[House Report 108-730]
[From the U.S. Government Publishing Office]



108th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     108-730
======================================================================
 
     TO IMPROVE ACCESS TO PHYSICIANS IN MEDICALLY UNDERSERVED AREAS

                                _______
                                

October 5, 2004.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

 Mr. Sensenbrenner, from the Committee on the Judiciary, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 4453]

                  [Including Committee Cost Estimate]

  The Committee on the Judiciary, to whom was referred the bill 
(H.R. 4453) to improve access to physicians in medically 
underserved areas, having considered the same, reports 
favorably thereon with an amendment and recommends that the 
bill as amended do pass.

                                CONTENTS

                                                                   Page
The Amendment....................................................     1
Purpose and Summary..............................................     2
Background and Need for the Legislation..........................     2
Hearings.........................................................     4
Committee Consideration..........................................     4
Vote of the Committee............................................     4
Committee Oversight Findings.....................................     4
New Budget Authority and Tax Expenditures........................     4
Committee Cost Estimate..........................................     4
Performance Goals and Objectives.................................     5
Constitutional Authority Statement...............................     5
Section-by-Section Analysis and Discussion.......................     5
Changes in Existing Law Made by the Bill, as Reported............     6
Markup Transcript................................................     7

                             The Amendment

  The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

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) Exemption From Geographic Limitations.--Section 214(l)(1)(D) of 
the Immigration and Nationality Act (8 U.S.C. 1184(l)(1)(D)), as 
amended by subsection (c), is further amended--
            (1) by striking ``except that,'' and all that follows 
        through the period at the end 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; and
                    ``(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 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 described in subparagraph (B)) in accordance 
                with the conditions of this clause to exceed 5.''.

                          Purpose and Summary

    H.R. 4453 would extend and modify the program whereby 
aliens who participate in medical residencies in the United 
States on exchange program visas (known as ``J'' visas) do not 
have to leave the U.S. at the conclusion of their residencies 
to reside abroad for 2 years if they agree to practice medicine 
for 3 years in an area designated by the Secretary of Health 
and Human Services (``HHS'') as having a shortage of health 
care professionals.

                Background and Need for the Legislation

                             I. BACKGROUND

    Aliens who participate in medical residencies in the United 
States on ``J'' exchange program visas must generally leave the 
U.S. at the conclusion of their residencies to reside abroad 
for 2 years before they can be eligible for permanent residence 
or status as ``H-1B'' or ``L'' visa nonimmigrants.\1\ The 
intent behind this policy is to encourage American-trained 
foreign doctors to return home to improve health conditions and 
advance the medical profession in their native countries.
---------------------------------------------------------------------------
    \1\ See Immigration and Nationality Act Sec. 212(e)(iii).
---------------------------------------------------------------------------
    In 1994, Congress created a waiver (until June 1, 1996) of 
the 2-year foreign residence requirement when a state 
department of public health requested it for a foreign doctors 
who committed to practicing medicine for no less than 3 years 
in a geographic area or areas designated by the Secretary of 
HHS as having a shortage of health care professionals.\2\ The 
number of foreign doctors who could receive the waiver was 
limited to 20 per state. In 1996, Congress extended the waiver 
to June 1, 2002.\3\ In 2002, Congress extended the waiver until 
June 1, 2004.\4\ At the same time, the numerical limitation on 
waivers was increased to 30 per state.
---------------------------------------------------------------------------
    \2\ See the Immigration and Nationality Technical Corrections Act, 
Pub. L. No. 103-416, Sec. 220 (1994).
    \3\ See the Illegal Immigration Reform and Immigrant Responsibility 
Act, Pub. L. No. 104-208, Sec. 622 (1996).
    \4\ See the 21st Century Department of Justice Appropriations 
Authorization Act, Pub. L. No. 107-273, Sec. 11018 (2002). Section 
11018 incorporated the language of H.R. 4858, which was reported by the 
House Judiciary Committee on June 24, 2002, and passed the House on 
June 25, 2002.
---------------------------------------------------------------------------
    The waiver requirements are as follows: the Secretary of 
Homeland Security may authorize a waiver upon the request of an 
interested U.S. government agency or a director of a state 
department of public health (or its equivalent) as in the 
public interest \5\ if:
---------------------------------------------------------------------------
    \5\ See INA Sec. 212(e).

        1) in the case of an alien who is otherwise 
        contractually obligated to return to a foreign country, 
        the government of such country furnishes the U.S. 
        government with a statement in writing that it has no 
---------------------------------------------------------------------------
        objection to a waiver,

        2) the alien demonstrates a bona fide offer of full-
        time employment at a health facility or health care 
        organization and that employment has been determined by 
        the Secretary of Homeland Security to be in the public 
        interest,

        3) the alien agrees to begin employment within 90 days 
        of receiving the waiver, and agrees to continue to work 
        for not less than 3 years (unless the Secretary 
        determines that extenuating circumstances exist, such 
        as closure of the facility or hardship to the alien, 
        which would justify a lesser period of employment at 
        such facility or organization, in which case the alien 
        must demonstrate another bona fide offer of employment 
        at a health care facility or health care organization 
        for the remainder of the 3 year period), and

        4) the alien agrees to practice medicine for the 3 year 
        period only in the geographic area or areas which are 
        designated by the Secretary of HHS as having a shortage 
        of health care professionals (except in the case of a 
        request by the Department of Veterans Affairs or in the 
        case of a request by an interested Federal agency to 
        employ the alien full-time in medical research or 
        training).\6\
---------------------------------------------------------------------------
    \6\ See INA Sec. 214(l)(1).
---------------------------------------------------------------------------

                        II. THE BILL AS REPORTED

    H.R. 4453 as introduced would have extended the waiver for 
a year and continued the practice of allowing foreign doctors 
receiving a waiver to receive H-1B nonimmigrant status 
regardless of the annual H-1B visa quota.\7\ At the full 
Committee markup, Representatives Hostettler and Jackson Lee 
offered an amendment in the nature of a substitute that would 
extend the program until June 1, 2006, specify that the H-1B 
cap exemption would apply to doctors whether they were 
sponsored by a state or Federal agency, allow foreign doctors 
receiving a waiver to work in medically-underserved areas in 
either primary care or specialty medicine, and allow five of 
each state's 30 waivers to go to doctors that would practice 
medicine in areas not designated by the Secretary of Health and 
Human Services as having a shortage of health care 
professionals, if the doctors receiving the waivers would 
practice in facilities that serve patients who reside in areas 
designated by the Secretary as having a shortage of health care 
professionals. The Committee adopted the Hostettler-Jackson Lee 
amendment in the nature of a substitute, and the bill as 
reported reflects that text.
---------------------------------------------------------------------------
    \7\ See The American Competitiveness in the Twenty-First Century 
Act of 2000, Pub L. No. 106-313, Sec. 114 (2000). The H-1B quota is now 
65,000 each fiscal year. See INA Sec. 214(g)(1)(A).
---------------------------------------------------------------------------

                                Hearings

    No hearings were held in the Committee on the Judiciary on 
H.R. 4453.

                        Committee Consideration

    On June 3, 2004, the Subcommittee on Immigration, Border 
Security, and Claims met in open session and ordered favorably 
reported the bill H.R. 4453, without amendment, by a voice 
vote, a quorum being present. On September 30, 2004, the 
Committee met in open session and ordered favorably reported 
the bill H.R. 4453, with an amendment, by a voice vote, a 
quorum being present.

                         Vote of the Committee

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives, the Committee notes that there 
were no recorded votes during the Committee's consideration of 
H.R. 4453.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII of the Rules 
of the House of Representatives, the Committee reports that the 
findings and recommendations of the Committee, based on 
oversight activities under clause 2(b)(1) of rule X of the 
Rules of the House of Representatives, are incorporated in the 
descriptive portions of this report.

               New Budget Authority and Tax Expenditures

    Clause 3(c)(2) of rule XIII of the Rules of the House of 
Representatives is inapplicable because this legislation does 
not provide new budgetary authority or increased tax 
expenditures.

                        Committee Cost Estimate

    In compliance with clause 3(d)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee believes that 
the bill will have no significant cost for the current fiscal 
year, and no significant cost for the next five fiscal years. 
The Committee did not receive any estimates of the costs of 
this legislation from any other government agency as outlined 
in clause 3(d)(2)(B) of rule XIII. The bill does not authorize 
programs so the Committee cannot provide a comparison with 
relevant programs under current law as outlined in clause 
3(d)(2)(C) of rule XIII.

                    Performance Goals and Objectives

    The Committee states that pursuant to clause 3(c)(4) of 
rule XIII of the Rules of the House of Representatives, H.R. 
4453 would extend and modify the program whereby aliens who 
participate in medical residencies in the United States on 
``J'' exchange program visas do not have to leave the U.S. at 
the conclusion of their residencies to reside abroad for 2 
years if they agree to practice medicine for 3 years in an area 
designated by the Secretary of Health and Human Services as 
having a shortage of health care professionals. This would 
increase the availability of doctors in these underserved 
areas.

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee finds the authority for 
this legislation in article I, Sec. 8 of the Constitution.

               Section-by-Section Analysis and Discussion

    The following discussion describes the bill as reported by 
the Committee.
Section 1. Modification of Visa Requirements with Respect to 
        International Medical Graduates.
    Subsection 1(a) would amend Sec. 220(c) of the Immigration 
and Nationality Technical Corrections Act of 1994 to extend 
until June 1, 2006, the program under which aliens who 
participate in medical residencies in the United States on 
``J'' exchange program visas do not have to leave the U.S. at 
the conclusion of their residencies to reside abroad for 2 
years if they agree to practice medicine for 3 years in an area 
designated by the Secretary of HHS as having a shortage of 
health care professionals. This change shall take effect as if 
enacted on May 31, 2004.
    Subsection 1(b) would amend Sec. 214(l)(2)(A) of the 
Immigration and Nationality Act to provide that the 65,000 
annual H-1B visa numerical limitation shall not apply to any 
alien who has obtained a waiver of the 2 year foreign residence 
requirement upon a request by an interested Federal agency or 
an interested state agency.
    Subsection 1(c) would amend Sec. 214(l)(1)(D) of the 
Immigration and Nationality Act to clarify that an alien 
participating in the waiver program can practice primary care 
or specialty medicine.
    Subsection (d) would amend Sec. 214(l)(1)(D) of the 
Immigration and Nationality Act to provide that for up to five 
of a state's 30 yearly waivers, the head of an interested state 
agency may determine that the alien may practice medicine in a 
facility that serves patients who reside in one or more 
geographic areas designated by the Secretary of the Department 
of HHS as having a shortage of health care professionals 
without regard to whether such facility is within such a 
designated geographic area.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italics, existing law in which no change 
is proposed is shown in roman):

 SECTION 220 OF THE IMMIGRATION AND NATIONALITY TECHNICAL CORRECTIONS 
                              ACT OF 1994

SEC. 220. WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT WITH RESPECT 
                    TO INTERNATIONAL MEDICAL GRADUATES.

    (a) * * *

           *       *       *       *       *       *       *

    (c) Effective Date.--The amendments made by this section 
shall apply to aliens admitted to the United States under 
section 101(a)(15)(J) of the Immigration and Nationality Act, 
or acquiring such status after admission to the United States, 
before, on, or after the date of enactment of this Act and 
before June 1, [2004.] 2006.
                              ----------                              


                  SECTION 214 OF THE IMMIGRATION AND 
                            NATIONALITY ACT

                       admission of nonimmigrants

      Sec. 214. (a) * * *

           *       *       *       *       *       *       *

      (l)(1) In the case of a request by an interested State 
agency, or by an interested Federal agency, for a waiver of the 
2-year foreign residence requirement under section 212(e) on 
behalf of an alien described in clause (iii) of such section, 
the Attorney General shall not grant such waiver unless--
            (A) * * *

           *       *       *       *       *       *       *

            (D) in the case of a request by an interested 
        Federal agency (other than a request by an interested 
        Federal agency to employ the alien full-time in medical 
        research or training) or by an interested State agency, 
        the alien [agrees to practice medicine] agrees to 
        practice primary care or specialty medicine in 
        accordance with paragraph (2) for a total of not less 
        than 3 years only in the geographic area or areas which 
        are designated by the Secretary of Health and Human 
        Services as having a shortage of health care 
        professionals, [except that, 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.] except that--
                    (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; 
                and
                    (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 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 
                described in subparagraph (B)) in accordance 
                with the conditions of this clause to exceed 5.
            (2)(A) Notwithstanding section 248(2), the Attorney 
        General may change the status of an alien who qualifies 
        under this subsection and section 212(e) to that of an 
        alien described in section 101(a)(15)(H)(i)(b). 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.

           *       *       *       *       *       *       *


                           Markup Transcript



                            BUSINESS MEETING

                      THURSDAY, SEPTEMBER 30, 2004

                  House of Representatives,
                                Committee on the Judiciary,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:05 a.m., in 
Room 2141, Rayburn House Office Building, Hon. F. James 
Sensenbrenner, Jr. [Chairman of the Committee] presiding.
    [Intervening business.]
    Chairman Sensenbrenner. The next item on the agenda is the 
adoption of H.R. 4453, the ``Access to Rural Physicians 
Improvement Act of 2004.'' The Chair recognizes the gentleman 
from Indiana, Mr. Hostettler, the Chairman of the Subcommittee 
on Immigration, Border Security, and Claims for a motion.
    Mr. Hostettler. And, Mr. Chairman, the Subcommittee on 
Immigration, Border Security, and Claims reports favorably the 
bill, H.R. 4453, and moves its favorable recommendation to the 
full House.
    Chairman Sensenbrenner. Without objection, the bill will be 
considered as read and open for amendment at any point. The 
Chair recognizes the gentleman from Indiana to strike the last 
word.
    [The bill, H.R. 4453, follows:]
    
    
    Mr. Hostettler. Thank you, Mr. Chairman. Today we are 
marking up Terry Moran's bill, H.R. 4453, the Access to Rural 
Physicians Improvement Act of 2004. Aliens who participate in 
medical residencies in the United States on J exchange program 
visas must generally leave the U.S. after the completion of 
their residencies to reside abroad for 2 years. After this 
foreign residency they can be eligible for permanent residence 
or status as H-1B or L visa nonimmigrants. The intent behind 
the policy is to encourage American trained foreign doctors to 
return home to improve health conditions and advance the 
medical profession in their native countries.
    In 1994, Congress created a waiver of the 2-year foreign 
residence requirement. State departments of health, public 
health may request a waiver for foreign doctors to 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 could receive the waiver was limited to 
20 per State.
    In 1996, Congress extended the waiver to June 1, 2002. In 
2002, Congress extended the waiver until June 2004. At the same 
time the numerical limitation on waivers was increased to 30 
per State. The waiver has proven to be an important means of 
ensuring quality medical care in areas of the United States 
with physician shortages.
    H.R. 4453, as introduced by Mr. Moran, as approved by the 
Immigration, Border Security, and Claims Subcommittee would 
extend the waiver until 1 year after the bill's date of 
enactment. I plan to have the Subcommittee utilize that time 
frame to investigate the impact of foreign students and 
residents on comparable Americans before deciding on the longer 
term status of the program.
    Ms. Jackson Lee and I have agreed to offer a substitute 
amendment that will extend the program until June 2006 and give 
the Committee a bit more time to consider the issue. A number 
of organizations have proposed that States be able to utilize 
their waivers in locations not designated as physician shortage 
areas by the Department of Health and Human Services. Not 
surprisingly, HHS is very much opposed to such proposals. I was 
hesitant to eliminate this requirement for all waivers without 
a hearing. The substitute that Ms. Jackson Lee and I will offer 
will allow each State to place five of the doctors it sponsors 
each year in areas not designated by HHS as physician shortage 
areas. The Committee will then have a year and a half to 
examine this pilot program and decide whether to extend it to 
the entire waiver program.
    I urge my colleagues to support H.R. 4453 and to support my 
and Ms. Jackson Lee's substitute amendment.
    Chairman Sensenbrenner. The gentlewoman from Texas, Ms. 
Jackson Lee.
    Ms. Jackson Lee. I thank the Chairman very much, and I 
thank the Chairman of the Subcommittee and his cooperation and 
working with me on the upcoming amendment to the Access to 
Rural Physicians Improvement Act of 2004, H.R. 4453. In our 
hearings of course it was certainly determined and acknowledged 
that the utilization of the J-1 visas to assist with physicians 
in rural communities is pivotal. In fact, it is a key element 
to good health in America. I would not want to say to our rural 
communities throughout America today that we were not allowing 
good strong professional physicians to be able to come into the 
community to provide good health care.
    The Chairman and myself have agreed from the beginning that 
the J-1 visa waiver program for doctors in underserved areas 
should be continued. But we have had, as I have indicated, 
significant differences of opinions over the details of 
extending the program. I wanted a 5-year program, which Members 
of the Senate joined me in, and also greater flexibility in 
dealing with the State health departments. I am gratified, 
however, that we are willing and collaborating on a compromise 
that will provide a 2-year extension and as well give some 
flexibility. Aliens who attend medical school in the United 
States on J exchange program visas generally must leave the 
country afterwards and reside abroad for 2 years before they 
can apply for another visa on some other basis such as an H-1B 
visa or an L visa.
    In 1994, Congress created a temporary waiver of the 2-year 
foreign residence requirement. 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 is sunsetting on June 1 of this year.
    The first physician recommended for a waiver in Texas was a 
doctor Maria Camacho, a pediatric internist. Her services to 
the residents of Harlingen in Cameron County provide a level of 
health care to children that was previously unable in that 
country. It is extremely important that she happens to be of 
course bilingual. Additionally, she serves on the faculty of 
the Valley Regional Academic Health Center to train new 
physicians.
    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 brand new 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 
treatments. Now it is available in this area.
    Where else throughout the Nation do we find those same 
circumstances? The Gateway Community Clinic in Laredo is a 
federally qualified health center on the Texas-Mexico border. 
It obtained a J-1B waiver for Dr. Garcia-Cavazos. This doctor 
is a rheumatologist who provides specialty services to a 
patient population without regard to their insurance status or 
their ability to pay. The Access to Rural Physicians 
Improvement Act would authorize a 1-year extension of the 
waiver.
    Our amendment, which is in the nature of a substitute, 
would provide a 2-year extension. It also has a pilot 
flexibility provision which would allow a State agency to place 
a doctor in an area that has not been designated as underserved 
if the doctor will nevertheless serve patients from an 
underserved area. This exception is limited to five doctors in 
each State. I would venture to say that every Member of 
Congress, House and Senate, would be impacted positively by 
this compromise amendment, and I am gratified to be able to 
offer it and to support it.
    Under the Access to Rural Physicians Improvement Act H-1B 
doctors who receive the waiver to serve at a State facility do 
not count towards the annual H-1B cap. Our amendment makes the 
same provision for H-1B doctors who serve at a Federal 
facility. The amendment also permits Federal J-1 visa waivers 
to apply to specialists in addition to the primary care 
physicians.
    I would urge my colleagues to support the underlying 
legislation with the amendment, and I would venture to say that 
this amendment will contribute to positive health care in 
America. With that, I yield back and I thank the Chairman.
    Chairman Sensenbrenner. Without objection, all Members' 
opening statements will appear in the record at this point.
    [The prepared statement of Ms. Jackson Lee follows:]
       Prepared Statement of the Honorable Sheila Jackson Lee, a 
Representative in Congress From the State of Texas, and Ranking Member, 
        Subcommittee on Immigration, Border Security, and Claims
    I want to thank my distinguished colleague, the gentleman from 
Indiana, Mr. Hostettler, for working with me on this amendment to the 
Access to Rural Physicians Improvement Act of 2004, H.R. 4453. Although 
we have agreed from the beginning that the J-1 visa waiver program for 
doctors in underserved areas should be continued, we have had 
significant differences of opinion over the details of extending the 
program. I appreciate Mr. Hostettler's willingness to negotiate a 
compromise that can be moved forward as a bipartisan bill.
    Aliens who attend medical school in the United States on J exchange 
program visas generally must leave the country afterwards and reside 
abroad for two years before they can apply for another visa on some 
other basis, such as an H-1B or an L visa. In 1994, Congress created a 
temporary waiver of the two-year foreign residence requirement. It 
applied to foreign doctors who would commit to practicing medicine for 
no less than three 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 ten years in 
bringing highly qualified physicians to medically underserved areas. It 
sunsetted on June 1st of this year.
    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. Additionally, she 
serves on the faculty of the Valley Regional Academic Health Center to 
train new physicians.
    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 brand new dialysis center. Patients requiring dialysis 3 
times per week in that part of Texas used to have to travel more than 
70 miles each way for the treatments. Now it is available in Pecos.
    The Gateway Community Clinic in Laredo is a Federally Qualified 
Health Center on the Texas-Mexico border. It obtained a J-1 waiver for 
Dr. Rogelio Garcia-Cavazos. This doctor is a Rheumatologist who 
provides specialty services to a patient population without regard to 
their insurance status or their ability to pay.
    The Access to Rural Physicians Improvement Act would authorize a 
one-year extension of the waiver. Our amendment, which is in the nature 
of a substitute, would provide a two-year extension. It also has a 
pilot flexibility provision which would allow a state agency to place a 
doctor in an area that has not been designated as underserved if the 
doctor will nevertheless serve patients from an underserved area. This 
exception is limited to five doctors in each state.
    Under the Access to Rural Physicians Improvement Act, H-1B doctors 
who receive the waiver to serve at a state facility do not count 
towards the annual H-1B cap. Our amendment makes the same provision for 
H-1B doctors who serve at a federal facility. The amendment also 
permits federal J-1 visa waivers to apply to specialists in addition to 
primary care physicians.
    I urge you to vote for this amendment. Thank you.

    Chairman Sensenbrenner. Are there amendments? The gentleman 
from Indiana has the substitute.
    Mr. Hostettler. Mr. Chairman, I have a substitute at the 
desk.
    Chairman Sensenbrenner. The Clerk will report the 
substitute.
    The Clerk. Amendment in the nature of a substitute to H.R. 
4453 offered by Mr. Hostettler of Indiana and Ms. Jackson Lee 
of Texas.
    [The amendment in the nature of a substitute follows:]
    
    
    Chairman Sensenbrenner. Without objection, the substitute 
is considered as read and open for amendment at any point. The 
Chair recognizes the gentleman from Indiana, Mr. Hostettler.
    Mr. Hostettler. Mr. Chairman, I thank you, and as we said 
earlier, Mr. Chairman, H.R. 4453, introduced by Representative 
Moran, extends the J visa for foreign residency waiver program 
until 1 year after the bill's date of enactment. On June 3, 
2004, the bill was approved by the Subcommittee on Immigration, 
Border Security and Claims by a voice vote. This substitute 
that Ms. Jackson Lee and I are offering would accomplish the 
following:
    First, the substitute would extend the waiver until June 1, 
2006. This will give the Subcommittee adequate time to fully 
explore all the issues involved with foreign medical students 
and foreign medical residents.
    Second, the substitute would allow foreign doctors 
receiving a waiver to receive H-1B status regardless of the 
annual H-1B visa quota, whether they are sponsored by a State 
or Federal agency.
    Third, the substitute would explicitly allow foreign 
doctors receiving a waiver to work in medically underserved 
areas in either primary care or specialty medicine. A number of 
State public health agencies have utilized the waiver program 
to meet needs for specialty care providers, and the substitute 
recognizes this practice.
    Fourth, the substitute will allow five of each States 30 
waiver recipients to practice medicine in areas not designated 
by the Secretary of Health and Human Services as having a 
shortage of health care professional, if the doctors receiving 
the waivers will practice in facilities that serve patients who 
reside in areas designated by the Secretary as having a 
shortage of health care professionals. The Subcommittee will 
review the operation of this program to ensure not only that 
the goal of the waivers is maintained; that is, serving the 
underserved, but also to determine the impact on American 
citizens who by very definition, at least 30 in each State, 30 
per State spots, slots in medical schools must be, by 
definition of the result of this, the presence of this program, 
must be denied to American citizens for the purpose of 
practicing medicine. And so in the interim time we will not 
only be looking at the situation as it seeks to serve those 
that are in underserved areas, but obviously the impact on 
American citizens and their ability to attend medical school.
    On that, Mr. Chairman, I yield back the balance of my time.
    Chairman Sensenbrenner. The question is on the adoption.
    Ms. Jackson Lee. Chairman.
    Chairman Sensenbrenner. The gentlewoman from Texas.
    Ms. Jackson Lee. Thank you very much, Mr. Chairman. As the 
Chairman mentioned, of the Subcommittee, this is a compromise. 
I would simply--I will be including most of my statement into 
the record, but I do want to make the point that this is a 
very, very well respected program and a well-needed program. I 
hope after we have had a successful study of this program in 
the 2-year extension we will be able to implement a J-1 visa 
program that will allow a 5-year program continuously. These 
are physicians who in most instances adhere to their visa time 
frame. They will return back to their nation of origin, but 
more importantly, they serve a very vital need in the battle 
for good health care in America to underserved areas, and I 
believe it is crucial that this program continue with a 5-year 
program and the flexibility for the States.
    The compromise I accept and support, and I ask my 
colleagues to support the amendment in the nature of a 
substitute of myself and Mr. Hostettler.
    I would yield back.
    Chairman Sensenbrenner. Are there amendments to the 
amendment in the nature of a substitute? If there are none, the 
question is on agreeing to the amendment in the nature of a 
substitute offered by the gentleman from Indiana, Mr. 
Hostettler. Those in favor will say aye. Opposed, no. The ayes 
appear to have it. The ayes have it, and the amendment in the 
nature of a substitute is agreed to.
    A reporting quorum is present. The question occurs on the 
motion to report the bill H.R. 4453 favorably, as amended. All 
in favor will say aye. Opposed, no. The ayes appear to have it. 
The ayes have it and the motion to report favorably is adopted.
    Without objection, the bill will be reported favorably to 
the House in the form of a single amendment in the nature of a 
substitute incorporating the amendment adopted here today. 
Without objection, the Chairman is authorized to move to go to 
conference pursuant to House rules. Without objection, the 
staff is directed to make any technical and conforming changes, 
and all Members will be given 2 days as provided by the House 
rules in which to submit additional, dissenting, supplemental, 
or minority views.

                                  
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