and Rural Populations 31 (Aug. 2009),
https://www.ers.usda.gov/webdocs/publications/44424/9371_eib57_1_.pdf?v=41136 (footnote omitted).
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See, e.g., William F. Rayburn M.D. et al., Drive Times to Hospitals with Perinatal Care in the United
States, Obstetrics & Gynecology, 119(3):611-616 (March 2012) (evaluating driving times to hospitals offering
perinatal services in the United States); Laura-Mae Baldwin, M.D. MPH et al., Low Birth Weight Rates in the
Rural United States, 2005, Rural Health Research Center, Univ. of Wash. (Oct. 2013),
http://depts.washington.edu/uwrhrc/uploads/RHRC_PB138_Baldwin.pdf (explaining that barriers to low-birth
weight prevention include insufficient provider supply and longer distances to provider offices).

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ATTORNEY GENERAL OF NEW YORK
120 Broadway
New York, NY 10271-0332