Rural areas say more J-1 visas needed

At its peak in 1999, the Dept. of Agriculture pumped 242 international medical graduates into clinics and hospitals in rural communities. The same J-1 visa waiver program, in the hands of the Dept. of Health and Human Services since 2002, placed just four physicians in 2005.

That dramatic drop is a big concern for medically underserved communities that rely on these programs to help recruit doctors, who commit to stay a minimum of three years.

"You can't just cut the program," said L. Gary Hart, PhD, director of the Rural Health Research Center at the University of Washington School of Medicine. "It would leave places in catastrophically bad situations."

With work-force experts anticipating a national physician shortage, shortfalls in underserved areas are likely to deepen.

"The J-1 visa waiver physicians are an essential pipeline for rural places that would find it nearly impossible to find a physician otherwise," said Keith Mueller, PhD, director of the Rural Policy Research Institute's Center for Rural Health Policy Analysis at the University of Nebraska Medical Center.

Other agencies sponsor J-1 visa waivers, but HHS' program is the only one with a national scope. It also has no limits on the number of doctors it can sponsor. For example, state-administered Conrad 30 J-1 programs are capped at 30 physicians per state, per year. Regional groups, such as the Appalachian Regional Commission and the Delta Regional Authority, don't have numerical limits, but are bound by geographical constraints.

The National Health Service Corps and state loan-forgiveness programs also help underserved rural communities attract doctors, but the national J-1 waivers remain vital.

"If you don't have all three [programs] active, you're in trouble," Dr. Mueller said.

Michael Berry, who leads the J-1 visa waiver program at HHS, said the decline in physicians approved for waivers reflects a change in demand.

He said fewer IMGs are entering the United States on J-1 visas, which require the person to return home for two years before applying to work in the United States. Instead, they are entering using an H-1b visa, under which doctors don't have to work in an underserved area. "The pool of J-1 physicians is shrinking," Berry said.

All IMGs seeking a J-1 visa must be sponsored by the Educational Commission for Foreign Medical Graduates. ECFMG data show a decline in IMGs seeking J-1 visas, with 6,600 in 2003-04, down from 8,600 in 2000-01.

Berry said the agency also is facing more competition for IMGs. For example, the state Conrad programs are consuming more J-1 visa waiver applicants, he said.

All 50 states and the District of Columbia use the Conrad program, up from 41 states in 2001. Also, since 2002, the government has increased the number of waivers available to each state, raising it to 30 from 20.

"Put these two factors together, and the Conrad programs are taking practically all the [interested J-1 applicants] available," Berry said.

Because of this, he said, HHS changed its requirements to ensure physicians go to the neediest of the needy communities.

The agency no longer accepts waivers for positions in areas designated as medically underserved. Instead, HHS grants waivers only for federally designated health professional shortage areas with a rating of 14 or higher, on the one to 25 scale. Plus, only rural, community and American Indian health centers are eligible. Overall, this means only 20% of federally designated health professional shortage areas are eligible.

HHS critics agreed there's been a decline in J-1 visa waiver applicants, but they said it wasn't enough to justify HHS' actions.

"If HHS is correct in its statement, you would not see the Conrad 30 program maxed out every single year [in many states]," Dr. Mueller said.

The Texas Dept. of Health Primary Care Office, which appears to be the only agency tracking this data nationally, calculates 836 physicians received waivers through the state Conrad programs in 2005.

Combined with 20 physicians placed through the Delta Regional Authority that year, 36 through the Appalachian Regional Commission and the four through HHS, that's 896 physicians who joined the work force treating patients in underserved communities in 2005.

Of an available pool of roughly 6,600 to 8,600 physicians, that means about 5,700 to 7,700 are leaving the country instead of seeking J-1 waivers to stay and use their skills in the United States, according to Greg Siskind, an immigration attorney with Siskind Susser in Memphis.

"We have a nice pool of doctors to choose from, even with the numbers being down," he said. "You can increase the pool or encourage more of them to stay. It's cynical to say that HHS changed its rules to get more doctors into the most needy areas. Its program restrictions are so onerous, virtually no one can qualify."

Largely rural states, such as Texas, have felt HHS' changes deeply, said Connie Berry, manager of the Texas Dept. of Health Primary Care Office. The state filled its allotment of 30 J-1 waivers in a day and a half and easily could fill 50 more slots, Berry said. When USDA ran the national J-1 visa waiver program, it was able to fill this gap, she said. In 2005, Texas received one J-1 visa waiver through HHS.

Despite a full Conrad program, Berry's office continues to get queries. "We haven't had a week go by that someone hasn't called," she said.