    [Senate Hearing 117-919]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-919

                        FLATLINING CARE: WHY IMMIGRANTS
                         ARE CRUCIAL TO BOLSTERING OUR
                             HEALTH CARE WORKFORCE

    =======================================================================

                                    HEARING

                                   before the

                          SUBCOMMITTEE ON IMMIGRATION,
                         CITIZENSHIP AND BORDER SAFETY

                                     OF THE

                           COMMITTEE ON THE JUDICIARY
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                               SEPTEMBER 14, 2022

                                   __________

                              Serial No. J-117-76

                                   __________

             Printed for the use of the Committee on the Judiciary

             GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

                            www.judiciary.senate.gov

                                www.govinfo.gov

                               _______

                 U.S. GOVERNMENT PUBLISHING OFFICE
     59-432               WASHINGTON : 2025

                           COMMITTEE ON THE JUDICIARY

                       RICHARD J. DURBIN, Illinois, Chair
    PATRICK J. LEAHY, Vermont            CHARLES E. GRASSLEY, Iowa, Ranking
    DIANNE FEINSTEIN, California             Member
    SHELDON WHITEHOUSE, Rhode Island     LINDSEY O. GRAHAM, South Carolina
    AMY KLOBUCHAR, Minnesota             JOHN CORNYN, Texas
    CHRISTOPHER A. COONS, Delaware       MICHAEL S. LEE, Utah
    RICHARD BLUMENTHAL, Connecticut      TED CRUZ, Texas
    MAZIE K. HIRONO, Hawaii              BEN SASSE, Nebraska
    CORY A. BOOKER, New Jersey           JOSH HAWLEY, Missouri
    ALEX PADILLA, California             TOM COTTON, Arkansas
    JON OSSOFF, Georgia                  JOHN KENNEDY, Louisiana
                                         THOM TILLIS, North Carolina
                                         MARSHA BLACKBURN, Tennessee
                 Joseph Zogby, Chief Counsel and Staff Director
          Kolan L. Davis, Republican Chief Counsel and Staff Director

            .........................................................

                    SUBCOMMITTEE ON IMMIGRATION, CITIZENSHIP
                               AND BORDER SAFETY

                        ALEX PADILLA, California, Chair
    DIANNE FEINSTEIN, California         JOHN CORNYN, Texas, Ranking Member
    AMY KLOBUCHAR, Minnesota             LINDSEY GRAHAM, South Carolina
    CHRISTOPHER A. COONS, Delaware       TED CRUZ, Texas
    RICHARD BLUMENTHAL, Connecticut      TOM COTTON, Arkansas
    MAZIE K. HIRONO, Hawaii              JOHN KENNEDY, Louisiana
    CORY A. BOOKER, New Jersey           THOM TILLIS, North Carolina
                                         MARSHA BLACKBURN, Tennessee

                    Alyson Sincavage, Majority Chief Counsel
                     Ryan Raybould, Minority Chief Counsel
                                C O N T E N T S

                                  ----------

                               OPENING STATEMENTS

                                                                       Page

    Padilla, Hon. Alex...............................................     1
    Durbin, Hon. Richard J...........................................     5
    Cornyn, Hon. John................................................     3

                                   WITNESSES

    Alur, Dr. Ram Sanjeev............................................    11
        Prepared statement...........................................    34
        Responses to written questions...............................    61

    Martinez, Urbino ``Benny''.......................................    13
        Prepared statement...........................................    39
        Questions submitted with no response returned................    60

    Peterson, Sarah K................................................     9
        Prepared statement...........................................    42

                                    APPENDIX

    Items submitted for the record...................................    33

                        FLATLINING CARE: WHY IMMIGRANTS

                         ARE CRUCIAL TO BOLSTERING OUR

                             HEALTH CARE WORKFORCE

                                  ----------

                         WEDNESDAY, SEPTEMBER 14, 2022,

                                  United States Senate,
                      Subcommittee on Immigration, Citizenship,
                                             and Border Safety,
                                    Committee on the Judiciary,
                                                        Washington, DC.
        The Subcommittee met, pursuant to notice at 10:06 a.m., in
    Room 226, Dirksen Senate Office Building, Hon. Alex Padilla,
    Chair of the Subcommittee, presiding.
        Present: Senators Padilla [presiding], Klobuchar, Hirono,
    Cornyn, and Tillis.
        Also present: Senators Durbin and Grassley.

                OPENING STATEMENT OF HON. ALEX PADILLA,

              A U.S. SENATOR FROM THE STATE OF CALIFORNIA

        Chair Padilla. Morning, everybody. Welcome to the fifth
    hearing of the Senate Judiciary Subcommittee on Immigration,
    Citizenship, and Border Safety this Congress. We're here to
    talk today about the critical role that immigrant health care
    professionals play in our Nation's health care system. And the
    opportunity and, frankly, the obligation we have to confront
    our Nation's growing shortage of health care workers.
        I want to thank all of our witnesses who are here today,
    both in person, and we have one witness participating virtually
    who will speak about their personal experiences and our shared
    goal of improving care for millions of Americans. For that same
    reason, I want to thank Chairman Durbin, Ranking Member Cornyn,
    who will be joining us momentarily, and all the Committee staff
    who have worked so hard to organize today's hearing.
        Today will shed light on solutions to the challenges facing
    our health care system. Solutions, frankly, that can save lives
    and have a chance to improve our immigration laws in ways that
    better serve the needs of our population and our economy.
    Americans facing obstacles to access to the standard of health
    care they deserve is nothing new. But in recent years it has
    become even harder.
        Even before the COVID-19 pandemic, the United States was
    experiencing some concerning trends. Our population was aging
    with an increasing demand for care, while retirements by
    physicians continued to rise. Daunting student loan debts were
    discouraging prospective health care professionals from
    entering the field, and hundreds of hospitals in rural or low-
    income communities were at risk of closing after struggling to
    recruit or retain physicians. The onset of the COVID-19
    pandemic created an entirely new strain on our workforce,
    thrusting America's health care workers onto the front lines of
    a once in a century global health pandemic and accelerating
    burnout in an already fractured system.
        Tragically, since the beginning of the pandemic to November
    2021--so this was almost a year ago--at least 4,547 health care
    workers, including 458 nurses, have died while caring for their
    patients. As a result, we're now facing an even more dangerous
    shortage of health care workers. The Association of American
    Medical Colleges projects the U.S. is facing a shortage of up
    to 124,000 physicians by the year 2034. That means a shortage
    of up to 48,000 primary care physicians and more than 77,000
    non-primary care physicians.
        In addition, an estimated one million nurses are expected
    to retire in the next decade. For over 2 1/2 years of the
    pandemic, Americans had to put doctor's appointments and
    lifesaving screenings on hold. But as COVID becomes endemic and
    as we learn to better manage outbreaks, Americans should not be
    forced to further delay lifesaving care because we failed to
    invest in and grow our health care workforce. We have to
    protect our health care workers and ensure they're able to work
    reasonable hours, have better staffing ratios, and that they're
    paid adequately, and have the equipment needed to keep them
    safe.
        Now, I'm proud to be an original co-sponsor of the National
    Nursing Shortage Reform and Patient Advocacy Act. But that
    alone won't be enough to bridge our entire health care
    workforce gap. The good news is there are some commonsense
    solutions right before us. There are thousands of highly
    capable health care professionals living abroad with the desire
    to come to America to study, train, in their profession, and
    work saving lives. We know immigrant health care workers can
    help to fill the health care workforce gap and provide critical
    care because in communities throughout the United States,
    they're already there. They're already doing it.
        One in every four physicians in the United States is an
    immigrant. And one in every six nurses is an immigrant. Among
    them, there are approximately 34,000 DACA recipients and 11,600
    TPS holders working in health care. And with an aging
    population in increasing need of care, immigrants make up over
    half of our physicians practicing geriatric medicine in nearly
    38 percent of Americans home health aides.
        So, think about this. Immigrant doctors write
    prescriptions. Immigrant nurses care for us at our bedsides.
    Immigrant health care professionals perform highly skilled
    procedures each and every day. And they're often the
    cornerstone for rural and low-income communities, places where
    a single foreign-born physician can be tasked with treating an
    entire community. They can and they want to be part of the
    solution to our health care workforce crisis.
        However, even as we face unprecedented shortages in our
    health care system, the laws that limit the immigration of
    highly trained health care workers have gone largely unchanged
    since the 1990's. There continues to be significant backlogs in
    processing green cards for critical health care workers. There
    are annual caps to employment-based visa categories that have
    not been met and per country caps that should be updated to
    meet the demand of today's health care industry. And many of
    the federally recognized essential workers that we relied on at
    the peak of the COVID-19 pandemic still risk uncertainty with
    their legal status in America.
        In our hour of need, the United States is effectively
    discouraging potential health care workers from trying to come
    to and work in the United States. That needs to change. The
    very first bill I introduced in the Senate, co-sponsored by
    Chairman Durbin and other Members of this Committee, would
    start to protect many of those workers at risk by providing a
    pathway to citizenship for over 5 million essential workers
    without permanent status. The Citizenship for Essential Workers
    Act would protect health care workers who risk their lives to
    keep our communities safe during the pandemic.
        I'm also calling on the Senate to pass the Americans--
    excuse me, America's Children Act and protect documented
    dreamers, the children of long-term visa holders who face
    deportation at the age of 21 without a green card or other
    immigration status. Many health care professionals worry about
    their own children aging out of status or losing status
    completely if something were to happen to the primary visa
    holder.
        And as we'll hear today, what we need are system wide
    reforms that incentivize and welcome immigrants into our health
    care workforce. I'm looking forward to hearing from all of our
    witnesses today about their experiences and their ideas for
    fixing this broken system. I'll now recognize Ranking Member
    Cornyn for his opening remarks.

                     STATEMENT OF HON. JOHN CORNYN,

                 A U.S. SENATOR FROM THE STATE OF TEXAS

        Senator Cornyn. Well, thank you, Mr. Chairman. I enjoy
    working with you on these issues. But as we've discussed in
    private, it's hard for us to make progress on areas even where
    there is consensus on the topic of immigration while the border
    is on fire.
        Last year alone, 108,000 Americans died of drug overdoses
    and almost all that comes across the southwestern border.
    Seventy-one thousand of those 108,000 were overdosed on
    synthetic opioids like fentanyl, the precursors of which, of
    course, come from Asia and then are manufactured in Mexico come
    across the border because the Border Patrol is overwhelmed by
    the volume of humanity coming across, which is, of course, part
    of the plan, part of the business model of the drug cartels.
    Overwhelm the Border Patrol. They're busy taking care of
    unaccompanied children and other migrants in a humane way, as
    we would want them to do.
        But in the meantime, it takes Border Patrol off of the
    border where the drugs come across. And, of course, there are
    serious concerns, as there should be, about crime in America.
    And the truth is that most of these drugs are distributed by a
    network of gangs operating in all of our major cities and even
    in some of the rural parts of our country, and who are largely
    responsible for much of the gun violence you see in places like
    Chicago and elsewhere as they fight for market share and for
    territory.
        So, for at least now, a year and a half during the course
    of the Biden administration, our Democratic colleagues have
    been in the majority. The Chairman of this Committee has
    unilateral prerogative to mark up any bills that he wants. But
    as I have told him in private, trying to work in good faith
    with him and the Chairman of the Subcommittee, I can't imagine
    a path forward until we find some way to deal with the crisis
    at the border, which is basically a policy problem because of
    the way that asylum cases are treated.
        As long as catch and release is the rule, as long as our--
    the Biden administration refuses to detain people who are
    awaiting their asylum hearing and then gives them a notice to
    appear given the backlogs of the immigration courts, many
    people don't appear. And, of course, that is--that's the again,
    part of the plan, part of the model that is enriching some of
    the most dangerous transnational criminal organizations in the
    world.
        And finally, for those people like Vice President Harris
    and others who think this is a problem with just the Northern
    Triangle and Central America, that is refuted by the fact that
    if you go to the Rio Grande Valley sector or the Del Rio sector
    of the Border Patrol, that they have as many as--people from as
    many as from 150 different countries detained there.
        Of course, the numbers, the big numbers come from Mexico
    and Central America. But literally, if you have enough money,
    you can make your way to the southern border and claim asylum
    and then get placed into the interior of the United States to
    await your court hearing. And like I said, many people don't
    show up.
        And finally, I know there's been some objections raised by
    the mayors of Washington, DC, and New York, and Chicago over
    transporting migrants from the border communities where they
    cross into their cities, each of which I believe, continue to
    hold themselves out as a sanctuary city. But yet, when they
    begin to feel some of the pressures that our border communities
    feel every day with many, many multiples of the numbers to deal
    with, they ask, as Mayor Bowser has here in Washington, DC, for
    the National Guard because of a crisis they're experiencing.
        So, I'm--I remain an optimist. At some point, I think we
    will have tried everything except the real solution to the
    problem and which will break the log jam, which is to deal with
    the problem of catch and release and the broken asylum system
    at the border. Then maybe we can deal with things like the
    Conrad State 30 and Physician Access Reauthorization Act, or
    the Health Care Workforce Resilience Act, or maybe even provide
    some certainty to the DACA recipients that are anticipating a
    affirmance of the trial court's decision holding that that
    program 10 years ago started by President Obama when he said he
    didn't have the authority to do it.
        He did it anyway. And the district judge agreed with him.
    He did not have that authority. And I expect that to be
    enormously disruptive to these young people who've done nothing
    wrong.
        Chair Padilla. Thank you, Senator Cornyn. Before
    recognizing Senator Durbin, just want to remind us all, those
    in the Committee room and those watching from home, that the
    topic of today's hearing is what I mentioned earlier, why
    immigrants are critical to bolstering our health care
    workforce. But Senator Cornyn does raise some legitimate
    concerns.
        And so, for everybody's appreciation, I want to acknowledge
    that the vast majority of drugs that are smuggled into the
    United States are through land ports of entry with documented
    travelers, often United States citizens. In fact, statistics
    from the Department tells us that the Border Patrol has seized
    504,000 pounds of drugs. However, only 72,000 pounds were
    seized by Border Patrol agents. The vast majority make up 14
    percent. The vast majority was actually seized by the Office of
    Field Operations.
        And if you know the agents, you'll appreciate the
    distinction. The vast majority being seized at ports of entry
    by more than a 7-to-1 ratio. So, the key to stopping fentanyl
    smuggling or other drug smuggling operations is improved
    screening technology at our border and better utilization of
    new technologies at that.
        So, I'm happy to welcome the--or continue the more
    comprehensive conversations about immigration, the status of
    our border. But I'd like for us, for purposes of today to focus
    on today's topic and that is our health care workforce. And
    with that, let me recognize Senator Durbin.

                  STATEMENT OF HON. RICHARD J. DURBIN,

               A U.S. SENATOR FROM THE STATE OF ILLINOIS

        Chair Durbin. Thank you very much, Chairman Padilla. And I
    want to echo your remarks. We're here to discuss a shortage of
    health care workers, and yet the conversation so far from the
    other side of the aisle has not addressed that issue. They want
    to talk about border security and border safety. They're
    important issues. I agree with the Chairman on that. But I had
    hoped that we would focus more of our time on actually trying
    to help a problem, deal with a problem that is very real across
    the United States, including all of our States gathered here
    today.
        I just want to note a couple of things. Governor Abbott is
    putting recent entries into the United States, people who have
    passed the critical fear test, critical concern into the busses
    and sending them off to cities across the country without any
    warning. I visited one of those centers last Friday in Chicago
    at the Salvation Army. And let me spend a second or two
    thanking the people from the Salvation Army and all the
    wonderful charities that have stepped up to try to help these
    people who are in a desperate position.
        I'm concerned about their fate, as we all should be. But
    I'm concerned about the Governor of Texas and his decision just
    to dump busloads of these people without warning into
    communities. We are doing our best, and we're going to deal
    with them in a humane and American way. But it would be helpful
    if they didn't become the victims in this--or pawns in this
    political debate at the National level. I think we ought to be
    a little more caring for the women and children, families and
    individuals who are coming across our border and are here
    having been judged to be legally qualified to stay until they
    have a hearing ultimately deciding their fate.
        I met with them. I sat down. I talked to them. They're in a
    desperate situation. They've come, many of them, 4 or 5 months
    traveling to the United States, risking their lives and many of
    them suffering things that none of us would want to endure. I
    think they should be treated in a humane American way. And that
    means the Governor should at least give us warning if he's
    going to be shipped them off to county--cities around our
    country.
        Let me say back on the issue of health care workers. Some
    people look at the immigration issue and see murderers, and
    rapists, and drug dealers. What we're talking about today is
    looking at the immigration issue and seeing nurses, and
    doctors, and medical professionals, and caregivers. They're
    already here and we need more of them. I think that is a worthy
    topic of conversation. I traveled my State in the month of
    August from the city of Chicago down to the most rural areas of
    Illinois. The message was consistently the same.
        Dr. Alur, who is here today--thank you for being here--
    works at the Marion, Illinois Veterans Hospital, has for 11
    years. I went down to Southern Illinois Healthcare. Mack's
    buddy, met with him, and talked about what they're facing. They
    are facing a dramatic shortage in nurses, dramatic shortage in
    doctors. And what we're trying to do here is to try to find a
    solution to this. But as long as we're stuck on the issue of
    law enforcement, we can't even address this. I would just say
    this.
        I'm going to go out on a limb here. And, boy, I guess I
    could be proven wrong. But if you can show me a nurse or doctor
    immigrant to this country who is now still in immigrant status,
    who has committed a serious crime, I'd like to know about it. I
    haven't heard it. Just the opposite is true. These men and
    women are coming to the aid of people who desperately need
    medical care. And to brand them as part of the surge at the
    border and somehow criminal in their--in some respects, I don't
    think is fair. I don't think it really addresses the reality of
    what immigrants bring to this country.
        Our immigration system is broken, and the reason we haven't
    changed it is not for lack of effort. Everyone gathered here
    today has been part of that conversation. But we're a 50-50
    Senate and a 50-50 Committee within the Senate, and it's
    difficult to find a bipartisan approach that does ring true to
    everyone involved in it. We've tried, and I'm afraid we haven't
    reached it yet, but I hope we do soon.
        I want to thank the Chairman for identifying health care
    workers and health care professionals as one possibility.
    Wouldn't it be something if we did before the end of the year,
    a bipartisan bill that brought more doctors and nurses to
    America where we desperately need them right now? If we put
    aside all our differences on all the other things and dealt
    with that, wouldn't it be refreshing to the American people
    that we get it, that we understand the message we're receiving?
        The American Hospital Association called the current
    hospital workforce shortage a national emergency. They project
    a shortage of 1.1 million nurses by the end of the year--by the
    end of the year. This is a critical emergency. To say that we
    have to solve the southern border crisis before we can consider
    allowing nurses to come to this country and care for Americans
    is just plain wrong. We need to deal with both, but we can deal
    with one immediately. The Association of American Medical
    Colleges estimates the U.S. could see a shortage of 124,000
    doctors by 19--2034. That's for real.
        I can tell you there are many of them that are here, these
    physicians already serving our communities and saving lives as
    we speak. And many of them, unfortunately, due to the lack of
    available green cards, are forced to remain on temporary visas.
    And as the Chairman has alluded, when their kids reach the age
    of 21, the protection that allowed them to stay with their
    parents in the United States evaporates, and they're subject to
    deportation.
        How would you like to be a doctor going into surgery
    knowing that next week your daughter, who you would give
    anything for, could be subject to deportation? We can fix that.
    That's what this Committee does. This is our jurisdiction.
    Wouldn't it be great if before the end of the year we had a
    bipartisan answer to that simple challenge? I know Dr. Alur has
    addressed this, and he knows it personally, and we do to from
    the professionals in this country.
        So, I'm going to conclude by just by saying there's work we
    can do. There are things we can achieve, and soon. The bills
    that have been addressed here, the Health Care Workforce
    Resilience Act, which I co-sponsored with Senator Cornyn, the
    Conrad State 30 and Physician Access Reauthorization Act, have
    more than a dozen Republican co-sponsors. You know what that
    means in terms of the Senate? That means we can hit the magic
    number of 60 and get this through.
        Now, there are some on the other side of the aisle, not
    alluding to any person who's present here, but there are some
    on the other side of the aisle who want not one single
    immigrant to come to this country. I'm not exaggerating. They
    don't want a single one. They happen to believe that makes us
    stronger as a nation. I couldn't disagree more. I'm the son of
    an immigrant and proud of it. I think I'm doing a service to
    this country, and I hope that I can continue it and many more
    just like me. Sons and daughters of immigrants and immigrants
    themselves want to make America a better and safer place.
    That's what this hearing is all about.
        Chair Padilla. Thank you, Chairman Durbin. We're also
    joined this morning by Ranking Member of the Judiciary
    Committee, Senator Grassley. Senator Grassley, did you have an
    opening statement, or do you want to wait for questions?
        Senator Grassley. I just have questions.
        Chair Padilla. Okay. Then let's hear from our witnesses,
    and we'll hear from Senator Grassley very soon. Now, let me
    just go through some of the mechanics for the rest of today's
    hearing. After we introduce and swear in witnesses, they will
    each have 5 minutes to make their opening remarks. We will then
    begin with our first round of questions, and each Senator will
    have 5 minutes. So, I ask colleagues that we please try to
    remain within your allotted time.
        As far as introductions go, let me start with Ms. Peterson.
    Ms. Sarah Peterson is the founder and principal attorney of
    SPS, Immigration PLLC, a law firm based in Minneapolis,
    Minnesota. Sarah's practiced immigration law for more than 15
    years. She advises health care systems, nonprofit
    organizations, hospitals, and universities throughout the
    United States on complex immigration matters relating to the
    hiring of physicians, researchers, and allied health
    professionals. Ms. Peterson is an adjunct professor at the
    University of Minnesota Law School and was a 2021-2022 policy
    fellow at the Humphrey School of Public Affairs.
        She also actively participates in the International Medical
    Graduate Task Force and currently serves as the chair of the
    IMGT Liaison Committee. Ms. Peterson is also active in the
    American Immigration Lawyers Association and has been
    recognized as a leader in her field. We also have Sheriff
    Martinez with us virtually, and I'll turn to Ranking Member
    Cornyn to do his introduction.
        Senator Cornyn. Well, thank you, Mr. Chairman.
    Unfortunately, I'm advised that Sheriff Martinez's video is not
    working correctly. He can join us by audio, and I expect him
    to--he will do that. But Sheriff Benny Martinez has served
    Brooks County, Texas, since 2009. Brooks County is where the
    Falfurrias checkpoint, which is one of the busiest checkpoints
    inland from the border where coyotes, human smugglers, will
    tell their--the migrants to get out of the vehicle south of the
    checkpoint, walk around the checkpoint, and meet them on the
    north side to be then transported on to their ultimate
    occasion.
        The problem is that Brooks County cannot afford to bury all
    the dead migrants that die in the rough country during hot
    weather, especially after suffering from exposure having come
    from long distances. They can't afford to bury those bodies and
    have asked the Federal Government for assistance. Actually,
    Vice President Harris, when she was a Member of the Senate, and
    I, passed a bill which unfortunately still has not seen the
    money flow to Brooks County for that purpose. But I'm hopeful
    it will soon.
        Prior to his service in Brooks County, Sheriff Martinez was
    a Texas State trooper from 1979 until his retirement in 2008,
    retiring at the rank of Sergeant. As a State trooper, he was
    charged with directing the State's enforcement efforts against
    illegal drug trafficking. And we're glad to have him here as a
    witness today, albeit solely by audio. Thank you.
        Chair Padilla. Thank you, Senator Cornyn. I'll now turn to
    Chairman Durbin for his introduction of Dr. Alur.
        Chair Durbin. I mentioned Dr. Alur a moment ago, but I want
    to say further. He's been a physician at the Marion Veteran
    Affairs Medical Center in Marion since 2011. Dr. Alur's
    hospital serves veterans in southern Illinois, Kentucky,
    Missouri, and Indiana. We love Marion, and the veterans love it
    even more. And thank you for 11 years of your life. I might add
    that Dr. Alur completed his medical degree in India, did his
    medical training in the United Kingdom and Philadelphia before
    coming to Illinois.
        He is caught up in the green card backlog, and I'll have
    him explain that when he makes his statement. But he now has
    helped to co-found an organization of similar physicians who
    want to be part of America's future and want their family to be
    part of America's future. And they are stymied by the
    limitating--limitations in green cards available to allow that.
    It's time for us to drop the blinders and realize we need you,
    Dr. Alur, the veterans of southern Illinois and Kentucky need
    you and people just like you all across the United States. So,
    I'm glad you're here today. We're honored for your presence.
        Chair Padilla. Thank you, Chairman Durbin. Now, I'll ask
    our witnesses to please stand and be sworn in. Sheriff, you're
    on your honor. Please raise your right hand.
        [Witnesses are sworn in.]
        Chair Padilla. Thank you very much. You may be seated. The
    record reflect the witnesses have responded in the affirmative,
    and now let's proceed to witness testimony. Ms. Peterson, you
    may begin.

                    STATEMENT OF SARAH K. PETERSON,

               PRINCIPAL ATTORNEY, SPS IMMIGRATION PLLC,

                         MINNEAPOLIS, MINNESOTA

        Ms. Peterson. Good morning, Chair Durbin, Chair Padilla,
    Ranking Member Grassley, Ranking Member Cornyn, and Members of
    the Subcommittee. My name is Sarah Peterson, and I am an
    immigration attorney who has helped doctors and their employers
    navigate our complicated and outdated immigration system for
    almost two decades. Thank you for this opportunity to discuss
    the growing U.S. health care emergency and how Congress can
    effectively advance bipartisan, smart, and targeted reform
    critical to addressing the existing lack of access to health
    care in the United States.
        The shortage of doctors in the U.S. is well-documented and
    continues to grow due to a variety of factors, including our
    aging population, which both increases the number of people
    seeking care as well as the numbers of doctors ready to retire.
    In the next decade, more than two out of five active physicians
    will be 65 or older. This crisis is only compounded by the
    increasing COVID burnout by our frontline workers. Further, in
    the U.S. today, more than 95 million people live in health care
    shortage areas. That's one third of the United States.
        This number will continue to grow and by 2034, the U.S.
    will face a shortage of up to 124,000 doctors as that sign
    reflected. This number balloons if every American had equal
    access to Medicare and their shortages grow to over 180,000
    physicians. Growing up myself in a poor rural community in
    central Minnesota, I saw firsthand the real effects that the
    lack of access to health care prepared. And for the past two
    decades, I have represented doctors who have heroically stepped
    up to fill this shortage.
        International doctors are a critical part of the immediate
    solution to this crisis. But our outdated physician immigration
    laws have not seen reform for over 20 years. To be a doctor in
    the U.S., every international doctor must first complete U.S.
    medical residency or fellowship training. Over 80 percent of
    these doctors train in J-1 status, but then are required to
    leave the United States and return to their home country for 2
    years. While our laws provide a small number of Conrad J-1
    waivers for doctors to stay in the U.S. based on their work in
    underserved communities, each State only receives 38 Conrad J-1
    waivers each year, which is simply not enough.
        Further, our laws should encourage and reward international
    doctors who work in underserved communities by removing
    numerical quotas. What follows are concrete steps for Congress
    to take to address this emergency. First, pass the two
    bipartisan bills pending in this Committee. The Health Care
    Workforce Resilience Act is a bipartisan bill led by Chairs
    Durbin and Cornyn. This bill is a direct recognition of the
    essential role international doctors have played in the
    national COVID pandemic and provides necessary green card
    relief to the international doctors who are working on our
    front lines.
        Similarly, the Conrad State 30 and Physician Access
    Reauthorization Act is also a bipartisan bill led by Senators
    Klobuchar and Collins. Through this bill, Congress would give
    States the ability to grant Conrad waivers based on need, not
    an artificial number. Just last year alone, more than half of
    the States fully exhausted their supply of Conrad J-1 waivers,
    leaving needy Americans without access to health care. Several
    more States used almost all of the allotted numbers, and the
    demand continues to grow each year.
        Doctors who are not granted a Conrad waiver in most
    instances must depart the U.S., potentially never to return.
    For example, the Mayo Clinic each year must prioritize which
    doctors to sponsor for its limited Conrad J-1 waiver slots,
    knowing that not all will be selected. Last year, 13 out of the
    23 doctors at the Mayo Clinic did not receive a waiver.
        One doctor, a highly influential oncologist treating breast
    cancer patients, has been waiting 7 years to obtain a Conrad
    waiver. While this doctor is lucky enough to qualify for a
    different work status to continue treating cancer patients in
    the U.S., most doctors do not qualify. For doctors who are not
    eligible for an alternative work status, the Mayo Clinic is
    forced to rescind the offer of employment, and these very
    doctors are almost always the ones seeking to work in the most
    neediest, underserved communities. This is not right.
        Second, we should exempt international doctors working in
    underserved areas from the numerical immigrant and nonimmigrant
    visa quotas that no longer serves United States national
    interests. Doctors from India and China comprise one quarter of
    all international doctors in the U.S. yet face years of delay
    in getting their green cards.
        In 2006, I began representing a primary care doctor from
    India on his green card process based on his work in an
    underserved community in Missouri, where he remains working
    today. Just 2 years ago, 13 years after starting this process,
    he finally received his green card. This doctor provided
    primary care in an underserved area, yet he still has to wait
    13 years. Thirteen years of wondering what would happen if he
    lost his job. Thirteen years of renewing his temporary visa
    over and over. Thirteen years of not knowing what to tell his
    kids about their ability to remain in the U.S. long term.
    Thirteen years.
        Similarly, the numerically limited H-1B program, which
    remains the primary pathway for most international doctors to
    work in the U.S., prevents Americans from receiving primary
    health care services. I work with a clinic in Southern Texas
    that has been trying to recruit OBGYN doctors for years to its
    underserved rural community. The need is so dire that this
    practice must bus women hours to the nearest health care
    facility for care, which results in delayed care, unnecessary
    complications, and substantial financial burden to these women
    and their families.
        Exempting international doctors who work in underserved
    communities both from the green card and the H-1B quota, is a
    smart, simple solution that will have an immediate and profound
    impact on the availability of quality health care for all
    Americans. Lack of access to equitable health care is a United
    States emergency. And this bipartisan issue demands immediate
    bipartisan solutions. Effectuating smart immigration reform, as
    I have reviewed today, will allow U.S. trained doctors to help
    address this country's ongoing shortage of access to basic
    medical care.
        I am lucky that despite growing up in my rural community,
    my community was eventually able to attract and recruit an
    international doctor who not only treats my family members but
    remains in this community after 20 years. Thank you for this
    opportunity to testify, and thank you for your efforts to solve
    this urgent health care crisis by ensuring all Americans have
    equitable access to the health care they deserve.
        [The prepared statement of Ms. Peterson appears as a
    submission for the record.]
        Chair Padilla. Thank you, Ms. Peterson. We'll now turn to
    Sheriff Martinez. Sheriff, please proceed with your testimony.
        [Pause.]
        Chair Padilla. We're having some technical difficulties.
    While we try to get Sheriff Martinez back on the line here, if
    it's okay with you, Senator Cornyn, we'll proceed with Dr. Alur
    and your opening statement.

                 STATEMENT OF DR. RAM SANJEEV ALUR, MD,

                 HOSPITALIST PHYSICIAN, MARION VETERANS

                AFFAIRS MEDICAL CENTER, MARION, ILLINOIS

        Dr. Alur. Good morning, everybody. Chairman Padilla,
    Chairman Durbin, Ranking Member Cornyn, Ranking Member
    Grassley, and honorable Members of the Committee, it is an
    honor to speak with you today on the role of immigrant
    physicians in the U.S. health care system. Thank you for the
    opportunity.
        My name is Dr. Ram Alur. I'm a physician at Marion Veterans
    Affairs Medical Center in Illinois. I came to the States in
    2007 on a J-1 visa as an exchange visitor from India for my
    medical residency training. Exchange visitors are generally
    required to leave the United States and return to their home
    country after completing their residency unless they can obtain
    a full waiver of that requirement via commitment to work in an
    underserved areas for 3 years. I chose to work in an
    underserved area and was lucky enough to obtain a waiver to
    stay in the States.
        More specifically, I chose to work with the Veterans
    Affairs because I thought I could put the training I had
    received in the U.S. to the best possible use by working for
    the largest integrated health care system and serving the most
    distinguished group of Americans, the veterans. I also believe
    that Marion was a great community to raise a family.
        The Veterans Affairs Hospital at Marion is a cherished
    institution serving veterans from Illinois, Missouri, Kentucky,
    and Indiana. Even though I completed my 3-year service
    commitment in 2014, I continue to work there to this day as it
    is a great honor and privilege to serve the Nation's heroes,
    and I have no plans to leave. However, the immigration system
    could have other plans for me.
        Why are immigrant physicians important? Well, one in four
    physicians in the U.S. are immigrants, and immigrant physicians
    are more likely to serve in the rural and underserved areas
    than American-born doctors. There is a huge disparity in health
    care access and outcomes in these areas, and immigrant
    physicians are a critical and important solution to that
    problem. But due to an outdated immigration system, that
    solution is at risk.
        I'm going to share my experience to highlight the problems
    faced by immigrant physicians today. Doctors like me are on a
    temporary work visa called H-1B. The H-1B visa only allows us
    to work in a specified location. Any work outside the specified
    location is considered a violation of a work permit. During the
    pandemic, I could not answer numerous calls for reinforcements
    near or far. Like me, there were an estimated 15,000 physicians
    that were restricted from being on the frontlines, providing
    lifesaving services.
        The H-1B allows me to stay in the country with my family
    legally because of my valid nonimmigrant worker status. If I
    can't work, we can't stay. This lack of protection with death
    or disability on the frontlines is every temporary visa
    worker's nightmare. The H-1B visa also makes it difficult for
    us to travel outside the country. The last time my wife and I
    saw our aging parents was in 2019. You see, we need a visa
    stamped in our passports by a consulate in India in order to
    reenter the United States. During the pandemic, this process
    was risky as consulates were either not open or were taking
    only few appointments. We just simply could not risk traveling
    outside when there was a great need here.
        My petition for permanent residency was approved in 2016
    because it was in the national interest based on my work at the
    VA. However, we still have to wait for an immigrant visa number
    or a green card to become available. And I've been waiting 6
    years, working 11 years, and been in the country for nearly 15
    years. My wait could be another decade or more. Until then, my
    work permit or status needs to be renewed at least every 3
    years, which is a huge administrative burden.
        I've had to renew my status five times so far. One hiccup
    in this long, complicated process and my whole family will be
    affected. It is deeply unsettling that my daughter, who was
    born in India, will age out of legal status when she turns 21.
    It is hard to say out loud, but this is only 6 short years
    away. If I do not become a permanent resident by then, she will
    lose legal status and have to leave. Sadly, many families do
    not have the time I have and have gone through painful family
    separations.
        Our family is also a victim of poor health care access. We
    could not find mental health services for our daughter in
    southern Illinois during the pandemic, and in June 2020, we
    decided to move to St. Louis area. But I continue to work at
    Marion VA and commute over 2 hours. During the same summer, my
    wife was restricted from driving for 6 months. For me, trying
    to balance home life and caring for patients was burdensome,
    exhausting, and unnecessary. The backlog in our immigration
    system and long processing delays were to blame. The time it
    took to process my wife's visa renewal was a trying time for
    our family.
        While we faced some hardships, they are no worse than many
    other immigrant stories you've heard here before this
    Committee. And unfortunately, they're not welcoming to the
    future generations of immigrant doctors. I do not want to give
    up on effecting change. I want to encourage more international
    physicians to come in and serve in this beautiful country we
    call home.
        So, I'm here today as a physician to share with you my on-
    the-ground perspective. America needs more health care workers,
    and immigrant physicians are a key solution to that.
    Unfortunately, this outdated system is a problem that will only
    get worse absent action from Congress, and it will impact the
    most vulnerable patients who've struggle with access long--long
    before the COVID-19 pandemic. Thank you very much for the
    opportunity to testify today.
        [The prepared statement of Dr. Alur appears as a submission
    for the record.]
        Chair Padilla. Thank you, Dr. Alur. We can try one more
    time with the sheriff. Are you with us?
        Sheriff Martinez. Mr. Chairman, can you hear me?
        Chair Padilla. We can hear you now.

                STATEMENT OF URBINO ``BENNY'' MARTINEZ,

                BROOKS COUNTY SHERIFF, FALFURRIAS, TEXAS

        Sheriff Martinez. Thank you, sir. Chairman Padilla, Ranking
    Member Cornyn, thank you for the opportunity to appear before
    this Committee to discuss this important issue. I've been
    having technical difficulties. I'm up here in Arizona on the
    conference. I'm Ben Martinez. I'm the Brooks County Sheriff in
    South Texas. Brooks County Sheriff's Office has five deputies
    and command staff and is responsible for maintaining law and
    order within a rural region of 943 square miles that
    encompasses the county seat of Falfurrias.
        Outside of the city of Falfurrias, the county consists of
    private ranch lands. The sandy terrain is mostly vegetative,
    with mesquite trees, scrub oaks, and prickly pear cactus. The
    county's population is about 7,400. Brooks County has the
    checkpoints, one of the busiest check points in the Southwest
    corridor, approximately 70 miles north of the U.S.-Mexican
    border on U.S. 281 or either 69 west. Highway 281 is the major
    north-south artery from the Rio Grande Valley area that leads
    to Houston, San Antonio, Austin, and Dallas, and other
    destinations throughout the interior of the United States.
        United States 281 is part of the Gulf Coast corridor, which
    is one of the most active drug and human smuggling corridors in
    the United States. The Falfurrias checkpoint is one of the
    busiest checkpoints in the Southwest corridor in regards to
    undocumented crossers, apprehensions, and narcotics seizures.
    Because of the Brooks County geographical location, the Border
    Patrol checkpoint, it has their very own unique challenges.
        In most cases, smugglers, coyotes, drop off undocumented
    crossers. They are led by the smugglers and made to walk east
    and west of Highway 281 to circumvent the checkpoint, moving
    north to private ranch lands to get picked up on Texas Highway
    285 and other roads by other smugglers, who will then transport
    them on the Gulf Coast corridor to cities north.
        In other cases, local gang members or others seeking
    financial gain who live in the county drive their human and
    drug loads through private property by cutting locks and
    fences. The sad reality is that most of those who are being led
    through the brush by the smugglers do not survive the demanding
    journey. Since 2009, the county has recovered 910 bodies of
    undocumented crossers. That includes 119 in 2021 and 78 so far
    this year. We estimate that the recovery is less than half of
    all those who perish with conditions or health issues.
        This year, we've had 30 smuggling pursuits, 42 bail outs,
    32 stolen vehicles, 5 stolen guns. In addition, we nearly have
    200 smuggling cases in Brooks County alone. It's costing us
    about $4,000 of fuel a week. We also help our landowners by
    repairing damaged fences, which averages approximately $600 for
    100 foot of barbed wire, and into the thousands for knit and
    high fence wiring. The Mexican cartels and the transnational
    statewide gangs continue to increase the level of organized
    criminal activity in the Rio Grande Valley and throughout the
    State.
        We, who live in and near border communities where drug
    cartels and human smugglers operations are prevalent, face
    additional public safety issues such as stolen vehicles,
    evasions, pseudo police stops, extortion, sexual assaults of
    illegal aliens. The gangs and cartels have contributed to the
    deaths of undocumented crossers on the Texas ranches and farms.
    Apprehensions are still skyrocketing through the Rio Grande
    Valley patrol sector. Totals for the month of August were
    nearly 28,000 encounters, bringing their Fiscal Year 2022
    totals over 440,000 encounters.
        There has been no change in the manpower situation, and the
    migrant surge and humanitarian crisis is at a constant toll on
    the already depleted workforce. Even with a depleted workforce,
    their local encounters were around 1,400 for the month in
    Brooks County. While Border Patrol is overwhelmed in the
    migrant processing duties, they aren't able to carry out their
    primary function by stopping the entry of contraband and
    dangerous criminals.
        Rescues continue to keep us busy with over 305 emergency
    call outs so far this year. And over 1,350 individuals were
    provided the assistance they so desperately needed. Even with
    all the technology in place, there continues to be those that
    succumb to the elements. Good news is that the border--
    Falfurrias Border Patrol is pleased with the results of the new
    aerostat, which are flying just south of Falfurrias and
    providing great situational awareness and has also been
    credited with assisting with over 700 apprehensions.
        In terms of fire, 32,000 acres of brush fires related to
    immigration of Brooks County, $6,000 plus in expenses to our
    fire department--our volunteer fire department in just
    immigration calls this year. The EMS related calls from January
    to August, 82 EMS calls related to breakdowns, three migrations
    actually were deceased and rushed to the hospital. Ambulances
    are being pulled from day-to-day operations to answer calls in
    remote areas where turnaround time is roughly 4 to 5 hours,
    leaving our constituents without emergency medical services.
    This puts a strain on the local health system. The border
    crisis is a result of not securing the border.
        When there are no consequences for unlawful entry into the
    United States, DHS does not adjudicate asylum cases in a timely
    manner and remove those who don't have valid claims. Trans-
    national criminal organizations will continue to be able to
    recruit migrants, to come up here and overwhelm Border Patrol
    resources while they run narcotics and criminals around the
    back end. In closing, I want to thank you for bringing us
    attention to this very important topic, and I look forward to
    any questions you have. Thank you, sir.
        [The prepared statement of Sheriff Martinez appears as a
    submission for the record.]
        Chair Padilla. Thank you, Sheriff. Thank you for sharing
    your perspective, your experience. I take it as a reminder to
    invest in modernizing and fixing the legal migration options,
    to undo the pressures for those who would consider the
    irregular migration that has led to so many tragedies.
        The focus of today's hearing, I remind us all again, is the
    role that immigrants play in the health care workforce crisis
    in the United States of America today. And so, we're going to
    begin with our questions, and I'll begin with this. One thing
    we hear often from immigrant health care professionals is that
    they are restricted in where they can practice medicine due to
    their status. And because these professionals are often tied to
    a specific employer, it is difficult for them to either move
    within the United States for better opportunities or to serve
    areas that might be in more need of their expertise or their
    services to move to other health care facilities in emergencies
    like the COVID-19 pandemic.
        Dr. Alur, in your testimony, you mentioned that your
    nonimmigrant status as an H-1B visa holder prevented you from
    being able to go to places like New York during the height of
    the pandemic, where there was an extreme shortage of doctors.
    Can you explain the limitations that come along with your
    status and how updating our immigration laws would improve the
    Nation's public health?
        Dr. Alur. Chairman Padilla, it's a very important question.
    When the pandemic took over the country, it did it in waves.
    New York was literally burning with the pandemic, and southern
    Illinois was relatively better protected. We could have stepped
    up and attended to the call. The Governor of New York was
    asking retired physicians to come back into the workforce, the
    students to graduate early. We could not do it because it is a
    violation of our work permit to work anywhere else other than
    what is specified.
        Going to the endemic problem of physician shortage, we have
    services that are not available in an area, and you bring a
    doctor to one employer. If he's not restricted, he could go to
    multiple hospitals and help those hospitals during the
    shortage. For example, in our neighborhood when the pandemic
    hit us, our neighboring hospitals were losing physicians to
    quarantine. There was a lot of attrition because a lot of
    senior physicians did not continue to work.
        And how would it help the United States public health?
    Primary care is a huge area of shortage all across the country.
    And again, if a physician who has been in that country--in that
    community for years is still restricted to one employer, he's
    limited. He could probably go 50 miles across his town and do a
    satellite clinic maybe one day a week that would help the
    community there. A lot of physicians in my community who were
    immigrants, who did their waiver commitments, stayed there. And
    after they got their green cards, they have open practices all
    across. And improving the primary care that way will address
    the public health.
        Chair Padilla. Thank you, Doctor. Ms. Peterson, I know that
    you're well aware that the U.S. has designated 8,069 health
    professional shortage areas across the country for primary
    care. There's a map behind me that illustrates this. This has
    resulted in 97 million people who live in the United States in
    an area that has a shortage of primary care providers. In my
    home State of California alone, there are 643 health
    professionals' shortage areas for primary care, affecting over
    7 million Californians.
        I'm sure many of my colleagues here also represent States
    with significant health care workforce shortages. If you look
    at the map, consider that every shade of green on this map
    represents a shortage area.
        Ms. Peterson, in your testimony, you recognize that these
    workforce shortages are due in large part to our increasing in
    aging population--our seniors, our aging health care workforce,
    and the stress imposed on health care workers around the
    country by the COVID-19 pandemic. So, drawing on your
    experiences, can you explain how immigrant physicians have
    stepped up to fill these gaps in these underserved areas and
    how they are part of the solution to end our health care
    workforce shortage emergency?
        Ms. Peterson. Thank you, Chair Padilla. Annually, over a
    thousand international doctors go to underserved areas and fill
    this need. But just on the Members of the Committee today, over
    two thirds of your State used all of the Conrad J-1 waiver
    numbers last year. And if we gave States the ability to grant
    these J-1 waivers based on their needs--California, you know,
    all of the other States, Texas--that would permit doctors like
    Dr. Alur to go to underserved areas and be rewarded and
    recognized for their work and to ensure that Americans were
    receiving the health care that they need by opening it up and
    giving States the ability to really give these waivers. And the
    Conrad Reauthorization Act does just that.
        Chair Padilla. Thank you. Senator Cornyn.
        Senator Cornyn. Ms. Peterson, let me just ask as a
    preliminary question. Well, let me make a brief statement
    before I do that. I personally believe that legal immigration
    has been one of the great secrets to our success as a country.
    By one account, since 1783 to 2019, we've had 96 million people
    legally immigrate to the United States, and we're better off
    for it. Illegal immigration is another matter, in my view.
        And as you know, many people showing up at the border these
    days are claiming asylum. But as an immigration attorney, do
    you--can you help us with a figure here? How many, how many
    claimants of asylum who actually appear in front of an
    immigration judge get that claim validated?
        Ms. Peterson. Thank you, Ranking Member Cornyn. Immigration
    law is like physicians. We subspecialize, and I specialize in
    high skilled physician immigration, so I don't have that
    number, but I'm happy to provide it to you.
        Senator Cornyn. Well, I think it's somewhere around 85 to
    90 percent do not qualify. But the problem is because of the
    huge backlogs and the fact that the Biden administration
    releases people into the interior of the United States, some of
    them show up in Chicago, some of them--they go to all four
    corners of the United States. And Sheriff, if you're still with
    us, I'm referring to your written statement here. When you say
    that there are no consequences for unlawfully entering the
    United States, could you explain what you mean by that?
        Sheriff Martinez [continuing]. From the----
        Senator Cornyn. We can hear you now.
        Sheriff Martinez. It's the fact that--okay, good--they're
    not prosecuting cases. We're not following the rule of law.
    There's nothing--no consequences, they're going to keep coming.
    And that's the issue. You know, here at the checkpoint, they
    just stopped a truck tractor with 115 in the trailer--115
    occupants--which, you know, you can see the same scenario that
    occurred in San Antonio, with those 53.
        Prior to that, 12 months ago, we had 73 in a trailer and
    the Federal guidelines were not met. So, that particular
    driver, we pick them up and prosecute them ourselves. You know,
    we're kind of educating the criminals as to what they can get
    away with. And I know this is about health care. I get that.
    But until we secure the border, until we shut that border down
    and start peeling off, I know that not every, not--you know,
    they talk about immigration. The issue is, is that not everyone
    is going to come in and stay in stash houses like they do here
    in the Rio Grande Valley sector.
        You know, where you have 200 people in a stash house.
    That's definitely in a health crisis. Okay? When we pick up
    bodies, we're testing for COVID. We have 20 percent of them
    tested for COVID. And those bodies are walking in with a group.
    So, the rest of them get away. We got 20 percent of COVID.
    Guess what? That group is going into the interior of the United
    States until we secure this border.
        Brooks County's a Democratic County. I'm a Democratic
    sheriff. And it's just absurd how we try to mix things together
    here. I, for instance, will have sexual assault cases, females
    in the brush. Okay? So, what I do, I work with immigration
    attorneys. I sign off on their waiver and they stay in the
    United States. Okay? The fact is, we're not going to be able to
    prosecute anyone because they're not going to actually say,
    ``Okay, this is the person that did it.''
        But we work along closely with Border Patrol and their
    intel group, you know, and talking about narcotics and
    businesses and the port of entry, it's simple. Those are actual
    narcotics that you can count. And I know this because when I
    did my covert operations with DEA and Customs back then, we
    used to prosecute, and they're still doing it. They're using
    the river. Those are amounts that you can't count on. You don't
    count those.
        It's just like the getaways. You don't know how many
    getaways, you know, are fleeing. I don't understand how we're
    mixing this whole operation into immigration. I have a friend
    of mine that's been waiting for 20 years to get his
    citizenship. Twenty years. You know what? All this is about
    policy. Work on policy. You know, reach over the aisle and work
    on policy. Fix it, and we won't have this fricking
    conversation. This is horrible. What I've just been listening,
    it's horrible. I don't get this.
        I'm a Democrat, and here we are going through all this
    issues, this green card issues, the same thing. Why does it
    take 20 years to become a citizen of the United States? Why
    does it take so long to get a green card? You know, we're
    talking about health issues. We don't have a hospital in Brooks
    County. We have three different hospitals that Border Patrol
    work with and we work with. They're out of Kingsville, which is
    30 minutes away, and Corpus Christi.
        We cannot mix this together. We have to decipher this. We
    have to reach over the aisle and get this thing fixed. I mean,
    it's frustrating for all the sheriffs along the Southwest
    corridor, and I think you all understand how frustrated I am,
    because I've been dealing with this since 2009. And I'm yet to
    have any Democrat come to my office, sit down so I can show
    them all the books I got of all the dead bodies, all the
    parents, all the family members that come to my office crying
    because they lost their loved ones of 10 years ago.
        I'm sorry. I think I went off a little bit. This is
    frustrating. It just bothers me, what I'm listening to. It's
    not--we need to divide this issue. We need to separate. I get
    it. Well, you know, we're all immigrants. I get that. So was I.
    So were my grandparents, so. But it's the right way to do it.
    There's a right way to do it. And I think everyone ought to
    just get together and put some common sense into this issue.
    Thank you.
        Chair Padilla. Thank you, Sheriff.
        Senator Cornyn. Thank you.
        Chair Padilla. Thank you, Senator Cornyn. And it sounds
    like an invitation, and I'd be happy to accept to work together
    to reinvest in the very departments and agencies that are
    charged with considering and processing these applications
    regardless of what the outcome would be. We've got to maintain
    due process. And I think we share the desire to significantly
    reduce the backlogs that have only grown for years and years in
    all categories of immigration applications.
        So, coming back to the topic at hand for today's hearing,
    the role of immigrants in the health care workforce, I now
    recognize Senator Durbin for questions.
        Chair Durbin. I just want to say that I thought the
    sheriff's comments were impassioned and genuine and reflected
    the reality of the almost impossible job we've given him on our
    border with so many others. Our border's under siege. There's
    no question about it. When I sat down in Chicago last Friday
    with a family that started out from Venezuela on May 15th--
    father, 32 years old, mother 22, a 5-year-old daughter, and a
    1-year-old daughter. And they set out to walk to America.
        It took them months to finally reach the Texas border. And
    in the meantime, the worst possible things happened to them.
    They were beaten and they were robbed. And they were abandoned
    in a Panamanian jungle for nine nights. And the man said, ``I
    thought we were going to die.'' And yet they pressed on. They
    were desperate to come to the United States because, he said,
    ``I couldn't feed my family in Venezuela.'' And I think that
    desperation brought on by poverty, or violence, or climate
    change is the reality of the moment.
        The question is, can we construct a system for legal
    immigration that says to this doctor and to many others like
    him, ``You are welcome in America. We need you in America. We
    thank you for being here in America. And we want you to have
    your family with you,'' and to have confidence that they can
    realize the American dream, too? And says to workers like this
    man from Venezuela, ``Yes, you can come in, but you're going to
    be legally recognized when you come in and what you're going to
    do here.''
        Perhaps you're going to work on that dairy farm in northern
    Illinois that's going to close down if they don't get foreign
    workers or the orchard in southern Illinois where they
    desperately need foreign workers. It is our failure, our
    failure in this Committee and in this Congress to establish
    legal immigration that has led to this desperate plunge by
    these people to come forward and risk their lives to do it, to
    cross our border. They are not here for--the ones I met were
    not here for any illegal purpose whatsoever. They just wanted a
    chance to work.
        How many times I heard that over and over again? Dr. Alur,
    your work in the Marion Veterans Hospital. Are there other
    foreign-trained physicians in that hospital?
        Dr. Alur. Almost every department in Marion Veterans
    Affairs Medical Center has immigrant doctors. I don't speak for
    the VA. I'm speaking about my experience. We looked at the
    whole region, the southern Illinois, when we initially met our
    Congressman in 2017 to give him an idea the important of
    immigrant doctors. No department in southern Illinois right
    from Mount Vernon until Metropolis would function without
    immigrant doctors.
        Chair Durbin. That point is so important for Members on
    both sides of the aisle. We love our veterans. You're right.
    They're our Nation's heroes. We promised to stand by them when
    they came home. And yet, the men and women who do that, we
    treat so badly when it comes to their devotion to our country
    and their yearning to be part of its future.
        Make you go through all the traps you have to go through
    year after year after year, uncertain as to whether, as you've
    mentioned, you're going to miss one little step and be judged
    ineligible for any future service to our country. That's not
    fair to you, and it's not fair to your family, and it's not
    fair to the veterans you serve. I will tell you--we know,
    others may not here--Marion is in a rural part of Illinois, a
    limited population area of Illinois. Attracting doctors there
    is harder than it is in Chicago or St. Louis, the veterans'
    facilities, and those of you who serve there, we especially are
    grateful.
        But I think we need to take into consideration just what
    kind of contributions you make. Ms. Peterson, this is maybe out
    of your area, but I want to put it in a plug for one thing
    that--before my time runs out here. I am embracing foreign-
    trained immigrant nurses, and doctors, and medical
    professionals, and I think they're essential to our future. But
    at the same time, we need to have more homegrown medical
    professionals, nurses and doctors in the United States. Can you
    comment on efforts that are underway, if you know of any along
    those lines?
        Ms. Peterson. Yes, it's a little bit out of my scope,
    Chairman Durbin, but what I can add is that you're right, this
    is a multi-faceted approach, and we do need to continue to grow
    and educate U.S.-born physicians and nurses. But what we're
    talking about today is an immediate solution to fix our urgent
    health care crisis in the United States.
        Chair Durbin. Spot on. That's exactly right. And I'll
    mention one other thing. In the American Rescue Plan, where
    some in a room did not vote for and some did, we put a billion
    dollars into scholarships and loan forgiveness for the National
    Health Service Corps. And the National Health Service Corps
    focuses on underserved areas. These are physicians we hope will
    be attracted to those areas, but we need to expand the
    graduation rates of our medical professionals. The boomers
    insist on it. And I happened to be close to that age group.
    Thank you, Mr. Chairman.
        Chair Padilla. Thank you, Chairman Durbin. Couldn't agree
    more. And I think to tackle that also pressing issue, it's both
    tackling the affordability of medical school education and the
    capacity of medical schools across the country to keep up with
    our growing and aging population. Next for questions is Senator
    Grassley.
        Senator Grassley. I don't think I have to repeat what
    Senator Cornyn has said about the problems, the political
    problems of solving this issue. They could go away fast if the
    border was secure. And, you know, three and three tenths
    million people already in 18 months of this administration
    crossing the border. And then we have the absurd statements by
    Vice President Harris, quote, unquote, ``the border is
    secured.'' I think I've heard Secretary Mayorkas say the same
    thing.
        So, Sheriff, I know that you also personally witnessed this
    impact at the open border. I guess you've already made a strong
    statement in regard to that. So, my first question is you've
    previously attributed migrant deaths to quote, ``the false
    compassion of open border,'' end of quote. I think that's a
    superb description of what we're seeing at the southern border.
    I'd like to have you elaborate on that phrase.
        Sheriff Martinez. Yes, sir. What's occurring here is just
    they're being taken advantage of, and they're being left to
    die, you know? It's not a good death because they know they're
    dying. And what I mean by that, it's not a quick death and that
    they're just going to die, as you would in a crash. But, you
    know, we get lots of 911 calls when you hear the last desperate
    voice on them saying that, you know, tell my mom I love them,
    tell my sister, my wife, children, whatever the case may be.
        We just picked up a 15-year-old that we recovered from the
    brush. And that's not only--you know, Brooks County has
    numerous deaths, but now the whole Southwest corridor is
    experiencing it. I got bodies from every county, Texas, in my
    morgue. I have a morgue myself in Brooks County that we house
    other bodies that are recovered from the different counties
    because it's a surge. And until we secure that border, until
    that is shut down completely, then we can start working on
    everything else.
        And I understand the health issues. I understand what
    they're trying to say. But it's policy. The policy says, ``Come
    over.'' And that's the rhetoric. That's been that narrative
    that's occurring right now. The narrative says come over. Well,
    guess what? We need to do it correctly. This is why I said the
    rule of law. It's got to be done correctly. I'm a Democrat, but
    it's just pathetic how things are going currently along the
    border and on the Southwest corridor.
        Senator Grassley. You've talked about the role played by
    transnational criminal organizations in migrant deaths that
    we've seen at the border. Like to have you tell me, how common
    is it in your county to come across migrants who are in need of
    medical care and attention.
        Sheriff Martinez. I did--I did visit with the secretary
    twice, sir. He was down in McAllen, and I visited with him
    twice. And I told him what we needed. We needed a simple triage
    so we can get the assit--medical assistance that they need
    quickly. And I haven't heard anything back from them. So, we
    need that. And I know what we need in Brooks County. They're
    just not listening to some of the sheriffs, including me, as to
    what's needed.
        And this is just for a quick fix. We don't have a hospital
    in Brooks County. Everything has got to get flown out to
    different hospitals that can manage these type of issues. But a
    triage would definitely help to--maybe assist in--you know,
    Border Patrol, there are gentlemen that are EMTs. They apply
    IVs. But by the time they apply that IV, sometimes it's just
    too late and they succumb to the heat or to the cold. I mean,
    we've picked up five bodies at one time, at one time when we
    had the freeze back several years ago. They're all stuck
    together. I mean, that's just not right.
        Senator Grassley. My last question. Could you describe how
    transnational criminal organizations handle migrants who get
    sick or experience health problems? And more broadly, to what
    extent you are able, can you comment on the impact that
    migrants in need of care have on the local health care
    infrastructure in your area?
        Sheriff Martinez. Well, in my area--and comments to that,
    in my area we don't have that because we don't have a hospital.
    But what it does take is the fact that our ambulance services
    that have to go out to the ranch lands, pick them up and then
    transport them, that leaves our community open to other issues
    that we have. Our county is elderlies. They over 60, 65, 70,
    probably 80's. So, they need the medical assistance locally.
    But when we're out there treating them, then that--that becomes
    an issue.
        Now, as far as the transnational gang members, they just
    leave them there. If someone just happens to get hurt, they get
    sick, they're gone. They're on their own. They fend for
    themselves. Now, thanks to Border Patrol, we have a lot of
    placards up there, probably over 200 placards, and put in
    different areas. We have beacons. Everything that can be done
    has been done in Brooks County to save lives.
        I work closely with the consulate. There's four consulates
    I work closely with and then on McAllen office and we give them
    a lot of literature to forward down south so they can
    understand what's going to happen to them if they come in into
    the United States, if they come into Brooks, the dangers that
    might be happening. So, everything has been out there. The
    outreach is there. You know, the fact is, the transnational
    gang members, they just don't care. It's all money for them.
        Chair Padilla. Thank you, Senator Grassley. And colleagues,
    I'd like to share just on the topic and the concerns raised by
    Senator Grassley and the sheriff. I was just down at the
    southern border in California during our August work period.
    And what I saw offered by the State of California and partner
    non-governmental organizations, together with the Border
    Patrol, was nothing short of incredible.
        The University of California, San Diego, has actually
    provided medical screening and stabilization for newly arrived
    asylum seekers to the San Diego County since December 2018. So,
    this isn't a short-term pilot project, this has been going on
    for a while. The program screens for conditions that would
    threaten the health of either the individual or the community.
    Medical screening for conditions of public health significance
    is done on all asylum seekers at the time of arrival from
    scabies to monkeypox. And I'm happy to report that there has
    not been a single case of monkeypox found during the screening
    of all the asylum seekers.
        In fact, asylum seekers they have found are generally
    healthy. For example, in August 2022, just last month, of the
    5,492 guests seen at the shelter hosted by Jewish Family
    Services, only 20 were sent to an emergency room. That's 0.4
    percent. This is--this has improved from our previous low rates
    from December 2018 to March 2020, when less than 1 percent of
    arrivals needed to be seen in an emergency room.
        So, I recognize that the California numbers may not be
    exactly representative of the whole border, but the less than 1
    percent statistic hardly sounds like an overwhelming drain on
    public health resources. Aside from the numbers I just offered,
    this model of Federal agencies working in partnership with
    States and NGO's to improve border safety and treat asylum
    seekers with dignity. With that, let me recognize Senator
    Hirono for her questions.
        Senator Hirono. Thank you, Mr. Chairman. There was a time
    in 2013 when this Committee spent around 2 weeks marking up a
    comprehensive immigration bill that addressed some critical
    needs in both the legal and illegal immigration situation, both
    of which systems are broken. I hope that at some point we can
    get back to that kind of a perspective. And clearly, we have
    some bipartisan bills that will help.
        Sheriff Martinez, I hear your frustration clearly. We need
    to address the issues in the border that deals with another
    Committee's jurisdiction also. But today, I would like to focus
    on the dire need in our country for health care workers. If
    there's one thing that the pandemic showed was the importance
    of the essential workers of whom many of them, of course, are
    doctors, are nurses, are health care workers stretched thin to
    the brink of exhaustion during the 2-years of the pandemic and
    still not over.
        So, in fact, just recently in Hawaii, our Governor signed
    an emergency rule authorizing out-of-State nurses to
    temporarily practice in Hawaii without obtaining a license from
    the State. And we have a shortage of some 732 physicians, 732
    physicians affecting our State. Pretty much right now. So, yes,
    thank you, Ms. Peterson, for focusing us on the immediacy of
    the challenges. What kind of steps have medical facilities had
    to take because of the shortages in the health care workforce
    that you can share with us?
        Ms. Peterson. Thank you, Senator Hirono. The immigration
    process is complicated. It involves multiple different Federal
    agencies, a lot of paper, a lot of time, and a lot of money. I
    have so many physician clients who have a job offer from a
    health care facility that wants to hire the physician, and they
    can't because we don't have enough numbers. It's not the right
    time. The list goes on. And so today, you know, the Conrad
    reauthorization bill provides so many reliefs to our system for
    my clients, for doctors like Dr. Alur, to be able to recruit
    and retain physicians.
        Senator Hirono. That is a bipartisan bill.
        Ms. Peterson. Absolutely bipartisan.
        Senator Hirono. Does it lift the cap for the Conrad 30
    program?
        Ms. Peterson. It does not. What it does is it looks at the
    States that use all of their 30 waiver numbers. And if they use
    them, then each year there's an add on so that the States can
    really control and supply the J-1 waivers that they need for
    their application.
        Senator Hirono. Would you support lifting the cap or
    increasing the cap substantially?
        Ms. Peterson. The demand is so great. And as I said, two
    thirds of the States that the Senators on this Committee
    represent fill every year. And so, I do think that the Conrad
    bill provides a smart solution to be able to give States back
    the power to get the numbers that they need.
        Senator Hirono. Well, how much longer do you think, for
    both of you, can our health care system and that includes a VA
    system where there are major shortages, I know of doctors and
    nurses. How long can these systems continue to use the kind of
    quick patches, such as a Governor issuing an emergency order
    for a problem that needs long-term investment and policy
    changes? Dr. Alur.
        Dr. Alur. Senator Hirono, thank you for the question. It's
    a very important question. I don't speak for the VA, but this
    is my experience. The shortage is already an emergency. When we
    try to, from a rural area, when we try to get a veteran out to
    a hospital that can provide them services, often there are no
    beds because they're all working at reduced capacity because
    they don't have nurses.
        Often, there are no doctors for 2 hours or so. So, we are
    already in an emergency. I know the COVID pandemic has given a
    stress test of sorts to the healthcare system here, and we
    haven't recovered from that. Combine to that, the rural areas
    which have more aging population and aging doctors are
    projected to face even more shortage than the urban areas. And
    it has to be fixed now. There's really no time.
        Senator Hirono. Ms. Peterson, the nurses in Minnesota have
    gone on strike because there aren't enough nurses to safely
    provide care for the patients. So, are we going to see more of
    those kinds of actions by nurses and other health care
    providers who are just totally up to here with what is being
    asked of them?
        Ms. Peterson. I think we'll see that. I also think that the
    stress falls on patients. Just a week ago, I was told that one
    of my family members has to wait over 2 months to see a
    cardiologist. And I'm not alone. This experience was just
    backed up by a survey that looked at 15 major metropolitan
    communities, DC included, that says the average wait time for a
    physician is 30 days. And that depends on where you live and
    the specialty that you're seeking care from.
        So, in addition to the stress on the doctors and nurses,
    it's impacting us. It's impacting my family, and it's impacting
    your family. It's urgent. And we need to address that through
    smart immigration reform.
        Senator Hirono. Ms. Peterson, you mentioned that your
    support for two bipartisan bills that we could push, and I
    would ask the Chairman to, and the Ranking Member, to focus our
    minds on getting those bills, bipartisan bills, passed this
    session. Thank you.
        Chair Padilla. Thank you, Senator Hirono. Senator Tillis.
        Senator Tillis. Thank you, Mr. Chairman, for holding this
    hearing. I don't even know if I'll have time to ask you all any
    questions, but I do want to talk a little bit about how we
    resolve a series of crises that I think we have. There's no
    question we have a health care crisis. I was just down at a
    hospital, an institution you all would recognize, one of the
    most admired health care institutions in the United States,
    down in North Carolina. They have 80 beds that they can't make
    available because they don't have the nursing staff. We all
    know the pyramid. You got to have nurses in order to staff a
    room. We don't have them.
        Capacity that's lost because we don't have health care
    workers. We have a food security crisis. Now, getting away from
    health care, there's an agriculture group meeting with my staff
    right now. I'll guarantee you. The first issue, the top issue
    that they have our resources to actually work, and meat
    processing facilities, picking delicate fruits, doing the kinds
    of things that we need, labor force. We have a food security
    crisis. We have a housing crisis.
        The cost of labor has gone up astronomically. The length of
    time it takes to build a house has gone up. The cost of
    affordable housing has gone up and made less affordable because
    we don't have labor inputs there. But we also, contrary to what
    Vice President Harris said this week, we have a border crisis.
    The border is not secure. And 80 percent of the people that are
    crossing the border do not have a valid asylum claim. That is
    not, in my opinion, that's buried out by facts of the
    adjudication process someone goes through.
        When they claim credible fear, they go through the process,
    are adjudicated as not having a credible claim. So, how do we
    solve all these crises? We recognize we have a problem at the
    border. We have labor input problems, and we solve the problem
    as a group. It will not be done in isolation. The bipartisan
    bills that Senator Hirono talked about, I agree with on its
    face. They don't have a prayer of getting passed unless we look
    at this more holistically.
        If we take a look, Ms. Peterson, at just even trying to
    process I--in North Carolina, we use up our caps. I track it
    very closely. We have dozens of cases of trying to get nurses
    here on work visas. And it's frustrating. I know it's got to be
    frustrating for the outside. Imagine how frustrating it is for
    a Senate office having to go through that just to make sure
    that we can get as many beds open as possible.
        But we keep talking around the strategy that is necessary
    to solve the problem. Those bills are not going to get passed.
    They're not going to get--they're not even going to get a
    chance to be voted on on the floor--likely not unless we do the
    work to come up with a comprehensive solution that recognizes
    if we reduce future flows, we're going to have more resources
    to process visas. Just imagine if two thirds of the future
    flows went away, how many other resources could be freed up to
    focus on legal immigration, guest worker programs, the kinds of
    things that you're looking at.
        And I know your head's about probably about to explode
    going, ``Yes, but that's not my problem.'' It is our problem,
    and we have to solve it. And there are some simple solutions
    for solving it. And we have come so damn close so many times
    only to not get into the end zone. We have to recognize that
    there are people on both sides of the aisle who are willing to
    work together to address these worker shortages.
        But not a single one of us, or at least me, I won't speak
    for my colleagues, will, unless we fix the underlying problem
    with border--border security and 2 million plus people coming
    across the border illegally every year. We can do that with
    asylum reform. We could reduce the future flows overnight. We
    could shift resources to value added processes like addressing
    these worker shortages that go across every sector. And if we
    all take the time to do that, stop talking past each other,
    recognize that all of us are going to have to make some
    difficult political decisions, we can fix us.
        This is not rocket science. This is something we know what
    the fixes are. And this Committee has a role to play in it.
    Other Committees have a role to play in it. But Congress has a
    responsibility to do this. And I hope that before the end of
    this Congress, we can stop talking past each other, deal with
    the asylum issues that are, I think, probably the primary
    concern that Senator Cornyn and I have, and we're ready to
    address these empirically driven shortages in critical areas,
    not only health care, but across the spectrum of sectors in the
    United States.
        And I, for one, hope that we get it done before the end of
    this Congress. I do recognize your problem. We feel it every
    day in North Carolina. And I'm going to do everything I can to
    help be a part of the solution. Other people need to step up.
    Thank you. I yield back my second.
        Chair Padilla. Thank you, Senator Tillis. I'm going to take
    that second just to thank you, because I think the public does
    deserve to hear that you have been engaged on this issue and in
    our conversations and over striving to--we have yet to find the
    common ground that enough of us right here can vote, to have a
    final work product approved by the Senate as a body that would
    be meaningful and helpful.
        The frustration that only mildly share publicly is in some
    conversations you've got in the direction of, well, like if you
    try to be too global, too comprehensive, it's all going to fall
    apart. Yet at the same time, I hear, well, this is too narrow,
    it's not big and robust enough, so we can't do this. So,
    finding that balance is what we're striving for. Obviously, we
    haven't found it yet. Not yet, but I'm not giving up. I
    appreciate you not giving up.
        Senator Tillis. Yes. Mr. Chairman, I would just say, just
    for you all, if we don't get this thing done before the end of
    this Congress, my guess is we're 5 years away from getting
    another opportunity, and I hope people pay attention to that.
        Senator Cornyn. Mr. Chairman, you allow me just 30 seconds?
        Chair Padilla. Sure. Senator Cornyn.
        Senator Cornyn. I think we can talk this thing for the next
    20 years and never reach a conclusion. Or we could do what
    Senator Tillis and I have asked the Chairman of the Judiciary
    Committee to do that the Committee with jurisdiction over
    immigration matters has scheduled a markup. Bring a bill before
    the Committee, have an amendment process, which we--as part of
    that process and see if we can come up with a majority of
    Senators who would find a bill that they would support.
        If we just continue to talk about this, we're never going
    to get this resolved. We've been talking about for--DACA for 10
    years and never gotten it resolved. So, we have the tools
    available to us. But the only person who can convene that
    markup would be the Chairman of the Committee. And so, I hope
    our Democratic colleagues would support us in that effort.
    Thank you.
        Chair Padilla. Senator Klobuchar.
        Senator Klobuchar. Well, thank you very much, Chairman, and
    thank you very much for taking on this issue. And this is
    something that I appreciated, Senator Tillis, Senator Cornyn,
    your support for a number of these immigration measures,
    including the Conrad 30 bill that Senator Collins and I
    introduced. We now have 26 bipartisan co-sponsors, including
    Senator Ernst, Senator Rosen, on this Committee, the two of
    you, as well as Senators Durbin, and Coons, and Blumenthal.
        And I thank our witnesses. I really want to--I don't think
    our economy can withstand it if we don't move. My State has the
    lowest--as Ms. Peterson well knows, lowest unemployment rate in
    the country. We don't have enough workers all the way down the
    line and some combination--and I've been here. Your point,
    Senator Cornyn, when we have been able to pass an immigration
    bill that would have fixed a lot of this. We got it through the
    Senate with bipartisan support, a comprehensive immigration
    bill, and then, unfortunately, it did not pass in the House.
        I've seen a bill passed in the House and not here. And I'm
    hoping that third time's a charm and we simply cannot wait. As
    pointed out by Senator Durbin, national shortage of as many as
    124,000 physicians. In Minneapolis, there's one doctor for
    every 304 people. And, you know, we're the land of 10,000
    lakes, as well as 10,000 medical clinics, as you know, along
    with Mayo, so many University of Minnesota that we're so proud
    of. But in rural northwestern Minnesota, there's only one
    doctor for every 686 people.
        That is why I took on Kent Conrad's Bill many, many years
    ago to be able to allow for more doctors that are studying at
    our great medical clinics, medical schools throughout the
    country to be able to stay for their residency and the like.
    And I would like to expand that. The legislation reauthorizes
    and expands the Conrad 30 program that has brought more than
    15,000 doctors to underserved areas, including rural and urban
    in the last 15 years. Ms. Peterson, by the way, thank you for
    graduating with degrees from the University of Minnesota,
    working, I understand, at the law school. Where were you born
    in Minnesota?
        Ms. Peterson. Wisconsin, but lived in Minnesota.
        Senator Klobuchar. Did you see the Vikings and Packers
    game?
        Ms. Peterson. I did.
        Senator Klobuchar. You can imagine I was happy with the
    outcome. My mom came from Wisconsin, so all is good. So, could
    you talk about how, in your experience, what role do immigrant
    doctors who have been trained in the U.S. play in providing
    essential medical care to rural and underserved communities?
        Ms. Peterson. Yes. Thank you, Senator Klobuchar. I mean, I
    think a statistic that's really telling is that 28 percent of
    these international doctors who go into underserved areas stay
    there well past their 5 years as compared to 11 percent of U.S.
    doctors. And I think that's telling because we need to expand
    our programs to continue to reward and recognize international
    doctors who are going into these communities like Dr. Alur.
    They're building lives.
        They are staying there long term. A doctor who came to my
    small town has been there for over 20 years. He's built his
    life there. And so, we have a shortage. It's documented and we
    have the vehicle to immediately address it, which is your bill,
    Senator Klobuchar.
        Senator Klobuchar. Okay. Can you talk about why
    reauthorizing the program would be, in your words, a win-win?
        Ms. Peterson. It gives States the ability to control the
    doctors that they can place. It also encourages and rewards
    physicians like Dr. Alur to work in underserved areas by
    helping them get over the H-1B numerical cap, which this year
    alone, we had over 480,000 people apply for 85,000 numbers. So,
    it also rewards physicians on the green card side of things for
    going into underserved communities. And these are three very
    critical components to ensuring that Americans are getting the
    access to health care they need.
        Senator Klobuchar. I note that recently the United Kingdom
    introduced a health care visa program that fast tracks visas
    for health care workers, not just doctors. And Canada, which is
    very close to our borders, also offers an expedited pathway to
    permanent residency for doctors. I note that in Great Britain
    they have a conservative prime minister. They had one with
    Boris Johnson, they have one with Liz Truss, yet they're moving
    ahead on this. Could you talk about why this is a problem for
    the U.S., if you want to chime in, doctor. If we lose, not just
    we don't keep people here, we're losing them to other
    countries.
        Dr. Alur. Thank you, Senator Klobuchar, for your
    leadership. Great question. My personal experience, I've shared
    my burdens here. If I was to talk to a doctor who's hoping to
    come here or who's planning to stay after training, I would
    tell him, it's fantastic to work here. My experience working
    with the veterans is very rewarding, very satisfying. But if
    they listen to my family's troubles and if they have to talk to
    their families and then say, a doctor has been working here for
    11 years, he's been in the country for 15 years. This is the
    prime of his youth when he can do a lot. Should we go here?
        And I'll leave it to your imagination, what would their
    families say. As a physician, this is fantastic. As a family,
    the way the system is currently, how would it help? I want to
    extend this to say what would happen if people get green cards.
    I have a example of a pediatrician from my community who
    finished his waiver in 2008, went on to build six practices,
    employ 18 providers, employ 48 employees, and served pediatrics
    in my community. Thank you.
        Senator Klobuchar. And just to make clear, our bill updates
    modernize the program by allowing States to bring in more
    doctors and then additional incentives for doctors to continue
    serving an underserved area for up to 5 years. And I think that
    also would make a tremendous--tremendous difference. So, I
    just, again, want to thank both of you, want to thank Senator
    Padilla and Senator Cornyn for holding this hearing.
        We can't wait. Whether we do a bill that's focused on parts
    of this, I know that Senator Rounds valiantly tried to do a
    bill, during the--I was part of the group during the Trump
    administration, and we had a number of Republicans on board.
    And then we were, in my mind, got punched by the
    administration. Yet with many Republicans having been willing
    to support it here, this is our chance. We've got to move
    quickly. And thank you for bringing this, Senator Padilla, to
    our attention, and then Ms. Peterson, as well as Dr. Alur,
    thank you very much. Thanks, Senator.
        Chair Padilla. Thank you, Senator Klobuchar. I know the
    clock is ticking. We have votes open, but there are a couple of
    more questions I want to raise and have responses for the
    record. I'll try to be brief. The lack of access to health care
    in rural communities is a serious emergency. According to data
    tracked by the University of North Carolina Chapel Hill, 182
    rural hospitals have closed since 2005, leaving residents in
    those areas no options but to forgo receiving health care or to
    travel long distances to see a doctor.
        Dr. Alur, in your testimony, you mentioned at the Veterans
    Affairs Hospital where you work is located in Marion, Illinois,
    a town with a population of about 17,000. You also mention that
    your hospital serves veterans from a number of States,
    including Missouri, Kentucky, and Indiana. Can you briefly
    describe what health care disparities you've witnessed in your
    work and how those disparities impact individuals living in
    rural areas in particular?
        Dr. Alur. Thank you, Chairman Padilla. Our veterans come
    from 2 hours, 2 1/2 hours away, going past emergency rooms and
    hospitals to receive care at the VA. It's such a cherished
    institution. Once we get the veterans, we take care of what we
    can take care of there. It's a small hospital. The shortage in
    the community glares at us once we try to transfer veterans to
    places that need. We expurse no effort, energy, or expense in
    getting care to the veterans.
        And like I alluded before, hospitals are closed. Whoever is
    in the community whoever is coming to a hospital for a problem
    is at an advanced stage because they don't have access to
    primary care. And that's a huge problem. The pediatrician I was
    talking about who is established a huge practice there, he is
    having to recruit out of his expertise so that he can provide
    care. So, he's recruiting psychologists, he's recruiting dental
    assistants so that that shortage is compensated. The
    disparities are projected to even get worse as aging physicians
    retire. So, the outcomes are already poor. We have to act now
    so that we can arrest the decline and secure the rural areas.
        Chair Padilla. Thank you. If you don't mind, I'd like to
    ask a slightly more personal question, Dr. Alur. You've
    mentioned that moving a substantial distance away from work in
    order to put your daughter's needs first. You shared that in
    the testimony you submitted. You also mentioned the trials and
    tribulations that you and your wife have faced navigating our
    complex immigration laws. But yet, despite all of that, you
    remain committed and steadfast in your passion for your work,
    the work that you do serving our Nation's veterans.
        I'd like to thank you again for the work that you do in
    your service. And I just want to hear from you. What would
    obtaining a green card mean for you and your family?
        Dr. Alur. Thank you, Chairman Padilla. One word I would say
    is stability. We've been working in the community. We've been
    living in the community. But we are not really part of the
    community. We don't belong there because we are still temporary
    immigrant workers. Stability to my family, to my children,
    especially my daughter, who will age out if I don't get a green
    card in 6 years. Stability to my patients. Travel is a problem.
        Being on a visa, if I leave the country and if I can't come
    in, there is a gap. That has been the case with many immigrant
    physicians in our organization. Freedom from simple day-to-day
    restrictions like not able to drive. Right now, there is a
    physician in East Tennessee, a real rural country. A
    gastroenterologist is not able to drive because of his visa
    problem. He's decided to relocate. His children and wife are
    already gone. He says he cannot take calls because he can't go
    to the hospital if there is a bleeder in the hospital.
        There is a liver transplant program director in Iowa City
    right now who is not seeing patients because his immigration
    process is screwed up. He's not doing anything since Monday.
    His patients are waiting. All these restrictions and problems
    we face are actually--they reflect on the patients. They
    reflect on the communities. One day of work I can't do is care
    delayed for many patients. Thank you.
        Chair Padilla. Thank you. Senator Cornyn, any final
    questions?
        Senator Cornyn. Mr. Chairman, I don't have any more
    questions. I do want to thank all of our witnesses for being
    here. I have no doubt that the problems that you've identified
    are real, and we have it within our power to fix them. If we
    can find the political will to do so. But just as I believe the
    testimony of Ms. Peterson and Dr. Alur are real and valid
    concerns, I believe the concerns expressed by Sheriff Martinez
    are equally real and valid.
        And the message that I have tried to communicate to
    Chairman Durbin and my friend, Senator Padilla, is that there
    will be no solution to--your issues that you've highlighted as
    much as I would like for us to be able to do that until we find
    a solution to what's happening at the border now.
        What's happening at the border is simply unsustainable. I
    talked about the drug deaths associated and distribution of
    those drugs by criminal gangs across the United States. It's
    completely intolerable, and the burden should not fall to the
    States like mine or other border States like Senator Padilla's
    to deal with it. This is a Federal responsibility, but the only
    way we can do that is if we actually do our job here, which is
    not just to talk about it, it's actually to do something.
        And that doing something means marking up legislation,
    trying to build consensus and then get it to the President's
    desk. And we can't do that as long as all we're doing is
    talking. So, thank you very much for being here. I hope that I
    hope that we can make some progress here. And thanks to Sheriff
    Martinez for joining us remotely and dealing with the huge
    challenges that border communities in Texas deal with 24 hours
    a day, 365 days a year. Thank you.
        Chair Padilla. Thank you, Senator Cornyn. There's one last
    question I'd like to ask, and then we'll proceed with the
    closing statement. But after listening to all the testimony
    today, one thing is made clear. It was frankly clear before
    today's hearing. Our outdated immigration laws are not working.
    Period. In addition to the other impacts of a broken
    immigration system, we attempted to focus today on how it's
    exacerbating the crisis that is our health care workforce
    shortage.
        So, Ms. Peterson, can you just comment briefly on how if
    Congress does not act swiftly to remedy this outdated system,
    what are the implications for the health of Americans across
    the country?
        Ms. Peterson. Thank you, Chair Padilla. I'd like to go on
    record by saying, I think we can do both. I think we can deal
    with our border crisis and deal with the urgent health care
    shortage crisis in the United States. Because if we don't do
    both immediately, the numbers will continue to grow. At the
    beginning, we were talking about, you know, the 124,000
    shortages of doctors over the next several years. It's only
    going to continue to grow.
        And what that translates into is Americans are going to
    continue to have longer wait times, have worse patient outcomes
    in terms of complications, more financial burdens. It will
    continue to compound. And it's not just the rural and the
    underserved anymore. It's all of us in the urban areas. It's
    your family's and mine. Thank you.
        Chair Padilla. Thank you. I actually think that's a great
    note to begin to conclude, because we can do both. We must do
    both. But to utilize one situation, policy, issue, or challenge
    to keep us from making progress, bipartisan progress, on a
    clear crisis is unconscionable. I want to, before concluding,
    read aloud a number of statements that have been submitted into
    the record and I'll read who they are from.
        We have received statements for the record from the
    American Association of International Health Care Recruitment,
    the American College of Physicians, the American Hospital
    Association, the American Medical Association, the Association
    of American Medical Colleges, the Cato Institute, the
    Educational Commission for Foreign Medical Graduates, the
    Health Care Leadership Council, National Hospice and Palliative
    Care Organization, National Immigration Law Center, Southern
    Illinois Health Care, Upwardly Global and World Education
    Services. So, without objection, these statements will be
    included, and the record will close 1 week from today.
        [The information appears as a submission for the record.]
        Now, as this hearing concludes, I want to thank our
    witnesses again for joining us today, as well as Chairman
    Durbin, Ranking Member Cornyn, and our fellow Committee
    Members. As I mentioned at the outset, today's hearing was not
    just about fixing our immigration system or about providing
    support to the health care workers who need it. It's about
    tackling the crisis of our health care workforce shortage. It's
    about saving lives.
        It was my hope today that in order to address an issue as
    important as saving American lives, that we could stand united
    to reform our system. That was the spirit that all the Members
    of the Committee showed up with. I want to make sure I make one
    thing clear before I close this hearing.
        The border has nothing, I repeat, nothing to do with the
    fact that we all need to hire up to 124,000 doctors by 2034 to
    fill current workforce gaps. We have a health care workforce
    shortage that is affecting millions of Americans. And there are
    productive solutions to address this. Two bipartisan bills
    which Ms. Peterson raised today, each of which have 25
    bipartisan co-sponsors.
        And I'll note, I know he just left, and this is meant
    respectfully, Senator Cornyn is the lead on one of them. But
    instead of utilizing our time today to focus on meaningful
    change, we were met with repeatedly a misleading narrative.
    It's a frustrating pattern among many of my Republican
    colleagues. Now, I, too, was at the border just a few weeks
    ago. Among--on the itinerary that day was a Border Patrol ride
    along, in addition to visits to ports of entry and detention
    facilities.
        So, let me be clear. Our border is secure. Let me also be
    clear about this point. People presenting themselves at the
    border seeking asylum is a legal right that they have. But the
    reality is it's the process that's broken and it is in need of
    reform. But many of my Republican colleagues are only
    interested in fearmongering. That's what I keep hearing. And if
    the only solution that the offer is to completely close the
    border, it's a nonstart.
        I was interested in hearing the Ranking Member speak today
    about working in good faith. We've been able to do so on a
    number of other issues. And he's right. We do need Republicans
    to work in good faith to help millions of Americans and to
    reform our immigration system. But working in good faith is
    acknowledging that we can do two things at once. Good faith is
    coming to the table to engage with experts, and to respect and
    recognize data from our departments and agencies. Good faith is
    not showing up at a national workforce shortage hearing and
    focusing on statistics about gun violence in Chicago.
        Good faith is seeing a complex issue facing our health care
    workforce and coming together to find common ground that will
    save lives or to advance solutions when we've already found
    that common ground, solutions that enjoy bipartisan support and
    not find excuses to not move those forward. But when Republican
    colleagues actually want to talk about solutions to improve our
    immigration system so that we uphold our Nation's values and
    our economy, then absolutely, I am more than ready and willing
    to listen. And I can say the same for Chairman Durbin.
        Now, that starts with being honest about cruel and
    misguided policies like Title 42 and MPP that are unlawful and
    have only created more bottlenecks and put more people in
    danger. And as I said earlier in the hearing, we need to
    improve the legal migration pathways to undo the pressure on
    irregular migration. Legal migration pathways used to be a
    bipartisan issue, and they weren't conflated with border
    reform. Once upon a time. And we have bipartisan solutions just
    sitting here in front of us waiting to be passed.
        So, it's a shame for this Nation. It's a disservice,
    frankly, and especially those in underserved areas when it
    comes to health care, that Republicans won't let us move the
    needle forward even onto solutions they support. For the 95
    million Americans living in an area with a shortage of health
    care professionals, including those living in Sheriff
    Martinez's County, we cannot afford to wait.
        It's not just health, it's lives that are at stake because
    every day that this workforce gap exists is another day that a
    loved one has to travel hundreds of miles for a doctor's
    appointment, or friend has to wait too long for a lifesaving
    preventative screening if they can get to a health care
    provider at all.
        What we've heard today leaves no doubt, we cannot address
    this shortage without reforming our immigration laws. There are
    thousands of highly qualified health care professionals already
    living in the United States who can join our health care
    workforce. As we heard from Dr. Alur, immigrant physicians are
    eager to serve the rural and underserved areas of our country
    that so desperately need care.
        And as Ms. Peterson pointed out, Congress can make reforms
    to allow more physicians to not just come to the United States
    but remain in the United States after they complete their
    training. Congress can make more visas available for health
    care workers by recapturing unused visas in years past. And
    Congress can make exceptions to numerical caps to specifically
    address health care workforce shortages. For the sake of our
    Nation's health, we must act swiftly to pass laws that will
    provide much needed reforms to our broken immigration system
    and bring care to communities in need.
        So, I want to thank again all of our witnesses for your
    participation here today, all my colleagues who attended and
    participated here today. And with that, this hearing is
    adjourned.
        [Whereupon, at 11:57 a.m., the hearing was adjourned.]
        [Additional material submitted for the record follows.]

                                A P P E N D I X

    Miscellaneous submissions:

     American Academy of Family Physicians (AAFP).....................    64

     American Academy of Neurology....................................    67

     American College of Physicians (ACP).............................    75

     American Health Care Association and the National Center for
        Assisted Living (AHCA/NCAL)...................................    79

     American Hospital Association....................................    81

     American Medical Association (AMA)...............................    86

     American Seniors Housing Association (ASHA)......................    97

     Argentum.........................................................   100

     Association of American Medical Colleges.........................   102

     Catholic Health Association of the United States (CHA)...........   108

     Cato Institute...................................................   110

     Healthcare Leadership Council....................................   118

     Intealth.........................................................   115

     Jeffrey, Patty, Statement........................................    69

     National Hospice and Palliative Care Organization (NHPCO)........   121

     National Immigration Law Center (NILC)...........................   122

     Southern Illinois Healthcare (SIH)...............................   126

     Upwardly Global (UpGlo)..........................................   129

     World Education Service (WES) and Refugee Advocacy Lab...........   131

     Physicians for American Healthcare Access (PAHA) Statement
      https://www.govinfo.gov/content/pkg/CHRG-117shrg59432/pdf/CHRG-
        117shrg
        59432-add1.pdf

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