Need for doctors in rural areas deepens

Medically underserved areas in Texas would have a lot more physicians if the U.S. Dept. of Agriculture were still sponsoring J-1 visa waivers, according to Dave Pearson, spokesman for the Texas Organization of Rural & Community Hospitals.

"If not for the state Conrad 30 program, we wouldn't have any J-1 placements in the state," Pearson said.

Texas used to get about 100 doctors a year through the USDA. Now it's only able to get 30 physicians a year, and that's through the state Conrad program, a device authorized by Congress that allows participating states to sponsor up to 30 J-1 visa waivers a year.

"We certainly have felt the impact of losing the USDA program," said Connie Berry, manager of the Texas Dept. of Health Primary Care Office.

The pinch Texas is feeling also is being experienced in underserved areas, both rural and urban, across the nation, experts said.

In February 2002, the USDA opted to stop sponsoring waivers because of security concerns following Sept. 11, 2001. The U.S. Dept. of Health and Human Services volunteered to take over the program, but it has not approved nearly the number of applications that the USDA approved.

From 1994 through 2001, the USDA approved more than 3,000 applications. From June to September 2002, HHS processed 43 applications. It then closed the program for evaluation and reopened it in December 2003 with new requirements. Since that time only 10 physicians have been granted waivers.

Alan Morgan, vice president of government affairs for the National Rural Health Assn., said the change under HHS has been dramatic.

"The HHS-sponsored J-1 visa waiver program is a complete disaster," he said.

Waivers have been critical in improving access to health care, Morgan said. An estimated 4 million people are treated by J-1 waiver doctors. The J-1 visa, used by many international medical graduates as a way to train in the United States, requires them to leave for two years before applying to re-enter the country. A waiver allows the visa holder to stay.

David Rutstein, MD, deputy associate administrator for health professions for the Health Resources and Services Administration, the agency charged with the waiver program's day-to-day operations, said its goal was to make the J-1 waiver program similar to the National Health Service Corps, which provides incentives for U.S. medical graduates to practice in underserved areas.

"We're treating foreign nationals the same as American citizens obligated to go to underserved areas," he said.

HHS changed three things when it reopened the waiver program in December 2003. First, it no longer accepts waivers for positions in areas designated medically underserved by the federal government. Now waivers are only issued for those who are going to practice in federally designated health professional shortage areas.

In addition, these HPSAs must have a rating of 14 or higher to be considered for the waiver program. HPSAs are scored from 1 to 25 based on need, with 25 being the most needy.

Lastly, only rural health centers, community health centers and Indian health centers are counted as eligible employers. Hospitals, private clinics or private practices are no longer allowed to participate.

Morgan said these changes immediately excluded 1,500 rural hospitals. Other sources noted the state of Delaware no longer has any eligible areas and that 90% of the underserved communities in Texas are now out of contention for J-1 waivers.

Greg Siskind, an immigration attorney with Siskind Susser in Memphis, said that HHS has changed the program so dramatically that very few employers and physicians will apply. "No lawyers even tell clients about it," he said. Instead they direct them to the state Conrad programs or regional groups like the Delta Regional Authority.

Conrad serves as alternative

When the USDA announced it was ending its sponsorship of J-1 waivers, states that did not have Conrad programs began setting them up. Soon there will be programs up and running in all 50 states and in the District of Columbia.

States are now relying heavily on Conrad 30 programs, though many admitted that it is not enough to solve their physician shortage problems. A survey by the Texas Dept. of Health of all Conrad programs found 15 states would expand their programs by five to 50 slots if Congress allowed such an alteration.

Dr. Rutstein said there could be several reason why HHS was receiving fewer waiver applications. It could be an extension of a downtrend that began when the USDA was administering the program -- it slipped from a peak of 696 physicians in 1996 to 104 in 2001. It could also be that the Conrad programs are pulling a larger share of the applicant pool, reducing the number looking to HHS.

However, critics said under the new restrictions HHS would be hard-pressed to sponsor more than a dozen waivers in 2004, more than a 50% drop from the last year the USDA operated the program.