HHS Proposes Changes in J Waivers for Doctors
Secretary of Housing
& Urban Development
Washington, D.C. 20410
Dear Henry:
I am writing to request that your Department undertake a review of its policies related to waivers of the two-year foreign residence requirement under the Exchange Visitor Program for foreign national international medical graduates.
For many years, the United States has been addressing problems related to the geographic and specialty distribution of physicians. Federal and State government programs have dramatically increased the capacity of medical schools, expanded primary care residency programs, and provided a variety of financial incentives for service in rural and inner-city shortages areas. At the same time international medical graduates have entered the United States in large numbers; over 100,000 physicians who are practicing here today were foreign nationals at the time they entered our country as exchange visitors, temporary workers, or for some other purpose.
Now, as new managed-care arrangements are rapidly replacing the traditional fee-for-service system, our national requirements for physicians are also changing. In fact, the Council on Graduate Medical Education has recently determined that by the year 2000, the national supply could well exceed the need by more than 100,000 physicians; all of the excess supply will be for non- primary care physicians. Even with this impending surplus, in 1993 we increased the number of international medical graduates entering residencies in the United States to 6,700 compared to 18,500 graduates of US schools.
Last year, the President signed the Immigration and Nationality Technical Corrections Act of 1994, P.L. 103-416, enacted on October 25. Section 220 of the Act authorizes each State's department of public health or its equivalent to request the Director of USIA to recommend that INS grant waivers for up to 20 physicians per year. The physician must have a bona fide offer of full employment and must agree to work for a total of not less than three years in a health care facility in an area designated by the Secretary of Health and Human Services as having a shortage of health care professionals. Even though the foreign residence requirement may now be waived by INS based on a request from an interested US government agency and recommended by USIA, the new law provides a much stronger means for requiring service in areas where physicians are most needed and for enforcing their service agreements, i.e., requiring they leave the United States if they do not fulfill their agreements.
The Department of Health and Human Services endorses the philosophy of the Exchange Visitor Program in which participants are committed to return home for at least two years after completing their educational program. This requirement was imposed to prevent the program from becoming a stepping stone to immigration and to insure that exchange visitors make their new knowledge and skills available in their home countries. In summary, this Department has viewed the J-1 visa to be a means of sharing advanced medical knowledge and allowing the benefits of training to accrue to the home country. The Department does not view waivers as a mechanism to help resolve the problems of shortage areas.
On occasion, some departments and agencies have taken a different approach, viewing the granting of a waiver as a means of finding and placing physicians in underserved areas. This objective may now be met under the authority provided to States to request waivers for shortage area service under P.L. 103-416. Therefore, one option we would like to explore with you is whether the State-based program could be the sole mechanism for placing exchange visitor physicians in shortage areas. We might consider requesting both extension of the authorization of the State-based program and increasing flexibility with respect to the numbers of physicians that can be placed, thus eliminating the need for other types of service-based waivers.
Given these considerations, I request that your Department review its policy in regard to exchange visitor waivers for physicians. I would appreciate hearing the results of your review so that we can facilitate the development of a consistent approach with regard to waivers for international medical graduates. I have designated staff in the U.S. Public Health Service to help coordinate our efforts to develop a consistent government-wide approach. Dr. Jo Ivey Boufford, the Principal Deputy Assistant Secretary for Health, is available to work with your staff on this matter. She may be reached at 202/690-7694.
I am also writing to Secretaries Brown and Glickman and the Federal Co-Chairman of the Appalachian Regional Commission and am sharing copies with Attorney General Reno and the Director of the United States Information Agency. I hope that together we can make progress in developing a consistent U.S. Government policy.
Sincerely,
Donna E. Shalala
(Courtesy of Jan M. Pederson)
27MM5J14