Need for doctors in rural areas deepens

Few J-1 visa waivers are being issued via the Dept. of Health and Human Services, leaving many clinics with vacancies.

By Myrle Croasdale — Posted July 26, 2004

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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.

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Sources shift for J-1 visa waivers

Various sponsoring agencies issue J-1 visa waivers to international medical graduates to work in underserved communities. The U.S. Dept. of Agriculture stopped sponsoring waivers at the end of February 2002. The Dept. of Health and Human Services and the Delta Regional Authority did not begin sponsoring waivers until 2003. Number of J-1 visa waivers issued over the last five years:

1999 2000 2001 2002 2003
U.S. Dept. of Agriculture 242 163 104 14 0
Health & Human Services 43
Appalachian Regional Commission 92 58 66 60 58
Delta Regional Authority 10
State Conrad programs* na na na na 1,017

*Not available. The State Dept. was unable to compile J-1 visa waiver numbers for these years before press time.

Source: U.S. Dept. of Health and Human Services, U.S. Dept. of Agriculture, State Dept., Appalachian Regional Commission, Delta Regional Authority

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Delta group starts waiver program

The Delta Regional Authority, an economic development organization, is the latest government agency to begin sponsoring waivers for J-1 visa physicians willing to work in rural areas.

Dr. Claudia Velarde, an internist with a subspecialty in nephrology is originally from Peru. She's one of the first physicians to get a waiver through the authority.

Based at the Northwest Mississippi Regional Medical Center in Clarksdale, Miss., most of her patients are black, many are elderly and many are poor. She estimates 60% to 70% are on both Medicaid and Medicare and 20% are uninsured.

"Sometimes I feel like I'm in Peru," she said. "It's the same situation. My patients are not well-educated; they're poor people who really need [health care] and appreciate it more than those with access to so much else."

The DRA covers 240 counties in eight states along the lower Mississippi River. Such waivers are the only way many of its communities can attract a physician.

Justin Ferguson, federal policy coordinator for the Delta Regional Authority in Clarksdale, Miss., said it was the U.S. Dept. of Agriculture's exit from the waiver sponsoring business that spurred the Delta Regional Authority to become a sponsoring body.

"USDA used to be the big federal agency with a J-1 waiver program," he said. "When they shut it down, it created a huge gap.

Ferguson said his region is short 3,277 physicians and the 14 applications DRA has processed to date are a tiny but welcome effort toward filling the need.

The authority only accepts physicians in family medicine, internal medicine, pediatrics or obstetrics.

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