[Congressional Record (Bound Edition), Volume 150 (2004), Part 17]
[Senate]
[Pages 23842-23847]
[From the U.S. Government Publishing Office, www.gpo.gov]




     IMPROVING ACCESS TO PHYSICIANS IN MEDICALLY UNDERSERVED AREAS

  Mr. SENSENBRENNER. Mr. Speaker, I move to suspend the rules and pass 
the Senate bill (S. 2302) to improve access to physicians in medically 
underserved areas.
  The Clerk read as follows:

                                S. 2302

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. MODIFICATION OF VISA REQUIREMENTS WITH RESPECT TO 
                   INTERNATIONAL MEDICAL GRADUATES.

       (a) Extension of Deadline.--
       (1) In general.--Section 220(c) of the Immigration and 
     Nationality Technical Corrections Act of 1994 (8 U.S.C. 1182 
     note) (as amended by section 11018 of Public Law 107-273) is 
     amended by striking ``2004.'' and inserting ``2006.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall take effect as if enacted on May 31, 2004.
       (b) Exemption From H-1B Numerical Limitations.--Section 
     214(l)(2)(A) of the Immigration and Nationality Act (8 U.S.C. 
     1184(l)(2)(A)) is amended by adding at the end the following: 
     ``The numerical limitations contained in subsection (g)(1)(A) 
     shall not apply to any alien whose status is changed under 
     the preceding sentence, if the alien obtained a waiver of the 
     2-year foreign residence requirement upon a request by an 
     interested Federal agency or an interested State agency.''.
       (c) Limitation on Medical Practice Areas.--Section 
     214(l)(1)(D) of the Immigration and Nationality Act (8 U.S.C. 
     1184(l)(1)(D)) is amended by striking ``agrees to practice 
     medicine'' and inserting ``agrees to practice primary care or 
     specialty medicine''.
       (d) Exemptions.--Section 214(l)(1)(D) of the Immigration 
     and Nationality Act (8 U.S.C. 1184(l)(1)(D)) is further 
     amended--
       (1) by striking ``except that,'' and all that follows and 
     inserting ``except that--''; and
       (2) by adding at the end the following:
       ``(i) in the case of a request by the Department of 
     Veterans Affairs, the alien shall not be required to practice 
     medicine in a geographic area designated by the Secretary;
       ``(ii) in the case of a request by an interested State 
     agency, the head of such State agency determines that the 
     alien is to practice medicine under such agreement in a 
     facility that serves patients who reside in one or more 
     geographic areas so designated by the Secretary of Health and 
     Human Services (without regard to whether such facility is 
     located within such a designated geographic area), and the 
     grant of such waiver would not cause the number of the 
     waivers granted on behalf of aliens for such State for a 
     fiscal year (within the limitation in subparagraph (B)) in 
     accordance with the conditions of this clause to exceed 5; 
     and
       ``(iii) in the case of a request by an interested Federal 
     agency or by an interested State agency for a waiver for an 
     alien who agrees to practice specialty medicine in a facility 
     located in a geographic area so designated by the Secretary 
     of Health and Human Services, the request shall demonstrate, 
     based on criteria established by such agency, that there is a 
     shortage of health care professionals able to provide 
     services in the appropriate medical specialty to the patients 
     who will be served by the alien.''.

  The SPEAKER pro tempore. Pursuant to the rule, the gentleman from 
Wisconsin (Mr. Sensenbrenner) and the gentlewoman from Texas (Ms. 
Jackson-Lee) each will control 20 minutes.
  The Chair recognizes the gentleman from Wisconsin (Mr. 
Sensenbrenner).


                             General Leave

  Mr. SENSENBRENNER. Mr. Speaker, I ask unanimous consent that all 
Members may have 5 legislative days within which to revise and extend 
their remarks and include extraneous material on S. 2302, the bill 
currently under consideration.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Wisconsin?
  There was no objection.
  Mr. SENSENBRENNER. Mr. Speaker, I yield myself such time as I may 
consume.
  Mr. Speaker, I rise in support of S. 2302. This legislation will 
extend the program under which alien doctors can avoid having to return 
home for 2 years by agreeing to practice in medically underserved areas 
here in America.
  Aliens who participate in medical residencies in the United States on 
a ``J'' visa program visa must generally leave the United States after 
the completion of their residencies to reside abroad for 2 years. The 
intent behind the policy is to encourage American-trained foreign 
doctors to return home to improve health conditions that advance the 
medical profession in their native countries.
  In 1994, Congress created a waiver of the 2-year foreign residence 
requirement. State departments of public health may request a waiver 
for foreign doctors who commit to practicing medicine for no less than 
3 years in geographic areas designated by the Secretary of Health and 
Human Services as having a shortage of health care professionals. The 
number of foreign doctors who can receive the waiver is limited to 30 
per State each year. The waiver has proven to be an important means of 
ensuring quality medical care in areas of the United States with 
physician shortages.
  S. 2302 is substantially similar to H.R. 4453, a bill introduced by 
the gentleman from Kansas (Mr. Moran) that this body passed by voice 
vote on October 6. It will extend the waiver program to June 2006. It 
will also allow each State to place five of the doctors it sponsors 
each year in areas not designated by HHS as physician shortage

[[Page 23843]]

areas. The bill continues the practice of allowing foreign doctors 
receiving waivers to receive H-1B visas regardless of the annual H-1B 
visa quota. Finally, the bill clarifies that doctors receiving waivers 
can practice specialty medicine. However, when a doctor works in a 
specialty, there must exist a shortage of health care professionals 
able to provide services in that specialty to the patients he or she 
will serve.
  I urge my colleagues to support this bill.
  Mr. Speaker, this time I will insert into the Record an exchange of 
jurisdictional letters between the chairman of the Committee on Energy 
and Commerce, the gentleman from Texas (Mr. Barton), and myself.

                                    U.S. House of Representatives,


                             Committee on Energy and Commerce,

                                Washington, DC, November 16, 2004.
     Hon. F. James Sensenbrenner, Jr.,
     Chairman, Committee on the Judiciary, U.S. House of 
         Representatives, Rayburn House Office Building, 
         Washington, DC.
       Dear Chairman Sensenbrenner: This week the House is 
     scheduled to consider S. 2302 under suspension of the rules.
       S. 2302, as passed by the Senate, contains language, which 
     provides for exemptions to section 214(l)(1)(D) of the 
     Immigration and Nationality Act, involving the Secretary of 
     Health and Human Services. As you know, Rule X of the Rules 
     of the House of Representatives gives the Committee on Energy 
     and Commerce jurisdiction over public health.
       I recognize your desire to bring this legislation before 
     the House in an expeditious manner. Accordingly, I will not 
     exercise my Committee's right to a referral. By agreeing to 
     waive its consideration of the bill, however, the Energy and 
     Commerce Committee does not waive its jurisdiction over S. 
     2302. In addition, the Energy and Commerce Committee reserves 
     its right to seek conferees on any provisions of the bill 
     that are within its jurisdiction during any House-Senate 
     conference that may be convened on this legislation. I ask 
     for your commitment to support any request by the Energy and 
     Commerce Committee for conferees on S. 2302 or similar 
     legislation.
       I request that you include this letter and your response in 
     the Record during consideration of the bill. Thank you for 
     your attention to these matters.
           Sincerely,
                                                       Joe Barton,
     Chairman.
                                  ____

                                    U.S. House of Representatives,


                                   Committee on the Judiciary,

                                Washington, DC, November 17, 2004.
     Hon. Joe Barton,
     Chairman, Committee on Energy and Commerce, House of 
         Representatives, Washington, DC.
       Dear Chairman Barton: Thank you for your letter regarding 
     S. 2302, a bill to improve access to physicians in medically 
     underserved areas. Subsection 1(d) of the bill reduces the 
     number of slots assigned to underserved areas that are 
     designated by the Secretary of Health and Human Services. To 
     the extent they affect duties of the Secretary, these 
     provisions fall within the Rule X jurisdiction of the 
     Committee on Energy and Commerce. I appreciate your 
     willingness to forgo consideration of the bill, and I 
     acknowledge that by agreeing to waive its consideration of 
     the bill, the Committee on Energy and Commerce does not waive 
     its jurisdiction over these provisions.
       I will include a copy of your letter and this response in 
     the Congressional Record during consideration of S. 2032 on 
     the House floor.
       Thank you for your assistance in this matter.
           Sincerely,
                                      F. James Sensenbrenner, Jr.,
                                                         Chairman.
  Mr. Speaker, I reserve the balance of my time.
  Ms. JACKSON-LEE of Texas. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, I thank the distinguished chairman. This might be the 
last time the Subcommittee on Immigration is on the floor, possibly, in 
the 108th Congress; and I want to thank the full Committee on the 
Judiciary staff, and I want to particularly offer my appreciation to 
the Democratic staff of the Committee on the Judiciary for their very 
fine work during this Congress and their efforts toward bipartisanship, 
and thank Nolan Rappaport on the Subcommittee on Immigration for his 
work on this legislation and others dealing with immigration concerns.
  Let me share with my colleagues from an Associated Press article 
dated August 24: ``Before doctors like Mircea Rachita from Romania 
arrived in town, patients in this small town had to wait months for 
doctors' appointments. Now, underserved communities are finding good 
doctors easy to come by due to a visa waiver program which creates 
incentives for foreign-born physicians to work in communities American 
doctors may shun.''
  Clearly there is room and need for a bill to improve access to 
physicians in medically underserved areas, and S. 2302 is the 
embodiment of that bill, along with a similar House bill.
  The purpose of this bill is to make it possible for foreign doctors 
to provide medical services in geographic areas which have been 
designated by the Secretary of Health and Human Services as having a 
shortage of health care professionals. S. 2302 is almost identical to 
H.R. 4453, which I cosponsored with my colleague, the chairman of the 
subcommittee, the gentleman from Indiana (Mr. Hostettler).
  H.R. 4453 passed the House on October 6 on the Suspension Calendar. 
The Senate bill has an additional provision which ensures that 
specialists sponsored by Federal and State agencies are placed in areas 
that have a shortage in that specialty. The additional provision 
requires the sponsoring agency to determine criteria for demonstrating 
a specialist shortage and to meet that criteria in order to sponsor the 
specialist, a way of broadening access to health care and recognizing 
the 44 million uninsured Americans who need access to sometimes public 
facilities that utilize these foreign doctors.

                              {time}  1730

  Aliens who attend medical school in the United States on J exchange 
program visas are required to leave the country afterward and reside 
abroad for 2 years before they can receive their visas to work here as 
physicians.
  In 1994, Congress created a new temporary waiver of this 2-year 
foreign residence requirement which allowed States as well as Federal 
agencies to sponsor the doctors. It applied to foreign doctors who 
would commit to practicing medicine for no less than 3 years in a 
geographic area designated by the Secretary of Health and Human 
Services as having a shortage of health care professionals.
  This program has been successful for 10 years in bringing highly 
qualified physicians to medically underserved areas. It sunsetted on 
June 1 of this year and created a chasm between the needs of those who 
need health care and the regulations of the Federal government. We now 
have brought those pieces together.
  The first physician recommended for a waiver in Texas was Dr. Maria 
Camacho, a pediatric intensivist. Her services to the residents of 
Harlingen in Cameron County provide a level of health care to children 
that was previously unavailable in that county.
  Dr. K.M. Moorthi is a nephrologist who was recommended for a waiver 
to serve at a facility in Pecos, Texas, in Reeves County. He works at a 
dialysis center. Patients requiring dialysis three times per week in 
that part of Texas used to have to travel more than 70 miles each way 
for the treatment. Now it is available in this county.
  The bill will provide a 2-year extension for this waiver program. We 
started out with 1 year. I asked for 5 years. We compromised on 2 
years. We have made progress.
  It will also establish a pilot flexibility program which will allow a 
State agency to place a doctor at a location that has not been 
designated as underserved if the doctor, nevertheless, will serve 
patients from an underserved area. That is a very effective compromise 
to ensure that the patients, no matter where they are, get served 
whether they are in an underserved area or those patients that reflect 
that community.
  The exception is limited to five doctors in each State. It targets 
rural underserved areas that typically get specialty medical care from 
a major medical facility that is not itself located within an 
underserved area.
  Finally, the doctors who receive a waiver to come here with H-1B 
visas will not count toward the H-1B cap.
  I urge my colleagues to consider this legislation as a very positive 
step for good health care in America and support it enthusiastically.
  Mr. Speaker, I reserve the balance of my time.

[[Page 23844]]


  Mr. SENSENBRENNER. Mr. Speaker, I yield such time as he may consume 
to the gentleman from Kansas (Mr. Moran), the author of the House 
counterpart to this bill.
  Mr. MORAN of Kansas. Mr. Speaker, I thank the chairman for yielding 
me time.
  I am here only once again in a series, it seems like, of a number of 
years in which I have been on the floor to support the provisions 
contained in this legislation. I commend the chairman and the ranking 
member in the Committee on the Judiciary for their work in getting this 
resolved this year.
  The J-1 visa program expired on May 31 of this year. It is a program 
that is so important to many areas of the country. Once again, I am 
here to express my support for the legislation and indicate that in 
many places across rural America and the core of our cities, absent 
this program, Americans will not be served with a physician. It is 
important. It needs to be passed. I thank the chairman for his 
leadership in seeing that that occurred.
  Ms. JACKSON-LEE of Texas. Mr. Speaker, I yield such time as he may 
consume to the gentleman from Michigan (Mr. Conyers).
  Mr. CONYERS. Mr. Speaker, I am so happy that we are working together 
on a health care issue. They are critical to the United States where we 
have so many people without the ability to get health care. Against 
that background and this positive attitude, someone in this body must 
say, well, why are we bringing doctors in from out of the country to 
the most affluent nation on planet Earth, and they are providing very 
important necessary care? I think that is a question that will be taken 
up in the following upcoming session, but it is one that is 
troublesome.
  Right now I join with the gentlewoman from Texas (Ms. Jackson-Lee), 
our ranking member, in proudly supporting the work that has taken place 
to expand the boards. There are places where, for example, Indian 
reservations, technically not within the jurisdiction, will now be able 
to receive help. And even more important is the ability now to bring in 
specialists, pediatric specialists, diabetes specialists, to work in 
areas where, without this intervention, patients would be hundreds and 
hundreds of miles away from the proper medical treatment.
  This is an excellent bill. It is a product of bipartisan work in the 
committee, and I am happy to be a part of it. I thank the gentlewoman 
for yielding me time.
  Ms. JACKSON-LEE of Texas. Mr. Speaker, I yield 3 minutes to the 
gentleman from North Dakota (Mr. Pomeroy), who I think understands the 
need for health care in rural America.
  Mr. POMEROY. Mr. Speaker, I thank the gentlewoman for yielding me 
time.
  I am pleased to associate myself with the ranking member on the 
Committee on the Judiciary, the gentleman from Michigan (Mr. Conyers), 
as well as my former co-chairman with the Rural Health Care Coalition, 
the gentleman from western Kansas (Mr. Moran).
  Truly, we have a growing problem relative to the delivery of rural 
health care, and that is we do not have enough professionals to deliver 
the care required. As we look at the pipeline, those coming along 
compared to those nearing the end of their practice years, we realize 
that we are working ourselves into a pretty serious problem here and 
that is especially so when you consider the aging of the population. So 
I agree with the gentleman from Michigan (Mr. Conyers). We need to look 
at this systemically, why this is happening, and address it. But in the 
near term, we need to take the step that offers a Band-Aid solution but 
an important Band-Aid at that, and that is the legislation before us.
  North Dakota receives about a dozen doctors a year through this 
important visa waiver provision. Twenty-six cities in the State I 
represent have participated in this program. We would have a situation 
where failure to authorize this would create immediate problems in six 
or seven small towns. They would face the departure of critical medical 
personnel under the loss of this visa waiver.
  With the passage of it, conversely, we will have opportunities to 
continue to build capacity. I have one city that has been going through 
an incredibly expensive proposition of hiring an anesthesiologist on a 
Locum Tenens basis. This is a temporary hire coming in from other parts 
of the country, and it costs a fortune. We hope to move through a 
resident hire through the application of this visa waiver provision.
  So, bottom line, while this is an immigration bill, it is all about 
making sure health care services for peoples' needs in rural areas and 
underserved communities are available, and I urge its adoption.
  Mr. CONYERS. Mr. Speaker, will the gentleman yield?
  Mr. POMEROY. I yield to the gentleman from Michigan.
  Mr. CONYERS. Mr. Speaker, I want to commend the gentleman, because it 
was the senior Senator from North Dakota that put this program together 
almost a decade ago, and I commend both of the gentlemen.
  Mr. POMEROY. I thank the gentleman very much.
  Senator Conrad has done very good work on this, as has the gentleman 
from Kansas (Mr. Moran) in the House and others. I am very pleased, as 
the gentleman mentioned earlier, a bipartisan moment on health care. 
This is a good bill. Let us pass it.
  Ms. JACKSON-LEE of Texas. Mr. Speaker, how much time remains?
  The SPEAKER pro tempore (Mr. Stearns). The gentlewoman from Texas 
(Ms. Jackson-Lee) has 9 minutes.
  Ms. JACKSON-LEE of Texas. Mr. Speaker, I yield myself such time as I 
may consume.
  In conclusion, I am very glad that the point that was made by the 
distinguished ranking member and the gentleman from North Dakota (Mr. 
Pomeroy) is that this is both a medical bill, a health care bill, and 
it is an immigration bill. And is it not interesting that we can find 
an opportunity for bipartisanship around two very key issues.
  I think it is also important to reemphasize the fact that we promote 
and encourage the education and training of individuals here in America 
in the medical professions, nurses, nurse practitioners, physicians, 
physician assistants and others that are the cornerstone of our health 
care system. But we know our hospital systems are overburdened. We know 
there are many, many people that are underserved. This bill serves a 
very valuable purpose.
  Might I reemphasize the fact that we will give opportunities to 
hospitals that are located or designated as not an underserved area? It 
reaches out to serve the underserved, which is something we try to 
encourage our teaching hospitals to do, who typically are not in areas 
that can be considered that, so that the individuals get high-quality 
service. They will be able to utilize this legislation.
  Mr. Speaker, in my concluding remarks, I think it is important to 
note that we do have before us an immigration bill. I was hoping before 
the conclusion of the 108th Congress we might be in a better position 
to really attack the question of comprehensive immigration reform. Many 
of us have had initiatives that have languished for a very long time. I 
cite for this body the Comprehensive Immigration Fairness Reform Act 
that really looked at immigration in a very comprehensive manner.
  Probably over the next couple of months we will hear a raging debate 
on immigration, those for it, those against it. The debate on 
immigration can be a very tense and conflicted debate. It raises some 
of the most unpleasant aspects of many of those who are pro and con, in 
many instances, not being able to find common ground. I would encourage 
my colleagues to look at this forthrightly and understand that we can 
no longer turn the lights out and close the curtains on this very 
important issue.
  We can no longer have a temporary guest program, albeit how well-
intentioned this administration may be, the Flat Earth Theory that 
allows people to come in for 3 years and then suggest to them that they 
must then leave the country in order to, if you will, remain in a 
position to possibly have another job again. The guest worker program

[[Page 23845]]

proposed by President Vincente Fox and this administration will not 
work. You will not get 8 million illegal immigrants in this country to 
accept that philosophy. Nor will you get to a point where you would 
like to be, a secure America, because we are not focusing on securing 
our borders. We are focusing on what I think is misdirected in a 
temporary guest worker program.
  Comprehensive reform allows us to allow individuals to earn access to 
legalization, to document those who are here, and be able to be safe 
from terrorists by distinguishing those who have come here for economic 
opportunity as opposed to those who have come to do us harm. Why can we 
not understand that in a bipartisan way?
  Now, let me say also, if we are going to do anything in the last 
hours of this session, make sure that we do something that helps legal 
immigrants who are here who for years who have been trying to reunite 
their families. We have passed out of the House in a bipartisan manner 
245-I which would allow legal immigrants to reunite with mothers and 
fathers, husbands and wives or children. That would be a fair approach, 
and the Senate needs to help us, the other body, if I might say, needs 
to help us in that. Any discussion about H-1Bs clearly should be a 
discussion in recognizing that we must protect American jobs. We must 
protect American jobs in order to have an open and adequate discussion 
on immigration.
  In conclusion, let me say this, Mr. Speaker, I would hope that our 
good friends who are dealing in the conference on issues of immigration 
reform would not pursue these in the 9/11 intelligence bill. Allow us 
to have a full, comprehensive debate and a full, comprehensive 
bipartisan approach to immigration reform that will last and will be 
invested in America and will make America work and comply with our 
principles of democracy and empowerment and equality.
  Putting poison pills on an intelligence bill that deals with fixing 
the intelligence system is no way to go forward on a vital question of 
how we bring America together and answer the questions of those who 
say, what do you do about those illegal immigrants? Are you just going 
to affirm them for doing the illegal wrong thing? No, we are not. We 
are going to give them the opportunity to earn access to legalization 
while they are already here paying taxes, children in school, building 
houses and contributing to this economy.

                              {time}  1745

  Let us wake up America and stop the divisive debate on immigration 
and stand up for what we believe in.
  This country was founded on immigration. How many of us can forget 
the early pinnings of this Nation; the turn of the century and the 
1900s and immigrants coming from Europe? This is the very same.
  Protect the borders, respond to those in Arizona and California and 
Texas who are concerned about the constant flow of illegal immigrants 
and the large deaths in the deserts. We do that by securing the 
borders, working with our friends in South and Central America, 
providing economic opportunity there, and working on a real immigration 
reform bill.
  It saddens me that we come to the close of the 108th Congress when we 
could have sat down, looked each other in the eye, sat around the table 
and done the right thing.
  I can only say that I applaud the J-1 visa legislation, a good sign 
of working together. It will help people in America, and I hope it will 
help us improve our health care system, but we can also heal a broken 
immigration system by doing the very same thing, looking each other in 
the eye and sitting around and putting the doctors to work, the 
political doctors to work, of good mind and good faith and make this 
country what it is, a country that believes in the Statue of Liberty's 
words: Bring us your poor and oppressed.
  I thank the distinguished Speaker, and I ask my colleagues to support 
this legislation, and I hope the charge is that we will face 
immigration the way it should be, in a fair, equitable and balanced 
way.
  Mr. Speaker, I yield back the balance of my time.
  Mr. SENSENBRENNER. Mr. Speaker, I yield myself the balance of the 
time.
  Mr. Speaker, lest anyone be confused as a result of the previous 
speaker that this is a wide-ranging, overall immigration bill that 
deals with amnesty and guest workers and all of those very contentious 
issues, let me lay that impression to rest. This bill does not do that, 
and I fear that the previous speaker's statement ends up hurting the 
support for this bill that is broad and bipartisan.
  All this bill does is allow a foreign national who is a graduate of 
an American medical school and who has completed his residency in an 
American hospital to practice in a medically-underserved area, 
somewhere in the United States, and the request would have to be made 
by a State Department of Public Health and limited to no more than 50 
doctors per State.
  Now, this is not what the gentlewoman from Texas is talking about. We 
will deal with that in due course, but let us make sure that this bill 
is not confused with the other more broad and contentious bills.
  This bill has to pass because it extends a program that expired in 
June of this year, and if we vote this legislation down, then we are 
not going to have those doctors in the medically-underserved areas.
  We should keep the discussion and bills like this confined to what is 
in the bill, rather than a wide-ranging overall debate on immigration 
policy.
  Ms. BORDALLO. Mr. Speaker, I rise today in support of S. 2302, which 
would reauthorize the ``Conrad 30 J-1 Visa Waiver Program.'' 
Reauthorization of this important program will help districts that 
experience shortages with respect to health care professionals, such as 
Guam, by allowing certain U.S.-trained foreign doctors to remain in the 
United States to practice medicine in these underserved areas.
  Like many rural and insular areas, Guam experiences great difficulty 
attracting and retaining qualified health professionals. The cost of 
providing health care is higher in Guam than in many areas on the 
mainland, and incidents of chronic disease are above national averages. 
The Conrad 30 J-1 visa Waiver Program is an important tool that allows 
poor, rural and insular areas to meet the health care needs of their 
communities by permitting International Medical Graduates to maintain 
their work visas in the United States if they agree to remain in areas 
defined by the Department of Health and Human Services as Health 
Professional Shortage Areas or Medically Underserved Areas or 
Populations. Normally, these foreign physicians would have to return to 
their respective home countries for 2 years before they could return to 
the United States to again practice medicine.
  While I believe priority should always be given to American doctors 
and health professionals for local hiring, it is clear that there are 
simply not enough health care professionals to meet demand in 
underserved areas such as Guam. Without the services of skilled foreign 
physicians from countries such as the Philippines, it would be 
difficult for Guam's public health care system to meet the medical 
needs of our community. S. 2302 reauthorizes a program that has been 
successful in addressing the issues of recruitment and retention of 
qualified health professionals in these areas, and I urge my colleagues 
to support its passage.
  Mr. DAVIS of Illinois. Mr. Speaker, I rise in support of S. 2302. The 
state of health care is one of the most critical issues facing this 
Nation. As the world's most powerful and wealthy country, our health 
care system is unacceptable. According to the Health Resources and 
Services Administration, there are 62 designated Health Professional 
Shortage Areas in Cook County, Illinois, alone. It is unacceptable that 
49 out of the 102 counties in Illinois lack hospitals with any 
obstetrical services. It is unacceptable that 49 of the 102 counties in 
Illinois lack hospitals with any psychiatric services. S. 2302 would 
help address the Nation's health care crisis by encouraging qualified 
medical professionals to serve in medically underserved areas. 
Increasing access to primary care providers and specialists would 
benefit the citizens of Illinois and the country as a whole.
  Therefore, this bill is a step in the right direction. However, much 
work remains to be done to reform our health care system as a whole. We 
need to ensure that no American is left behind in preventative care. We 
need to

[[Page 23846]]

ensure equal access to medical treatments. We need to ensure affordable 
health insurance. We need to erase the vast disparities in the 
incidents of illness and death among minorities compared to the overall 
U.S. population. African-American and Native-American babies die at a 
rate that is 2 to 3 times higher than the rate for white Americans. 
African Americans are 1.7 times as likely as white Americans to have 
diabetes; Latino Americans are twice as likely to have diabetes as 
their white counterparts.
  Mr. Speaker, the state of one's health sets the precedent for 
everything else in our lives. If we are not in good health, we cannot 
perform our jobs well or do well in school. We must work toward making 
quality healthcare accessible and available to all regardless of age, 
race, or economic status.
  Ms. CHRISTENSEN. Mr. Speaker, I rise today to join my fellow 
colleagues in support of S. 2302, also known as H.R. 4156. I first 
would like to thank Senator Conrad and Congressman Jerry Moran for 
sponsoring this important piece of legislation. I would also like to 
thank the committees jurisdiction for their quick actions in allowing 
this bill to come to the floor.
  Mr. Speaker, over the tenure of my congressional career I have come 
to the floor repeatedly to demand that Congress act to address the 
needs of the medically underserved and to ensure that we do everything 
possible to eliminate arbitrary barriers which give rise to healthcare 
disparities.
  As there is a vast amount of research on the subject of rural 
physician recruitment and retention, this bill is by no means a 
comprehensive policy. Rather, the purpose is to be a temporary stop gap 
measure to allay the crisis of rural health and healthcare providers.
  Mr. Speaker, more than 51 million Americans live in areas classified 
by the U.S. Office of Management and Budget (OMB) as nonmetropolitan. 
They comprise one-fifth of the U.S. population. Rural populations are 
found to be older, poorer, sicker, less educated and to have a 
perception of worse health status than their urban counterparts.
  They also have higher infant mortality and injury-related mortality 
rates, fewer hospital beds and physicians per capita, and are much less 
likely than urban residents to have private or public health insurance. 
Moreover, while the number of individuals living below the poverty line 
is disproportionately high in rural areas, the number receiving 
Medicaid benefits is disproportionately low.
  In a study of the utilization rates of 28 categories of medical 
services, found that, with the exception of major surgical procedures, 
urban residents received between 20 percent and 30 percent more of each 
type of service than did rural residents.
  With at least 20 percent of the population living in rural areas, 
less than 11 percent of the Nation's physicians are practicing in 
nonmetropolitan areas. Today, more than 2,500 physicians were needed in 
nonmetropolitan areas to remove all nonmetropolitan health professional 
shortage area (HPSA) designations for primary care. More than twice 
that number are needed to achieve a 2,000-1 ratio in those HPSAs. This 
is the current situation and does not factor in the aging physician 
population serving rural areas, nor does it factor in the statistical 
designation dealing with counties as the main reference point.
  As a medical doctor, I understand that nonmetropolitan physicians 
derive a larger share of their gross practice revenue from Medicare and 
Medicaid patients than metropolitan physicians. These public programs 
pay physicians at lower rates than private insurers. There is a 
decreased ability in nonmetropolitan areas to perform economically 
enhancing procedures (hospitals with decreasing obstetrical and 
surgical units, etc.), which further decreases relative reimbursement 
rates. Thus, nonmetropolitan physicians, on average, work more and earn 
less than their metropolitan counterparts.
  Rural Health Clinics (RHCs), Federally Qualified Health Centers 
(FQHCs) in designated HPSAs and medically underserved areas (MUAs), and 
differential Medicare payments to qualifying rural areas have helped to 
enhance reimbursement. But currently, the mandate that States pay RHCs 
and FQHCs their reasonable costs under Medicaid is being phased out. 
Medicare managed care program reimbursement to RHCs has threatened to 
be lower than the current reimbursement. Both of these payment changes 
will put providers in jeopardy.
  Mr. Speaker, I along with my Congressional Black Caucus counterparts 
have consistently pushed the Congress for more equitable fee 
reimbursement and to fully fund Title VII and Title VIII health 
profession training program. We have also called for the strengthening, 
expansion, and reauthorization of these programs in our minority health 
bill H.R. 3459, the Healthcare Equality and Accountability Act, which I 
look forward to moving on the 109th Congress.
  S. 2302/H.R. 4156 acknowledges that international medical graduates, 
through State initiated J-1 visa programs, have initially met some 
unmet needs of rural areas. But Mr. Speaker, I would like to highlight 
a recent study published by the Council on Graduate Medical Education 
that stated that although international medical graduates have made an 
important contribution to the provision of medical care in some rural 
areas, training these graduates is an inefficient way to expand 
physician supply in rural areas. Although many inner city hospitals are 
dependent on international medical graduates for providing care to 
underserved urban populations, more direct avenues exist for meeting 
the needs of these hospitals. The funds would be better targeted to 
programs that increase the flow of U.S. health professional graduates 
to underserved rural areas.
  Therefore, Mr. Speaker while I strongly support the underlying bill, 
I again call on Congress to move legislation in the 109th that will do 
the following.
  Increase ORHP funding for research related to physician recruitment, 
retention and networking should be supported and enhanced.
  Reevaluate how designation of HPSAs and MUAs are given so the 
designated areas accurately reflect underserved status.
  Increasing the Title VII funding for AHECs and health education 
training centers should be supported and enhanced.
  Encourage and mandate that medical schools confront their obligation 
to target admissions and training to underserved populations, both 
rural and urban, in the primary care professions.
  Encourage medical school environments to encourage individuals into 
primary care and encourage early and long-term rural exposure to 
positive rural physician role models, and such educational programs 
should be adequately funded.
  Increase scholarship programs to place medical students with 
mentoring physicians in rural or remote practices during an elective or 
vacation period should be encouraged.
  Support medical schools' and residencies' efforts to integrate 
community orientation and a team approach to health care. To achieve 
the full benefit of this effort, there needs to be further 
infrastructure building of rural allied health teams and rural 
communities' commitment to meeting the challenges of a changing health 
care system.
  Encourage family practice residencies to offer rural electives, rural 
emphasis and rural training tracks.
  Direct the Bureau of Health Professions (BHP) funding for residencies 
that are building rural-based programs and funding for those programs 
that have a history of producing rural physicians should become a 
staple rather than be at the mercy of national budget politics. An 
aggressive plan to increase funding should be sought.
  Increase support by the BHP to primary care residencies to be 
continued and enhanced.
  Decrease professional isolation by supporting teleinformatics and 
outreach education programs of states and by the use of nonphysician 
providers.
  Increase retention through more appropriately rural-trained 
candidates.
  Identify care needs at the community level. Use state and federal 
funds to assist rural hospitals where access to care would be 
threatened by hospital closure and physicians would be further deprived 
of opportunities to utilize their professional skills.
  Develop and use innovative delivery systems that emphasize 
coordination and cooperation among providers, institutions and 
communities.
  Develop programs allowing rural clinicians to undertake periodic 
rotations through academic hospital services (with locum tenens backup) 
in order to learn or update procedures.
  Provide for those areas that do not qualify for RHC or FQHC status 
but still are faced with the disproportionate numbers of Medicare and 
Medicaid patients, there should be enhanced Medicare and Medicaid 
payments to rural providers.
  Evaluate the enhanced reimbursement available through RHC and 
Community Health Center designations needs to be adequately maintained 
to retain providers and avoid decertification as the area's needs are 
met. If the same level of Medicare and Medicaid and uninsured patients 
persists and the area is decertified because of an adequate supply of 
physicians, a cycle will develop leading to economic unfeasibility, 
provider dissatisfaction and lower retention rates.
  Mandate the States to pay RHCs and FQHCs reasonable costs under the 
State's Medicaid program.

[[Page 23847]]

  Ensure that Medicare managed care reimbursement must equal or exceed 
the RHC and FQHC Medicare reimbursement.
  Increase the supply of primary care providers in rural areas by 
lessening speciality and geographic differentials in physician income.
  Establish relocation grants, especially for remote areas, to defray 
the costs of moving and setting up a practice.
  Mr. Speaker, in the 109th Congress I will introduce a bill that 
codifies these recommendations among others and will hopefully begin 
the process of ensuring that we provide healthcare for all Americans 
within or close to current expenditures.
  Mr. SENSENBRENNER. Mr. Speaker, I yield back the balance of my time.
  The SPEAKER pro tempore (Mr. Stearns). The question is on the motion 
offered by the gentleman from Wisconsin (Mr. Sensenbrenner) that the 
House suspend the rules and pass the Senate bill, S. 2302.
  The question was taken.
  The SPEAKER pro tempore. In the opinion of the Chair, two-thirds of 
those present have voted in the affirmative.
  Mr. SENSENBRENNER. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX and the 
Chair's prior announcement, further proceedings on this motion will be 
postponed.

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