Foreign Physicians: Preliminary Findings on the Use of J-1 Visa  
Waivers to Practice in Underserved Areas (18-MAY-06,		 
GAO-06-773T).							 
                                                                 
Many U.S. communities face difficulties attracting physicians to 
meet their health care needs. To address this problem, states and
federal agencies have turned to foreign physicians who have just 
completed their graduate medical education in the United States  
under J-1 visas. Ordinarily, these physicians are required to	 
return home after completing their education, but this		 
requirement can be waived at the request of a state or federal	 
agency if the physician agrees to practice in, or work at a	 
facility that treats residents of, an underserved area. In 1996, 
GAO reported that J-1 visa waivers had become a major means of	 
providing physicians for underserved areas, with over 1,300	 
requested in 1995. Since 2002, each state has been allotted 30	 
J-1 visa waivers per year, but some states have expressed	 
interest in more. GAO was asked to report on its preliminary	 
findings from ongoing work on (1) the number of J-1 visa waivers 
requested by states and federal agencies and (2) states' views on
the 30-waiver limit and on their willingness to have unused	 
waiver allotments redistributed. Such redistribution would	 
require legislative action. GAO surveyed the 50 states, the	 
District of Columbia, 3 U.S. insular areas--the 54 entities that 
are considered states for purposes of requesting J-1 visa	 
waivers--and federal agencies about waivers they requested in	 
fiscal years 2003-05.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-773T					        
    ACCNO:   A54201						        
  TITLE:     Foreign Physicians: Preliminary Findings on the Use of   
J-1 Visa Waivers to Practice in Underserved Areas		 
     DATE:   05/18/2006 
  SUBJECT:   Employment of foreign nationals			 
	     Foreign medical graduates				 
	     Health care personnel				 
	     J-1 Visa waiver					 
	     J-1 Visas						 
	     Physicians 					 

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GAO-06-773T

     

     * Background
     * Waivers Remain a Major Means for Providing Physicians, and S
     * States Requested Waivers for Physicians to Work in a Variet
     * Most States Reported Conducting Some Monitoring Activities
     * Most States Reported That the Annual Limit Was Adequate but
          * Most States Reported That the Annual Waiver Limit Was Adequa
          * States' Views Differed on Having Unused Waiver Allotments Re
     * Contact and Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Testimony

Before the Subcommittee on Immigration, Border Security, and Claims,
Committee on the Judiciary,House of Representatives

United States Government Accountability Office

GAO

For Release on Delivery Expected at 2:00 p.m. EDT

Thursday, May 18, 2006

FOREIGN PHYSICIANS

Preliminary Findings on the Use of J-1 Visa Waivers to Practice in
Underserved Areas

Statement of Leslie G. Aronovitz

Director, Health Care

GAO-06-773T

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today as you consider the states' authority to
request J-1 visa waivers for foreign physicians to practice in underserved
areas1 of the United States. As you know, many communities throughout the
country-including rural and low-income urban areas-experience difficulties
in attracting physicians to meet their health care needs. To address this
problem, states and federal agencies have turned to foreign physicians who
have just completed their graduate medical education in the United States.
Many of these foreign physicians entered the United States on temporary
visas, called J-1 visas, and are ordinarily required to return to their
home country or country of last legal residence for 2 years when they
complete their graduate medical education. This foreign residence
requirement, however, can be waived by the Department of Homeland Security
in certain circumstances, including at the request of a state or federal
agency if the physician agrees to practice in an underserved area for at
least 3 years.2 By law, up to 30 J-1 visa waivers per year can be granted
in response to each state's requests-regardless of the state's size or
need for physicians.3 There is no limit in the number of J-1 visa waivers
that may be granted in response to federal agencies' requests.

In 1996, we reported that the number of J-1 visa waivers requested by
states and federal agencies for physicians to work in underserved areas
had risen dramatically-from 70 in 1990 to more than 1,300 in 1995-and that
requesting waivers had become a major means of providing physicians for
underserved areas. We estimated that, in 1995, the number of waiver
physicians practicing in underserved areas exceeded the number of
physicians practicing there through the National Health Service Corps
(NHSC) programs-the Department of Health and Human Services' (HHS) primary
mechanism for addressing shortages of physicians and other primary care
health professionals.4 We reported that slightly over half of these waiver
physicians practiced internal medicine, and many also had medical
subspecialties. Further, more than one-third of the waiver physicians
practiced in nonprofit community and migrant health centers, while nearly
one-fourth were in private practices. We also noted that controls for
ensuring that these physicians met the terms of their waiver agreements
were somewhat weak.5 In the 10 years since our earlier report, the
Department of Agriculture and the Department of Housing and Urban
Development-which together requested more than 80 percent of the J-1 visa
waivers for physicians in 1995-decided to stop doing so.

1In this statement, we use the term "underserved areas" to refer to (1)
areas, population groups within areas, and facilities with shortages of
health care professionals or (2) areas or population groups with shortages
of health care services. The Department of Health and Human Services has
established specific criteria for identifying these areas, which are
described in more detail later in this statement.

2Throughout this statement, we refer to a waiver of the 2-year foreign
residence requirement as a "J-1 visa waiver" or "waiver."

38 U.S.C. S:S: 1182(e), 1184(l)(1)(B). States may request waivers for
foreign physicians who enter the United States before June 1, 2006, under
a J-1 visa for graduate medical education or who acquired such status
after admission. 8 U.S.C. S: 1182 note.

You and others have expressed an interest in determining how J-1 visa
waivers are being used to place physicians in underserved areas. We were
also asked to report on one option that has been raised as a possible
means to accommodate those states that have expressed an interest in
having more than 30 waivers granted at their request each year-the
possibility of redistributing some states' unused waiver allotments. My
remarks today are based on preliminary findings from our ongoing work and
will focus on (1) the number of waivers requested by states in relation to
the number requested by federal agencies; (2) practice specialties and
settings of physicians whose waivers were requested by states; (3) states'
activities to monitor compliance with waiver agreements; and (4) states'
views on both the adequacy of the annual limit of 30 J-1 visa waivers per
state and on having unused waiver allotments redistributed, which would
require legislation.

To address these issues, we administered a Web-based survey to the
entities eligible to request J-1 visa waivers for physicians under the
authority granted to the states-the 50 states, the District of Columbia,
Puerto Rico, Guam, and the U.S. Virgin Islands (hereafter referred to as
"states").6 We sent the survey to the official in each state authorized to
sign waiver requests or to his or her designee. The survey asked for
information on states' J-1 visa waiver requests7 for fiscal years 2003
through 2005 and on their views on the adequacy of the 30-waiver limit and
having their unused waiver allotments redistributed.8 We received a 100
percent response rate. We reviewed the surveys for internal consistency
and followed up with respondents to resolve discrepancies and clarify
responses; however, we did not verify the accuracy of the responses. We
also reviewed relevant laws, regulations, and documents, and interviewed
officials involved in reviewing and granting waivers at the Departments of
State and Homeland Security. We also interviewed officials at HHS and the
Educational Commission for Foreign Medical Graduates-the private,
nonprofit organization that sponsors foreign physicians as exchange
visitors for graduate medical education. We shared facts included in this
statement with officials at the Department of State, the Department of
Homeland Security, and HHS and made changes as appropriate. We conducted
our work from August 2005 through May 2006 in accordance with generally
accepted government auditing standards.

4NHSC places physicians and other health care professionals who are U.S.
citizens or U.S. nationals in underserved areas primarily through its
scholarship and educational loan repayment programs. Participating
students and health professionals are required to practice in underserved
areas for at least 2 years.

5See GAO, Foreign Physicians: Exchange Visitor Program Becoming Major
Route to Practicing in U.S. Underserved Areas, GAO/HEHS-97-26 (Washington,
D.C.: Dec. 30, 1996), and "Related GAO Products" at the end of this
statement.

68 U.S.C. S:1101(a)(36). We also sent a mail survey to the three federal
agencies that requested waivers for physicians to practice in underserved
areas in fiscal years 2003 through 2005. These included the Appalachian
Regional Commission, the Delta Regional Authority, and the Department of
Health and Human Services.

In summary, we found that the use of J-1 visa waivers remains a major
means of placing physicians in underserved areas of the United States,
with more than 1,000 waivers requested in each of the past 3 years for
physicians to practice in nearly every state. In fiscal year 2005, states
made more than 90 percent of these waiver requests. About 44 percent of
the states' waiver requests were for physicians to practice exclusively
primary care,9 while about 41 percent were for physicians to practice
exclusively nonprimary care specialties, such as anesthesiology or
cardiology. Regarding practice settings, more than three-fourths of the
states' waiver requests were for physicians to work in hospitals or
private practices. While states do not have explicit responsibility for
monitoring physicians' compliance with their waiver agreements, most
states reported that they had conducted some monitoring activities, such
as requiring periodic reports on patients treated and conducting site
visits to the practice locations. Six states-which together accounted for
about 13 percent of all state waiver requests in fiscal year 2005-reported
that their states had not conducted any monitoring activities that year.
Finally, regarding the states' authority to request waivers, about 80
percent of the states-including many of the states that requested the
annual limit or close to it-reported the 30-waiver limit was adequate for
their needs. About 13 percent, however, reported that this limit was less
than adequate. Of the 44 states that did not always request the limit, 25
reported that they would be willing to have their unused waiver allotments
redistributed, at least under certain circumstances, if authorized by law.
In contrast, another 14 states reported that they would not be willing to
have their unused waiver allotments redistributed. These states cited
concerns such as the possibility that physicians seeking waivers would
wait until a redistribution period opened and apply to practice in
preferred locations in other states.

7While comprehensive data on the number of J-1 visa waivers granted at the
request of states do not exist, the federal agencies responsible for
reviewing and granting state waiver requests indicated that, after review
for compliance with statutory requirements and security issues, nearly all
are recommended and approved.

8We did not ask states for their views on other options to accommodate
states that would like more than 30 waivers granted at their request each
year.

9For the purposes of this report, we define primary care to include family
practice, internal medicine, obstetrics/gynecology, and pediatrics.

                                   Background

Many foreign physicians who enter U.S. graduate medical education programs
do so as participants in the Department of State's Exchange Visitor
Program-an educational and cultural exchange program aimed at increasing
mutual understanding between the peoples of the United States and other
countries. Participants in the Exchange Visitor Program enter the United
States with J-1 visas.10 More than 6,100 foreign physicians with J-1 visas
took part in U.S. graduate medical education programs during academic year
2004-05. This number was about 40 percent lower than a decade earlier,
when about 10,700 foreign physicians with J-1 visas were in U.S. graduate
medical education programs.11

10In addition to foreign physicians seeking to pursue graduate medical
education, other categories of exchange visitors include professors and
research scholars, short-term scholars, trainees, college and university
students, teachers, secondary school students, specialists, international
visitors, government visitors, camp counselors, au pairs, and summer work
travel. See generally 22 C.F.R. pt. 62. Exchange visitors in these other
categories are subject to the 2-year foreign residence requirement under
certain circumstances. See 8 U.S.C. S: 1182(e)(i), (ii). For more
information on the Exchange Visitor Program, see GAO, State Department:
Stronger Action Needed to Improve Oversight and Assess Risks of the Summer
Work Travel and Trainee Categories of the Exchange Visitor Program,
GAO-06-106 (Washington, D.C.: Oct. 14, 2005).

Physicians participating in graduate medical education on J-1 visas are
required to return to their home country or country of last legal
residence for at least 2 years before they may apply for an immigrant
visa, permanent residence, or certain nonimmigrant work visas.12 They may,
however, obtain a waiver of this requirement from the Department of
Homeland Security at the request of a state or federal agency, if the
physician has agreed to practice in, or work at a facility that treats
residents of, an underserved area for at least 3 years.13

States were first authorized to request J-1 visa waivers on behalf of
foreign physicians in October 1994.14 Initially, states were authorized to
request waivers for up to 20 physicians each fiscal year; in 2002, the
annual limit was increased to 30 waivers per state.15 Physicians who
receive waivers may work in various practice settings, including federally
funded health centers and private hospitals, and they may practice both
primary care and nonprimary care specialties.16 States and federal
agencies may impose additional limitations on their programs beyond
federal statutory requirements, such as limiting the number of requests
they will make for physicians to practice nonprimary care specialties.

11The reasons for this decline are not completely understood. Foreign
physicians also enter the United States for graduate medical education
using other visa types, such as H-1B visas-temporary work visas for
foreign nationals employed in certain specialty occupations. These other
visa types may require the physician to meet additional statutory or
regulatory requirements, such as evidence that the physician has a license
to practice medicine in a particular state. Reliable data are not
available on the extent to which these other visa types are used.

128 U.S.C. S: 1182(e). Such foreign medical graduates with J-1 visas are
also prohibited from changing to any other type of nonimmigrant status. 8
U.S.C. S: 1258(2).

138 U.S.C. S:S: 1182(e), 1184 (l)(1)(D). Physicians may also obtain a
waiver at the request of the Department of Veterans Affairs (VA) if the
physician has agreed to practice at a VA facility for at least 3 years. To
obtain a waiver to practice in an underserved area or at a VA facility,
such employment must also be determined by the Department of Homeland
Security to be in the public interest. Physicians with J-1 visas may also
obtain a waiver of the 2-year foreign residence requirement if the
Department of Homeland Security determines that their departure from the
United States would create an exceptional hardship for the physician's
U.S. citizen or permanent resident spouse or child or if the return to the
physician's home country or country of last residence would subject the
physician to persecution because of race, religion, or political opinions.

14Pub. L. No. 103-416, S: 220, 108 Stat. 4305, 4319. Federal agencies were
first authorized to request J-1 visa waivers for physicians in graduate
medical education in 1961. Pub. L. No. 87-256, S: 109(c), 75 Stat. 527,
534.

15Pub. L. No. 107-273, S: 11018(a), 116 Stat. 1758, 1825.

Obtaining a J-1 visa waiver through a state request involves multiple
steps. A physician must first secure a bona fide offer of employment from
a health care facility that is located in, or that treats residents of, an
underserved area. The physician, the prospective employer, or both then
submit an application to a state to request the waiver. The state submits
a request for the waiver to the Department of State. If the Department of
State recommends the waiver, it forwards its recommendation to the
Department of Homeland Security's U.S. Citizenship and Immigration
Services (USCIS). USCIS is responsible for making the final determination
and notifying the physician when a waiver is granted. According to
officials involved in recommending and approving waivers at the Department
of State and USCIS, after review for compliance with statutory
requirements and security issues, nearly all states' waiver requests are
recommended and approved. Once physicians are granted waivers, they must
work at the site specified in their waiver applications for a minimum of 3
years.17 During this period, although states do not have explicit
responsibility for monitoring physicians' compliance with the terms and
conditions of their waivers, states may conduct monitoring activities at
their own initiative.

For purposes of J-1 visa waivers, HHS has specified two types of
underserved areas in which waiver physicians may practice: health
professional shortage areas (HPSAs) and medically underserved areas and
populations (MUA/Ps).18 In general, HPSAs are areas, population groups
within areas, or facilities that HHS has designated as having a shortage
of primary care health professionals and are identified on the basis of,
among other factors, the ratio of population to primary care physicians.19
MUA/Ps are areas or populations that HHS has designated as having
shortages of health care services and are identified using several factors
in addition to the availability of primary care providers.20 In 2004,
Congress gave states the flexibility to use up to 5 of their 30 waiver
allotments each year-which we call "flexible waivers"-for physicians to
work in facilities that serve patients who reside in a HPSA or MUA/P,
regardless of the facilities' location.21

16States and federal agencies requesting waivers for nonprimary care
physicians are required to demonstrate a shortage of health care
professionals able to provide services in that medical specialty for the
patients who would be served by that physician, based on their own
criteria. 8 U.S.C. S: 1184(l)(1)(D)(iii).

17Physicians may obtain approval from USCIS to transfer to another
facility or location when extenuating circumstances exist, such as when
the physician's assigned facility closes.

1860 Fed. Reg. 48515-6 (Sept. 19, 1995).

No one federal agency is responsible for managing or tracking states' and
federal agencies' use of J-1 visa waivers to place physicians in
underserved areas. Further, no comprehensive data are available on the
total number of waivers granted for physicians to practice in underserved
areas. HHS's Health Resources and Services Administration is the primary
federal agency responsible for improving access to health care services,
both in terms of designating underserved areas and in administering
programs-such as the NHSC programs-to place physicians and other providers
in them. However, HHS's oversight of waiver physicians practicing in
underserved areas has generally been limited to those physicians for whom
HHS has requested J-1 visa waivers.

 Waivers Remain a Major Means for Providing Physicians, and States Request Most
                                    Waivers

J-1 visa waivers continue to be a major means of supplying physicians to
underserved areas in the United States, with states and federal agencies
reporting that they requested more than 1,000 waivers in each of fiscal
years 2003 through 2005. We estimated that, at the end of fiscal year
2005, the number of physicians practicing in underserved areas through the
use of J-1 visa waivers was roughly one and a half times the number
practicing there through NHSC programs.22

19HHS's Health Resources and Services Administration (HRSA) designates
geographic areas, specific population groups within an area, or specific
facilities as HPSAs. Separate designations exist for primary care and for
other health care fields, such as mental health. For primary care HPSAs,
designation is based in part on the basis of the ratio of population to
the number of primary care physicians but may also include other factors
such as health care resources available in neighboring areas. See
http://bhpr.hrsa.gov/shortage /hpsacrit.htm, downloaded May 15, 2006.

20HRSA designates areas and populations as MUA/Ps. See
http://bhpr.hrsa.gov/shortage /muaguide.htm, downloaded May 15, 2006.

21Pub. L. No. 108-441, S: 1(d), 118 Stat. 2630.

In contrast to our findings a decade ago, states are now the primary
source of waiver requests for physicians to practice in underserved areas.
In fiscal year 2005, more than 90 percent of the waiver requests for
physicians were initiated by the states, compared with fewer than 10
percent in 1995.23 (See fig. 1.) Every state except Puerto Rico and the
U.S. Virgin Islands reported requesting waivers for physicians in fiscal
year 2005, for a total of 956 waiver requests. In 1995-the first full year
that states had authority to request waivers-nearly half of the states
made a total of 89 waiver requests.

22Data are not available on the number of waiver physicians practicing in
underserved areas at any given time. We estimated that number by totaling
the number of waiver requests in each of fiscal years 2003 through
2005-which would represent the physicians expected to be fulfilling their
3-year practice period or who had waivers in process to do so. We compared
that number with the number of NHSC physicians practicing in underserved
areas as of September 30, 2005.

23In 1995, up to 20 waivers per year could be granted in response to each
state's requests, so the maximum number of waivers that could be granted
that year in response to the 54 states' requests was 1,080. Since 2002,
the maximum number has been 50 percent higher, so the maximum number of
waivers that can be granted annually in response to the 54 states'
requests has been 1,620.

Figure 1: States' and Federal Agencies' Requests for J-1 Visa Waivers for
Physicians

Note: Data apply to calendar year 1995 and fiscal years 2003 through 2005.
In 1995, up to 20 waivers per year could be granted in response to each
state's requests. Since 2002, the annual limit has been 30 waivers per
state.

During the past decade, the two federal agencies that requested the most
waivers for physicians to practice in underserved areas in 1995-the
Department of Agriculture and the Department of Housing and Urban
Development-have discontinued their programs.24 These federal agencies
together requested more than 1,100 waivers for physicians to practice in
47 states in 1995, providing a significant source of waiver physicians for
some states. For example, these federal agencies requested a total of 149
waivers for physicians to practice in Texas, 134 for New York, and 105 for
Illinois in 1995. In fiscal year 2005, the three federal agencies that
requested waivers for physicians to practice in underserved areas-the
Appalachian Regional Commission, the Delta Regional Authority, and
HHS-requested a total of 56 waivers for physicians to practice in 15
states.25

24The Department of Housing and Urban Development stopped requesting
waivers for physicians in 1996; the Department of Agriculture stopped its
program in 2002.

With diminished federal participation, states now obtain waiver physicians
primarily through the 30 waivers they are allotted each year. The number
of waivers states actually requested, however, varied considerably among
the states in fiscal years 2003 through 2005. For example, in fiscal year
2005, about one-quarter of the states requested the maximum of 30 waivers,
while slightly more than a quarter requested 10 or fewer (see fig. 2).
Collectively, the 54 states requested 956 waivers, or roughly 60 percent
of the maximum of 1,620 waivers that could have been granted at their
request.

25The number of waivers requested by these agencies for physicians to
practice in each of the 15 states ranged from 1 request for each of 6
states to 14 requests for Mississippi.

Figure 2: States' Requests for J-1 Visa Waivers for Physicians to Practice
in Underserved Areas, Fiscal Year 2005

Note: Guam requested two waivers in fiscal year 2005; Puerto Rico and the
U.S. Virgin Islands requested no waivers that year.

    States Requested Waivers for Physicians to Work in a Variety of Practice
                            Specialties and Settings

Of the waivers states requested in fiscal year 2005, about 44 percent were
for physicians to practice exclusively primary care, while about 41
percent were for physicians to practice exclusively in nonprimary care
specialties, such as anesthesiology or cardiology. An additional 7 percent
were for physicians to practice psychiatry.26 A small proportion of
requests (5 percent) were for physicians to practice both primary and
nonprimary care-for example, for individual physicians who practice both
internal medicine and cardiology (see fig. 3).

Figure 3: Specialties Practiced by Physicians for Whom States Requested
J-1 Visa Waivers, Fiscal Year 2005

Note: Percentages are based on 956 waivers requested by 52 states in
fiscal year 2005. Puerto Rico and the U.S. Virgin Islands did not request
waivers that year. Psychiatry is reported as a separate medical specialty
because some states' J-1 visa waiver programs have requirements for
psychiatrists that differ from those for other physicians.

26Psychiatry is reported as a separate medical specialty because some
states' J-1 visa waiver programs have requirements for psychiatrists that
differ from those for other physicians. For example, a state might require
psychiatrists seeking J-1 visa waivers to practice in areas that HHS has
designated as mental health HPSAs.

More than 90 percent of the states that requested waivers in fiscal year
2005 reported that, under their policies in place that year, nonprimary
care physicians were eligible to apply for waiver requests. Some of these
states limited these requests. For example, some states restricted the
number of hours a physician could practice in a nonprimary care specialty.
Further, two states reported that they accepted applications from, and
requested waivers for, primary care physicians only.

Regarding practice settings, more than three-fourths of the waivers
requested by states in fiscal year 2005 were for physicians to practice in
hospitals and private practices, including group practices. In addition,
16 percent were for physicians to practice in federally qualified health
centers-facilities that provide primary care services in underserved
areas-or rural health clinics-facilities that provide outpatient primary
care services in rural areas (see fig. 4). More than 80 percent of the
states requesting waivers in fiscal year 2005 reported requiring
facilities where the physicians worked-regardless of practice setting-to
accept some patients who were uninsured or covered by Medicaid.27

27Authorized under title XIX of the Social Security Act, Medicaid is the
joint federal-state program that finances health care for certain
low-income individuals.

Figure 4: Practice Settings of Physicians for Whom States Requested J-1
Visa Waivers, Fiscal Year 2005

Note: Percentages are based on 956 waivers requested by 52 states in
fiscal year 2005. Puerto Rico and the U.S. Virgin Islands did not request
waivers that year.

           Most States Reported Conducting Some Monitoring Activities

Although states do not have explicit responsibility for monitoring
physicians' compliance with the terms and conditions of their waivers, in
fiscal year 2005, more than 85 percent of the states reported conducting
at least one monitoring activity. The most common activity-reported by 40
states-was to require periodic reports by the physician or the employer
(see table 1). Some states required these reports to specify the number of
hours the physician worked or the types of patients-for example, whether
they were uninsured-whom the physician treated.

Table 1: Monitoring Activities States Reported Conducting in Fiscal Year
2005

                                        Number of states Percentage of states 
Activity                          conducting activity  conducting activity 
Required periodic reports by the                                           
physician or employer                              40                   75
Monitored through regular                                                  
communication with employers                       21                   40
Monitored through regular                                                  
communication with physicians                      19                   36
Conducted periodic site visits                     18                   34 
Other                                               9                   17 

Source: GAO survey of states, 2005.

Note: Reported activities are for the 53 states that requested any waivers
in fiscal years 2003 through 2005. Puerto Rico did not request waivers
during that period.

Not all states that requested waivers conducted monitoring activities. Six
states, which collectively accounted for about 13 percent of all state
waiver requests in fiscal year 2005, reported that they conducted no
monitoring activities in that year.

 Most States Reported That the Annual Limit Was Adequate but Reported Differing
                    Views on Having Allotments Redistributed

The majority of the states reported that the annual limit of 30 waivers
per state was at least adequate to meet their needs for J-1 visa waiver
physicians. When asked about their needs for additional waiver physicians,
however, 11 states reported needing more. Furthermore, of the 44 states
that did not request their 30-waiver limit in each of fiscal years 2003
through 2005, more than half were willing, at least under certain
circumstances, to have their unused waiver allotments redistributed to
other states in a given year. Such redistribution would require
legislation. Fourteen states reported that they would not be willing to
have their states' unused waiver allotments redistributed.

Most States Reported That the Annual Waiver Limit Was Adequate, While Some
Reported the Need for More

About 80 percent of the states reported that the annual limit of 30
waivers per state was adequate or more than adequate to meet their needs
for J-1 visa waiver physicians. However, 13 percent of the states reported
that the 30-waiver limit was less than adequate (see fig. 5).

Figure 5: States' Views on the Adequacy of the Annual Limit of 30 J-1 Visa
Waivers for Physicians, 2005

Note: Percentages are based on all 54 states eligible to request waivers.

Among the 16 states that requested 29 or 30 waivers in fiscal year 2005,
10 states reported that the annual limit was at least adequate for their
needs. The other 6 states that requested all or almost all of their
allotted waivers that year reported that the 30-waiver limit was less than
adequate.

As mentioned earlier, states can use up to 5 of their waiver allotments
for physicians to work in facilities located outside of HPSAs and MUA/Ps,
as long these facilities serve patients who live in these underserved
areas. While we inquired about states' views on the adequacy of the annual
limit on these flexible waivers, fewer than half of the states reported
requesting flexible waivers in fiscal year 2005-the first year they were
authorized to do so. When asked about the annual limit of 5 flexible
waivers, half of the states (27 states) reported that this limit was at
least adequate, but nearly one-third (17 states) did not respond or
reported that they were unsure of their need for flexible waivers. The
remaining 10 states reported that the annual limit of 5 flexible waivers
was less than adequate (see fig. 6). Of these 10 states, 8 had also
reported that the annual limit of 30 waivers per state was at least
adequate for their needs, suggesting that some states may be more
interested in increasing the flexibility with which waivers may be used
than in increasing the overall number of waivers each year.

Figure 6: States' Views on the Adequacy of the Annual Limit of Five
Flexible J-1 Visa Waivers for Physicians to Practice Outside of HPSAs or
MUA/Ps, 2005

Note: Percentages are based on all 54 states eligible to request waivers.

In addition to commenting on the adequacy of the annual waiver limits,
states estimated their need for additional physicians under their J-1 visa
waiver programs. Specifically, 11 states (20 percent) estimated needing
between 5 and 50 more waiver physicians each. Collectively, these 11
states reported needing 200 more waiver physicians (see table 2).

Table 2: Number of Additional J-1 Visa Waiver Physicians States Estimated
Needing per Year, 2005

                   Estimated number of waiver physicians needed beyond annual 
State                                                          limit of 30 
Kentucky                                                                 5 
Arkansas                                                                10 
Iowa                                                                    10 
Louisiana                                                               10 
Massachusetts                                                           10 
West Virginia                                                           10 
California                                                              20 
Michigan                                                                20 
Arizona                                                                 25 
New York                                                                30 
Texas                                                                   50 
Total                                                                  200 

Source: GAO survey of states, 2005.

Note: Data are from the 11 states that reported needing additional J-1
visa waiver physicians beyond the current annual limit of 30.

Although 10 states reported requesting the annual limit of 30 waivers in
each of fiscal years 2003 through 2005, the large majority (44 states) did
not. When asked to provide reasons why they did not use all 30, many of
these states reported that they received fewer than 30 applications that
met their requirements for physicians seeking waivers through their state
J-1 visa waiver programs. Some states, however, offered further
explanations, which touched upon difficulties attracting physicians to the
state, low demand for waiver physicians among health care facilities or
communities, and mismatches between the medical specialties communities
needed and those held by the physicians seeking waivers. For example:

           o  Difficulties attracting waiver physicians: One state commented
           that the increase in the annual limit on waivers from 20 to 30 in
           2002 opened more positions in other states, contributing to a
           decrease in interest among physicians seeking waivers to locate in
           that state. Two states suggested that because they had no graduate
           medical education programs or a low number of them, fewer foreign
           physicians were familiar with their states, affecting their
           ability to attract physicians seeking J-1 visa waivers.
           o  Low demand for waiver physicians: Many states noted low demand
           for foreign physicians among health care facilities or communities
           in the states. Two of these states commented that they had
           relatively few problems recruiting U.S. physicians. Another state
           commented that health care facilities-particularly small
           facilities and those located in rural areas-may be reluctant to
           enter into the required 3-year contracts with waiver physicians
           because of their own budget uncertainties.
           o  Lack of physicians with needed specialties: One state commented
           that most communities in the state need physicians trained in
           family medicine and that few physicians with J-1 visas have that
           training. Similarly, another state noted a lack of demand among
           the health care facilities in the state for the types of medical
           specialties held by physicians seeking waivers.

           In response to a question about whether they had observed any
           significant changes in the number of physicians seeking J-1 visa
           waivers, 15 states reported seeing less interest from physicians,
           or fewer applications, since 2001. Some states suggested that the
           decline might be due to an overall reduction in the number of
           physicians with J-1 visas who were in graduate medical education
           programs. Three states mentioned the possibility that more
           physicians may be opting to participate in graduate medical
           education on an H-1B visa, which does not have the same foreign
           residence requirement as a J-1 visa.

           Of the 44 states that did not use all of their waiver allotments
           in each of fiscal years 2003 through 2005, slightly over half (25
           states) reported that they would be willing, at least under
           certain circumstances, to have their unused waiver allotments
           redistributed to other states. In contrast, about one-third of the
           states with unused waiver allotments (14 states) reported that
           they would not be willing to have their unused waiver allotments
           redistributed. (See table 3 and, for further details on states'
           responses, see app. I.)

           Table 3: Views Reported by States with Unused Waiver Allotments on
           Their Willingness to Have Them Redistributed, 2005.

           Source: GAO survey of states, 2005.

           Note: Data are from the 44 states that did not request the annual
           limit of 30 waivers in each of fiscal years 2003 through 2005.

           The 14 states that reported they would be willing under certain
           circumstances to have their unused waiver allotments redistributed
           listed a variety of conditions under which they would be willing
           to do so, if authorized by law. These conditions centered around
           the timing for redistribution, the approach for redistribution,
           and the possibility for compensation.

           o  Timing of redistribution: Seven states reported that their
           willingness to have their unused waiver allotments redistributed
           depended in part on when the redistribution would occur in a given
           year. Their comments suggested concerns about states being asked
           to give up unused waiver allotments before having fully determined
           their own needs for them. For example, three states reported that
           they would be willing to release at least a portion of their
           unused waiver allotments midway through the fiscal year. One state
           reported that it would be willing to have its unused waiver
           allotments redistributed once the state reached an optimal
           physician-to-population ratio. Finally, two states specified that
           states benefiting from any redistribution should be required to
           use the redistributed waivers within the same fiscal year.
           o  Approach for redistribution: Three states reported that their
           willingness to have their unused waiver allotments redistributed
           depended on how the redistribution would be accomplished. Two
           states reported a willingness to do so if the allotments were
           redistributed on a regional basis-such as among midwestern or
           southwestern states. Another state reported that it would be
           willing to have its unused waiver allotments redistributed to
           states with high long-term vacancy rates for physicians. This
           state was also willing to have its unused waiver allotments
           redistributed in emergency relief situations, such as Hurricane
           Katrina's aftermath, to help attract physicians to devastated
           areas.
           o  Possibility for compensation: Two states stated that they would
           be willing to have their unused waiver allotments redistributed if
           they were somehow compensated. One state remarked that it would
           like more flexible waiver allotments, equal to the number of
           unused waiver allotments that were redistributed. The other state
           did not specify the form of compensation.
           o  Other issues: One state commented that it would be willing to
           have its unused waiver allotments redistributed as long as
           redistribution did not affect the number of waivers it could
           request in future years. Another state responded that any
           provision to have unused waiver allotments redistributed would
           need to be pilot-tested for 2 years so that its effect could be
           evaluated.

           The 14 states that reported that they would not be willing to have
           their unused waiver allotments redistributed to other states cited
           varied concerns. Several states commented that, because of
           physicians' location preferences and differences in states' J-1
           visa waiver program requirements, a redistribution of unused
           waiver allotments could possibly reduce the number of physicians
           seeking waivers to practice in certain states.

           o  Physician location preferences: Three states commented that
           physicians seeking J-1 visa waivers might wait until a
           redistribution period opened so that they could apply for waivers
           to practice in preferred states. As one state put it, if
           additional waivers were provided to certain states, a physician
           might turn down the "number 15 slot" in one state to accept the
           "number 40 slot" in another. This concern was also raised by four
           states that reported they were willing to have their unused waiver
           allotments redistributed under certain circumstances; two of these
           states specifically mentioned the possible negative impact that
           redistribution could have on rural areas.
           o  Differences in state program requirements: One state commented
           that until state requirements for waivers were made consistent
           among states, having unused waiver allotments redistributed would
           benefit states with more lenient requirements or force states with
           more stringent requirements to change their policies. While this
           state did not specify what it considered to be stringent or
           lenient requirements, substantial differences in state programs do
           exist. For example, some states restrict their waiver requests
           solely to primary care physicians, while others place no limits on
           the number of allotted waivers they request for nonprimary care
           physicians. In another example, four states require 4- or 5-year
           contracts for all physicians or for physicians in certain
           specialties. One state commented that if it lost an unused waiver
           allotment to a state with more lenient requirements, it would have
           given away to another state a potential resource that it had
           denied its own communities.

           Mr. Chairman, this concludes my prepared statement. I will be
           happy to answer any questions that you or Members of the
           Subcommittee may have.

           For information regarding this testimony, please contact Leslie G.
           Aronovitz at (312) 220-7600 or [email protected]. Contact points
           for our Offices of Congressional Relations and Public Affairs may
           be found on the last page of this statement. Kim Yamane, Assistant
           Director; Ellen W. Chu; Jill Hodges; Julian Klazkin; Linda Y.A.
           McIver; and Perry G. Parsons made key contributions to this
           statement.

           Source: GAO survey of states, 2005.

           aStates that requested 30 waivers in each of fiscal years 2003
           through 2005 were not asked about their willingness to have unused
           waiver allotments redistributed to other states.

           State Department: Stronger Action Needed to Improve Oversight and
           Assess Risks of the Summer Work Travel and Trainee Categories of
           the Exchange Visitor Program. GAO-06-106 . Washington, D.C.:
           October 14, 2005.

           Health Workforce: Ensuring Adequate Supply and Distribution
           Remains Challenging. GAO-01-1042T . Washington, D.C.: August 1,
           2001.

           Health Care Access: Programs for Underserved Populations Could Be
           Improved. GAO/T-HEHS-00-81 . Washington, D.C.: March 23, 2000.

           Foreign Physicians: Exchange Visitor Program Becoming Major Route
           to Practicing in U.S. Underserved Areas. GAO/HEHS-97-26 .
           Washington, D.C.: December 30, 1996.

           Health Care Shortage Areas: Designations Not a Useful Tool for
           Directing Resources to the Underserved. GAO/HEHS-95-200 .
           Washington, D.C.: September 8, 1995.

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States' Views Differed on Having Unused Waiver Allotments Redistributed

                                                       Total number of unused 
Willingness to have their unused waiver   Number of   waiver allotments in 
allotments redistributed                     states       fiscal year 2005 
Willing                                          11                    161 
Willing under certain circumstances              14                    237 
Not willing                                      14                    200 
No opinion                                        2                     23 
Don't know/no answer                              3                     43 
Total                                            44                    664 

                          Contact and Acknowledgments

Appendix I: State Responses to Selected Survey Questions

                Number of    Views on                                   Willingness   
              waivers states adequacy                                   to have       
                 reported    of                                         unused waiver 
              requesting in  annual                                     allotments    
               each fiscal   limit of                                   redistributed 
                   year      30       Views on adequacy of annual limit to other      
State         2003 2004 2005 waivers  of 5 flexible waivers             states        
Alabama            18   19          24 Adequate Adequate Yes           
Alaska              5    0           1 Adequate Adequate Yes, under    
                                                         certain       
                                                         circumstances 
Arizona            30   30          30 Adequate Adequate a             
Arkansas           30   30          29 Less     Don't    Yes           
                                       than     know                   
                                       adequate                        
California         30   30          30 Much     No       a             
                                       less     answer                 
                                       than                            
                                       adequate                        
Colorado           11    3           5 Much     Much     Don't know    
                                       more     more                   
                                       than     than                   
                                       adequate adequate               
Connecticut        27   30          26 More     No       Yes           
                                       than     answer                 
                                       adequate                        
Delaware           21   21          16 Adequate Adequate Yes, under    
                                                         certain       
                                                         circumstances 
District of         3    9           3 More     Less     Yes           
Columbia                               than     than                   
                                       adequate adequate               
Florida            30   30          30 Adequate No       a             
                                                answer                 
Georgia            30   30          28 Adequate More     Yes           
                                                than                   
                                                adequate               
Guam                0    1           2 Much     Much     Yes           
                                       more     more                   
                                       than     than                   
                                       adequate adequate               
Hawaii              2    1           4 More     More     Yes, under    
                                       than     than     certain       
                                       adequate adequate circumstances 
Idaho               0    0           1 More     More     No            
                                       than     than                   
                                       adequate adequate               
Illinois           28   30          30 Adequate Too      No            
                                                early to               
                                                tell                   
Indiana            27   30          30 Adequate Adequate No            
Iowa               30   30          28 Less     Too      Yes, under    
                                       than     early to certain       
                                       adequate tell     circumstances 
Kansas             14   26          17 Adequate Adequate Yes, under    
                                                         certain       
                                                         circumstances 
Kentucky           30   30          30 Adequate Less     a             
                                                than                   
                                                adequate               
Louisiana          15   13          10 Too      Adequate No            
                                       early to                        
                                       tell                            
Maine              29   18          25 More     Adequate No            
                                       than                            
                                       adequate                        
Maryland           15   22          29 Adequate Adequate Yes, under    
                                                         certain       
                                                         circumstances 
Massachusetts      28   30          30 Less     No       No answer     
                                       than     answer                 
                                       adequate                        
Michigan           30   30          30 Less     Less     a             
                                       than     than                   
                                       adequate adequate               
Minnesota          30   15          21 Adequate Too      Yes           
                                                early to               
                                                tell                   
Mississippi        19   17          18 Adequate Less     No            
                                                than                   
                                                adequate               
Missouri           30   30          30 More     Much     a             
                                       than     more                   
                                       adequate than                   
                                                adequate               
Montana             2    1           2 More     Adequate Yes, under    
                                       than              certain       
                                       adequate          circumstances 
Nebraska           15    7          13 Adequate Adequate Yes, under    
                                                         certain       
                                                         circumstances 
Nevada             26   18          13 Adequate Adequate No            
New Hampshire       6   11          15 Much     Less     Yes, under    
                                       more     than     certain       
                                       than     adequate circumstances 
                                       adequate                        
New Jersey          2    1           2 Much     Adequate Yes, under    
                                       more              certain       
                                       than              circumstances 
                                       adequate                        
New Mexico         29   27          29 Adequate Adequate Yes           
New York           30   30          30 Less     Too      a             
                                       than     early to               
                                       adequate tell                   
North              10   11          16 More     More     No            
Carolina                               than     than                   
                                       adequate adequate               
North Dakota       11   13           6 More     Much     Yes, under    
                                       than     less     certain       
                                       adequate than     circumstances 
                                                adequate               
Ohio               30   30          30 Adequate Much     a             
                                                more                   
                                                than                   
                                                adequate               
Oklahoma            0   17          12 More     Less     No            
                                       than     than                   
                                       adequate adequate               
Oregon             20   19          22 Adequate Too      Yes, under    
                                                early to certain       
                                                tell     circumstances 
Pennsylvania       13   16          22 More     Too      No            
                                       than     early to               
                                       adequate tell                   
Puerto Rico         0    0           0 Much     Much     Yes           
                                       more     more                   
                                       than     than                   
                                       adequate adequate               
Rhode Island       30   30          30 Adequate Too      a             
                                                early to               
                                                tell                   
South              30   26          21 Adequate Adequate No            
Carolina                                                               
South Dakota       10    6           6 Much     Too      No            
                                       more     early to               
                                       than     tell                   
                                       adequate                        
Tennessee          21   27          12 Adequate Too      No            
                                                early to               
                                                tell                   
Texas              30   30          30 Much     Adequate a             
                                       less                            
                                       than                            
                                       adequate                        
Utah                4    6           5 Much     Don't    Yes           
                                       more     know                   
                                       than                            
                                       adequate                        
Vermont             0    1           2 Adequate Less     Yes           
                                                than                   
                                                adequate               
Virgin              1    0           0 Too      More     Yes, under    
Islands                                early to than     certain       
                                       tell     adequate circumstances 
Virginia           17   13          19 No       Much     No opinion    
                                       answer   less                   
                                                than                   
                                                adequate               
Washington         30   30          28 Adequate Too      Yes, under    
                                                early to certain       
                                                tell     circumstances 
West Virginia      22   14          18 Adequate Adequate No opinion    
Wisconsin          29   23          12 More     Too      Don't know    
                                       than     early to               
                                       adequate tell                   
Wyoming             3    3           4 Much     Much     No            
                                       more     less                   
                                       than     than                   
                                       adequate adequate               

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Highlights of GAO-06-773T , a testimony before the Subcommittee on
Immigration, Border Security, and Claims, Committee on the Judiciary,
House of Representatives

May 18, 2006

FOREIGN PHYSICIANS

Preliminary Findings on the Use of J-1 Visa Waivers to Practice in
Underserved Areas

Many U.S. communities face difficulties attracting physicians to meet
their health care needs. To address this problem, states and federal
agencies have turned to foreign physicians who have just completed their
graduate medical education in the United States under J-1 visas.
Ordinarily, these physicians are required to return home after completing
their education, but this requirement can be waived at the request of a
state or federal agency if the physician agrees to practice in, or work at
a facility that treats residents of, an underserved area. In 1996, GAO
reported that J-1 visa waivers had become a major means of providing
physicians for underserved areas, with over 1,300 requested in 1995. Since
2002, each state has been allotted 30 J-1 visa waivers per year, but some
states have expressed interest in more.

GAO was asked to report on its preliminary findings from ongoing work on
(1) the number of J-1 visa waivers requested by states and federal
agencies and (2) states' views on the 30-waiver limit and on their
willingness to have unused waiver allotments redistributed. Such
redistribution would require legislative action.

GAO surveyed the 50 states, the District of Columbia, 3 U.S. insular
areas-the 54 entities that are considered states for purposes of
requesting J-1 visa waivers-and federal agencies about waivers they
requested in fiscal years 2003-05.

The use of J-1 visa waivers remains a major means of placing physicians in
underserved areas of the United States. States and federal agencies
reported requesting more than 1,000 waivers in each of the past 3 years.
In contrast to a decade ago, states are now the primary source of waiver
requests for physicians to practice in underserved areas, accounting for
more than 90 percent of such waiver requests in fiscal year 2005. The
number of waivers individual states requested that year, however, varied
considerably. For example, about one-quarter of the states requested the
maximum of 30 waivers, while slightly more than a quarter requested 10 or
fewer.

Regarding the annual limit on waivers, about 80 percent of the
states-including many of those that requested the annual limit or close to
it-reported the 30-waiver limit to be adequate for their needs. About 13
percent reported that this limit was less than adequate. Of the 44 states
that did not always request the limit, 25 reported that they would be
willing to have their unused waiver allotments redistributed, at least
under certain circumstances. In contrast, another 14 states reported that
they would not be willing to have their unused waiver allotments
redistributed. These states cited concerns such as the possibility that
physicians seeking waivers would wait until a redistribution period opened
and apply to practice in preferred locations in other states.

States' Requests for J-1 Visa Waivers for Physicians to Practice in
Underserved Areas, Fiscal Year 2005

Note: Guam requested two J-1 visa waivers in fiscal year 2005; Puerto Rico
and the U.S. Virgin Islands requested no waivers that year.
*** End of document. ***