Foreign Physicians: Data on Use of J-1 Visa Waivers Needed to	 
Better Address Physician Shortages (30-NOV-06, GAO-07-52).	 
                                                                 
Many U.S. communities face difficulties attracting physicians. To
address this problem, states and federal agencies have turned to 
foreign physicians who have just completed graduate medical	 
education in the United States under J-1 visas. Ordinarily, these
physicians must return home after completing their programs, but 
this requirement can be waived at the request of a state or	 
federal agency if the physician agrees to practice in an	 
underserved area. In 1996, GAO reported that J-1 visa waivers had
become a major source of physicians for underserved areas but	 
were not well coordinated with Department of Health and Human	 
Services (HHS) programs for addressing physician shortages. GAO  
was asked to examine (1) the number of waivers requested by	 
states and federal agencies; (2) waiver physicians' practice	 
specialties, settings, and locations; and (3) the extent to which
waiver physicians are accounted for in HHS's efforts to address  
physician shortages. GAO surveyed states and federal agencies	 
about waivers they requested in fiscal years 2003-2005 and	 
reviewed HHS data.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-52						        
    ACCNO:   A63765						        
  TITLE:     Foreign Physicians: Data on Use of J-1 Visa Waivers      
Needed to Better Address Physician Shortages			 
     DATE:   11/30/2006 
  SUBJECT:   Data collection					 
	     Data integrity					 
	     Employment of foreign nationals			 
	     Foreign medical graduates				 
	     Health care personnel				 
	     Health care planning				 
	     Health care programs				 
	     J-1 Visa waiver					 
	     J-1 Visas						 
	     Labor shortages					 
	     Physicians 					 
	     Program evaluation 				 
	     HHS Health Professional Shortage Area		 
	     System						 
                                                                 
	     J-Visa Exchange Visitor Program			 

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GAO-07-52

   

     * [1]Results in Brief
     * [2]Background
     * [3]Waivers Remain a Major Means for Providing Physicians to Und
     * [4]Waivers Were Requested for Physicians to Work in a Variety o
     * [5]Most States and Federal Agencies Reported That They Conducte
     * [6]HHS Lacks Data to Account for Waiver Physicians in Its Effor
     * [7]Conclusions
     * [8]Recommendation for Executive Action
     * [9]Agency Comments and our Evaluation
     * [10]GAO Contact
     * [11]Acknowledgments
     * [12]GAO's Mission
     * [13]Obtaining Copies of GAO Reports and Testimony

          * [14]Order by Mail or Phone

     * [15]To Report Fraud, Waste, and Abuse in Federal Programs
     * [16]Congressional Relations
     * [17]Public Affairs

Report to Congressional Requesters

United States Government Accountability Office

GAO

November 2006

FOREIGN PHYSICIANS

Data on Use of J-1 Visa Waivers Needed to Better Address Physician
Shortages

GAO-07-52

Contents

Letter 1

Results in Brief 4
Background 6
Waivers Remain a Major Means for Providing Physicians to Underserved Areas
12
Waivers Were Requested for Physicians to Work in a Variety of Practice
Specialties, Settings, and Locations 15
Most States and Federal Agencies Reported That They Conducted Monitoring
Activities 20
HHS Lacks Data to Account for Waiver Physicians in Its Efforts to Address
Physician Shortages 25
Conclusions 27
Recommendation for Executive Action 27
Agency Comments and our Evaluation 27
Appendix I Physician Need and Number of Primary Care Waiver and National
Health Service Corps Physicians, by State 30
Appendix II States' and Federal Agencies' Requests for J-1 Visa Waivers 35
Appendix III Comments from the Department of Health and Human Services 43
Appendix IV Contact and Acknowledgments 45
Related GAO Products 46

Tables

Table 1: Physicians Needed and Number of Primary Care Waiver and NHSC
Physicians, by State, as of September 30, 2005 32
Table 2: J-1 Visa Waivers Requested by States and Federal Agencies for
Physicians to Practice in Underserved Areas, by State, Fiscal Years 2003
through 2005 35
Table 3: J-1 Visa Waivers Requested by Federal Agencies for Physicians to
Practice in Underserved Areas, by State, Fiscal Years 2003 through 2005 37
Table 4: J-1 Visa Waivers Requested by States and Federal Agencies for
Physicians to Practice in Underserved Areas, by Practice Specialty, Fiscal
Years 2003 through 2005 38
Table 5: J-1 Visa Waivers Requested by States and Federal Agencies for
Physicians to Practice in Underserved Areas, by Practice Setting, Fiscal
Years 2003 through 2005 39
Table 6: States' and Federal Agencies' Policies for Requesting J-1 Visa
Waivers, Fiscal Year 2005 40

Figures

Figure 1: Process to Apply for and Obtain a J-1 Visa Waiver for a
Physician to Work in an Underserved Area 10
Figure 2: J-1 Visa Waivers Requested by States and Federal Agencies,
Calendar Year 1995 and Fiscal Years 2003 through 2005 13
Figure 3: J-1 Visa Waivers Requested by States, Fiscal Year 2005 14
Figure 4: Practice Specialties of Physicians for Whom States and Federal
Agencies Requested J-1 Visa Waivers, Fiscal Year 2005 16
Figure 5: J-1 Visa Waivers Requested by States and Federal Agencies, by
Practice Specialty, Fiscal Year 2005 17
Figure 6: Practice Settings of Physicians for Whom States Requested J-1
Visa Waivers, Fiscal Year 2005 19
Figure 7: Proportion of J-1 Visa Waivers Requested by States and Federal
Agencies for Physicians to Practice in Rural and Nonrural Areas, Fiscal
Year 2005 20
Figure 8: Monitoring Activities That States and Federal Agencies
Requesting J-1 Visa Waivers Reported Conducting in Fiscal Year 2005 22
Figure 9: States' and Federal Agencies' Practices to Help Ensure
Physicians Meet Their Waiver Agreements 24

Abbreviations

ARC Appalachian Regional Commission DRA Delta Regional Authority ECFMG
Educational Commission for Foreign Medical Graduates FTE full-time
equivalent HHS Department of Health and Human Services HPSA health
professional shortage area MUA/P medically underserved area or population
NHSC National Health Service Corps USCIS U.S. Citizenship and Immigration
Services VA Department of Veterans Affairs

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separately.

United States Government Accountability Office

Washington, DC 20548

November 30, 2006

The Honorable Sheila Jackson Lee Ranking Minority Member Subcommittee on
Immigration, Border Security, and Claims Committee on the Judiciary House
of Representatives

The Honorable Kent Conrad United States Senate

Many communities throughout the country experience difficulties in
attracting physicians to meet their health care needs. To address the need
for physicians in underserved areas,^1 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. Once they
have completed their graduate medical education, these physicians are
required to return to their home country or country of last legal
residence for at least 2 years before they may apply to stay permanently
in the United States or for certain temporary work visas. This foreign
residence requirement can, however, be waived 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 J-1 visa
waivers are granted by the Department of Homeland Security at the
recommendation of the Department of State.^3

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 placing physicians in
underserved areas. We estimated that in 1995, the number of waiver
physicians practicing in underserved areas exceeded the number of
physicians practicing in such areas through 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 that nearly 40 percent
of them practiced in nonprofit community or migrant health centers.
Further, we noted that controls for ensuring that these physicians met the
terms of their waiver agreements were somewhat weak, and we found cases in
which physicians were not meeting their waiver agreements, such as not
practicing at the facilities or in the underserved areas for which the
physicians' waivers were granted. Finally, we reported that the use of
waivers was not effectively coordinated with HHS programs addressing
underservice, such as NHSC programs. As a result, some states had more
physicians than HHS identified as needed to alleviate shortages, while
other states were still experiencing shortages.^5

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

^28 U.S.C. SS 1182(e), 1184(l)(1)(D).

^3In this report, we refer to a waiver of the 2-year foreign residence
requirement for foreign medical graduates as a "J-1 visa waiver" or
"waiver."

You expressed an interest in how J-1 visa waivers are being used to place
physicians in underserved areas. In May 2006, we testified on preliminary
findings from our work, focusing primarily on states' requests for J-1
visa waivers.^6 This report provides information on both states' and
federal agencies' J-1 visa waiver requests and addresses (1) the number of
waivers requested by states and federal agencies in fiscal years 2003
through 2005; (2) the practice specialties, settings, and locations in
which waiver physicians work; (3) the activities states and federal
agencies undertake to help ensure that physicians are meeting their
agreements to work in underserved areas; and (4) the extent to which
waiver physicians are accounted for in HHS's efforts to address physician
shortages.

^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, [18]GAO/HEHS-97-26
(Washington, D.C.: Dec. 30, 1996), and "Related GAO Products" at the end
of this report.

^6See GAO, Foreign Physicians: Preliminary Findings on the Use of J-1 Visa
Waivers to Practice in Underserved Areas, [19]GAO-06-773T (Washington,
D.C.: May 18, 2006).

To address these issues, we administered a Web-based survey to the
entities eligible to request J-1 visa waivers under the authority granted
to the states: the 50 states, the District of Columbia, Guam, Puerto Rico,
and the U.S. Virgin Islands (hereafter referred to as "states").^7 We also
surveyed the three federal agencies that requested waivers for physicians
to practice in underserved areas in fiscal years 2003 through 2005--the
Appalachian Regional Commission (ARC),^8 the Delta Regional Authority
(DRA),^9 and HHS--using a structured data collection instrument. We sent
the surveys to the officials in each state or federal agency authorized to
sign waiver requests or to his or her designee. The surveys asked each
state and federal agency to provide information on the number of waivers
requested in each of fiscal years 2003 through 2005;^10 the practice
specialties, settings, and locations of physicians for whom waivers were
requested; the state's or federal agency's policies for requesting
waivers; activities undertaken to help ensure that waiver physicians are
meeting their agreements to work in underserved areas;^11 and incidents in
which physicians were not meeting their waiver agreements.^12 The response
rate to both surveys was 100 percent. We reviewed the survey responses for
internal consistency and for outliers, and we followed up with respondents
to resolve discrepancies and clarify responses; we did not, however,
verify the accuracy of the responses. Regarding federal agencies' J-1 visa
waiver programs, we interviewed officials from ARC, DRA, and HHS and
obtained from them data on their waiver requests by state. We reviewed
states' and federal agencies' policies and guidelines pertaining to their
J-1 visa waiver programs as of September 30, 2005; reviewed relevant laws,
regulations, and documents; and interviewed officials involved in
recommending and granting waivers at the Department of State and the
Department of Homeland Security.

^7The Immigration and Nationality Act defines "state" to include the
District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. 8
U.S.C. S1101(a)(36).

^8ARC is a federal-state economic development partnership between the
federal government and 13 states. The commission initiates economic and
community development programs and serves as an advocate for the people of
the Appalachian Region, including all of West Virginia and parts of 12
other states: Alabama, Georgia, Kentucky, Maryland, Mississippi, New York,
North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and
Virginia.

^9DRA is a federal-state partnership between the federal government and
eight states. The authority was created to remedy severe and chronic
economic distress by stimulating economic development and fostering
partnerships that will have a positive impact on the economy of the
region. The authority covers 240 counties and parishes in Alabama,
Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and
Tennessee.

^10Comprehensive data on the precise number of J-1 visa waivers granted at
the request of states and federal agencies for physicians to practice in
underserved areas are not available. The federal agencies responsible for
recommending and granting waiver requests (the Department of State and the
Department of Homeland Security) indicated, however, that after review for
compliance with statutory requirements and security issues, nearly all
states' and federal agencies' waiver requests are recommended and
approved.

^11For the purposes of this report, reference to waiver physicians'
meeting their agreements to work in underserved areas refers to complying
with the relevant statutory and regulatory requirements, along with the
terms and conditions of any agreements physicians enter into with their
employers or with the states or federal agencies that requested their
waivers. Terms and conditions may include practicing in a certain
specialty or serving patients who are uninsured or covered by Medicaid,
the joint federal-state program that finances health care for certain
low-income individuals.

To examine how the use of J-1 visa waivers is accounted for in HHS's
efforts to address physician shortages, we interviewed officials from
HHS's Health Resources and Services Administration and obtained from them
data on the number of NHSC physicians practicing in each state and the
number of physicians needed to remove shortage designations in each state
as of September 30, 2005. We estimated the number of waiver physicians
practicing primary care in each state as of September 2005, using states'
and federal agencies' responses to our survey. (See app. I for detailed
information on this analysis.) In addition, we interviewed officials at
the Educational Commission for Foreign Medical Graduates (ECFMG), the
organization that sponsors foreign physicians as exchange visitors for
graduate medical education. We conducted our work from August 2005 through
November 2006 in accordance with generally accepted government auditing
standards.

Results in Brief

The use of J-1 visa waivers remains a major means of providing physicians
to practice in underserved areas of the United States, with more than
1,000 waivers requested by states and federal agencies in each of fiscal
years 2003 through 2005. Similar to what we found in 1995, the estimated
number of waiver physicians practicing in underserved areas at the end of
fiscal year 2005 exceeded the number of physicians practicing there
through HHS's NHSC programs. In contrast to 1995, when we found that
federal agencies requested the vast majority of waivers, states have
become the primary source of waiver requests, accounting for 90 percent or
more of requests in each of fiscal years 2003 through 2005. In fiscal year
2005, every state except Puerto Rico and the U.S. Virgin Islands reported
requesting at least one J-1 visa waiver.

^12We also asked states about their views on the adequacy of the annual
limit on the number of waivers that may be granted in response to their
requests (states are limited to 30 waivers per state per year) and on
having their unused waiver allotments redistributed. For states' views on
these issues, see [20]GAO-06-773T .

States and federal agencies requested waivers for physicians to work in a
variety of practice specialties, settings, and locations. In fiscal year
2005, a little less than half of the waiver requests were for physicians
to practice exclusively primary care; a slightly smaller proportion were
for physicians to practice exclusively nonprimary care specialties, such
as anesthesiology or cardiology.^13 Regarding practice settings, more than
three-quarters of states' waiver requests were for physicians to work in
hospitals or private practices. Overall, about half of the waiver requests
were for physicians to practice in rural areas.

Most states and federal agencies that requested waivers for physicians
reported that they conducted some monitoring activities to help ensure
that physicians were meeting their agreements to work in underserved
areas. While monitoring waiver physicians is not explicitly required of
states and federal agencies that request waivers, more than 85 percent of
states and two of the three federal agencies that requested waivers in any
fiscal year from 2003 through 2005 reported that they had conducted at
least one monitoring activity in fiscal year 2005. The most common
activity reported was requiring periodic reports from waiver physicians or
their employers. For example, some states and federal agencies required
written reports that included information such as the number of hours the
physician worked. Six states and one federal agency--which together
accounted for about 13 percent of waiver requests in fiscal year
2005--reported that they did not conduct any activities to monitor waiver
physicians in fiscal year 2005.

Although thousands of physicians are practicing in underserved areas
through the use of J-1 visa waivers, HHS--the federal agency with primary
responsibility for addressing physician shortages--does not have the
information needed to account for waiver physicians in its efforts to
address physician shortages. Lacking such data, HHS is not able to
consider waiver physicians working in underserved areas when placing
physicians through its NHSC programs. The lack of information on waiver
physicians could also affect HHS's efforts to revise how it identifies
areas with shortages of physicians and other health care providers--its
health professional shortage area (HPSA) designation system. According to
HHS officials, the department has been working on a proposal to revise the
HPSA designation system that would, among other things, account for the
presence of waiver physicians practicing in underserved areas. HHS
officials acknowledged, however, that the department lacks complete data
on waiver physicians, needed to implement such a provision.

^13For this report, we define primary care to include family practice,
internal medicine, obstetrics/gynecology, and pediatrics. Psychiatry is
reported separately from primary care and nonprimary care specialties
because some states and federal agencies consider primary care to include
psychiatry while others do not.

To better account for physicians practicing in underserved areas through
the use of J-1 visa waivers, we are recommending that the Secretary of
Health and Human Services collect and maintain data on waiver physicians
and use this information when identifying areas experiencing physician
shortages and placing physicians in these areas.

In commenting on a draft of this report, HHS concurred with our
recommendation. HHS commented that the department's goal is to assure that
the limited resources of the J-1 visa waiver program and other programs
addressing areas and populations with limited access to health care
professionals are targeted most effectively. HHS added that the
availability of data on these additional providers would enhance the data
used to identify shortage areas.

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.^14 Nearly 6,200 foreign physicians with J-1 visas
took part in U.S. graduate medical education programs during academic year
2004-05.

^14In addition to foreign physicians who come to the United States for
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, [21]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.^15 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 they have
agreed to practice in an underserved area for at least 3 years.^16 States
were first authorized to request J-1 visa waivers on behalf of foreign
physicians in October 1994.^17 Federal agencies were first authorized to
request J-1 visa waivers for physicians in graduate medical education in
September 1961.^18

In general, waiver physicians must practice in areas that HHS has
designated as underserved. HHS has specified that waiver physicians may
practice in HPSAs or medically underserved areas or populations
(MUA/P).^19 HPSAs are geographic areas, population groups within areas, or
facilities that HHS has designated as having a shortage of health
professionals; HPSAs for primary care are generally identified on the
basis of the ratio of population to primary care physicians and other
factors.^20 MUA/Ps are areas or populations that HHS has designated as
having shortages of health care services; these are identified using
several factors in addition to the ratio of population to primary care
physicians. HPSAs and MUA/Ps can overlap; as a result, a facility can be
located in both a HPSA and an MUA/P.

^158 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).

^168 U.S.C. SS 1182(e), 1184 (l)(1)(D). Physicians with J-1 visas 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 legal residence would subject
the physician to persecution because of race, religion, or political
opinions.

^17Pub. L. No. 103-416, S 220, 108 Stat. 4305, 4319.

^18Pub. L. No. 87-256, S 109(c), 75 Stat. 527, 534.

^1960 Fed. Reg. 48515-6 (Sept. 19, 1995).

^20Separate HPSA designations exist for primary care and for other health
care fields, such as mental health. For primary care HPSAs, designation is
generally based on the ratio of population to the number of primary care
physicians and other factors, such as health care resources available in
neighboring areas. Some facilities, however, are not required to meet a
specific ratio of population to primary care physicians to be designated
as a primary care HPSA.

States and federal agencies have some discretion in shaping their J-1 visa
waiver programs to address particular needs or priorities. For example,
while states and federal agencies can request waivers for physicians to
work in both primary care and nonprimary care specialties and in a variety
of practice settings, they may choose to limit the number of waivers they
request for physicians to practice nonprimary care or require that waiver
physicians work in certain practice settings.^21 States and federal
agencies may also choose to conduct monitoring activities to help ensure
that physicians are meeting their waiver agreements--for example, that
they are working at the facilities for which their waivers were granted.

Although states and federal agencies are generally subject to the same
statutory provisions regarding requests for J-1 visa waivers for
physicians, there are two notable distinctions. First, states are limited
in the number of waivers that may be granted in response to their requests
each year. Initially, states were authorized to request waivers for up to
20 physicians each fiscal year; in 2002, the limit was increased to 30
waivers per state per year. Federal agencies are not statutorily limited
in the number of waivers that may be granted in response to their requests
each year. Second, while federal agencies' waiver requests must be for
physicians to practice in underserved areas, Congress gave states the
flexibility, in December 2004, to use up to 5 of their 30 waiver
allotments each year for physicians to work in facilities located outside
of HHS-designated undeserved areas, provided that the facilities treat
patients who reside in underserved areas.^22 We refer to these waivers as
"flexible waivers."^23

21States and federal agencies requesting waivers for physicians to
practice nonprimary care specialties are required to demonstrate,
according to their own criteria, a shortage of health care professionals
able to provide services in that medical specialty to the patients who
would be served by that physician. 8 U.S.C. S 1184(l)(1)(D)(iii).

^22Pub. L. No. 108-441, S 1(d), 118 Stat. 2630.

^23In this report, unless otherwise noted, when referring to waiver
physicians practicing or working in underserved areas, we include
physicians practicing with flexible waivers.

Obtaining a J-1 visa waiver at the request of a state or federal agency to
practice in an underserved area involves multiple steps (see fig. 1). A
physician must submit an application to obtain a case number from the
Department of State and must secure a bona fide offer of employment from a
health care facility that is located in an underserved area or, in the
case of flexible waivers, from a health care facility that treats
residents of an underserved area. The physician, the prospective employer,
or both apply to a state or federal agency to request a waiver on the
physician's behalf. If, after reviewing the application, the state or
federal agency decides to request a waiver, the state or federal agency
submits a letter of request to the Department of State affirming that it
is in the public interest for the physician to remain in the United
States. If the Department of State decides to recommend 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 the waiver
is granted. According to officials involved in recommending and approving
waivers at the Department of State and USCIS, after a review for
compliance with statutory requirements and security issues, nearly all
waiver requests are recommended and granted. Once the physician is granted
the waiver, the employer petitions USCIS for the physician to obtain H-1B
status (a nonimmigrant classification used by foreign nationals employed
temporarily in a specialty occupation). The physician must work at the
facility specified in the waiver application for a minimum of 3 years,
unless the physician obtains approval from USCIS to transfer to another
facility. USCIS considers transfer requests only in extenuating
circumstances, such as closure of the physician's assigned facility. Once
the physician fulfills the employment contract, the physician may apply
for permanent residence, continued H-1B status, or other nonimmigrant
status, if the physician wishes to remain in the United States.

Figure 1: Process to Apply for and Obtain a J-1 Visa Waiver for a
Physician to Work in an Underserved Area

aWaivers requested by ARC are first reviewed for eligibility and
completeness by the state in which the physician seeks to practice, then
forwarded to ARC for final review and processing.

No single federal agency is responsible for managing or tracking the use
of J-1 visa waivers for physicians to practice in underserved areas. HHS
is the primary federal agency responsible for addressing physician
shortages, both in terms of administering NHSC programs that place
physicians and other providers in areas experiencing shortages of health
professionals and in designating areas as underserved. HHS's oversight of
waiver physicians practicing in underserved areas, however, has generally
been limited to the few physicians for whom it has requested J-1 visa
waivers. USCIS and the Department of State process J-1 visa waiver
requests but do not maintain comprehensive information about waiver
physicians' numbers, practice locations, and practice specialties.^24
States and federal agencies that request waivers maintain such information
for the physicians for whom they request waivers, but this information is
not centrally collected and maintained by any federal agency.

Although the use of J-1 visa waivers has not been systematically tracked,
available data indicate that the pool of physicians who could seek
waivers--that is, the number of foreign physicians in graduate medical
education with J-1 visas--has declined in recent years. In academic year
1996-97, a little more than 11,600 foreign physicians took part in U.S.
graduate medical education programs with J-1 visas; by academic year
2004-05 this number had decreased more than 45 percent to slightly less
than 6,200. The reasons for this decrease are not completely
understood.^25

24According to USCIS officials, the agency's data systems are not able to
identify J-1 visa waivers granted specifically for physicians to practice
in underserved areas and do not include information on waiver physicians'
practice specialties. According to Department of State officials, the
department maintains data on the number of J-1 visa waivers it has
recommended but does not maintain data on the physicians' practice
locations or specialties.

^25Foreign 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.

Waivers Remain a Major Means for Providing Physicians to Underserved Areas

States and federal agencies reported requesting more than 1,000 J-1 visa
waivers in each of fiscal years 2003 through 2005 (see fig. 2).^26 We
estimated that, at the end of fiscal year 2005, there were roughly one and
a half times as many waiver physicians practicing in underserved areas
(3,128) as U.S. physicians practicing in underserved areas through NHSC
programs (2,054).^27

26See appendix II for states' and federal agencies' responses to selected
survey questions, including the number of J-1 visa waivers requested, in
total, by federal agency, by practice specialty, and by practice setting.

^27Although data are not available on the number of physicians granted J-1
visa waivers and 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. This number represents the physicians
expected to be fulfilling the minimum 3-year employment contract at the
end of fiscal year 2005 or who had waivers in process to do so. We
compared that estimate to the number of physicians practicing in
underserved areas through NHSC programs in the 50 states, District of
Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands as of September
30, 2005.

Figure 2: J-1 Visa Waivers Requested by States and Federal Agencies,
Calendar Year 1995 and Fiscal Years 2003 through 2005

Note: 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. There are no limits on the number of waivers that may be
granted in response to federal agencies' requests each year.

aIn our May 2006 testimony on preliminary findings ( [22]GAO-06-773T ), we
reported that federal agencies requested 110 waivers and that states and
federal agencies requested a total of 1,093 waivers in fiscal year 2003.
Our final analysis of agency data determined that federal agencies
requested 108 waivers and that states and federal agencies requested a
total of 1,091 waivers that year.

In contrast to our findings a decade ago, states have become the primary
source of waiver requests for physicians to practice in underserved areas,
accounting for 90 percent or more of requests in each of fiscal years 2003
through 2005. The number of states that reported ever having requested a
J-1 visa waiver has grown steadily since they were first authorized to do
so, from 20 states in fiscal year 1995 to 53 states (all but Puerto Rico)
as of fiscal year 2005. States varied, however, in the number of waivers
they requested in fiscal years 2003 through 2005. For example, in fiscal
year 2005, about one-quarter of the 54 states requested the maximum of 30
waivers, about one-quarter requested 10 or fewer, and two (Puerto Rico and
the U.S. Virgin Islands) requested no waivers (see fig. 3).

Figure 3: J-1 Visa Waivers Requested by States, Fiscal Year 2005

Notes: Guam, Puerto Rico, and the U.S. Virgin Islands are not shown. Guam
requested 2 waivers in fiscal year 2005; Puerto Rico and the U.S. Virgin
Islands requested no waivers that year. Additionally, ARC requested 36
waivers for physicians to practice in eight states, DRA requested 16
waivers for physicians to practice in six states, and HHS requested 4
waivers for physicians to practice in four states.

The number of waivers requested by federal agencies has decreased
significantly since 1995, with the exit of the two agencies that requested
the most waivers for physicians to practice in underserved areas that
year. The Department of Agriculture, which stopped requesting waivers for
physicians to practice in underserved areas in 2002, and the Department of
Housing and Urban Development, which stopped in 1996, together requested
more than 1,100 waivers for physicians to practice in 47 states in 1995,
providing a significant source of physicians for some states. Federal
agencies accounted for about 94 percent of waiver requests that year, in
contrast to fiscal year 2005, when federal agencies made about 6 percent
of requests. Of the 1,012 waivers requested by states and federal agencies
in fiscal year 2005, ARC, DRA, and HHS accounted for 56 requests for
physicians to practice in 14 states.^28

Waivers Were Requested for Physicians to Work in a Variety of Practice
Specialties, Settings, and Locations

States and federal agencies requested waivers for physicians to practice a
variety of specialties, with states requesting waivers for physicians to
practice both primary and nonprimary care and federal agencies generally
focusing on primary care. Although the waivers states and federal agencies
requested were for physicians to work in diverse practice settings, most
were for physicians to work in hospitals and private practices. These
practice settings were about equally divided between rural and nonrural
areas. Additionally, less than half of the states opted to request
flexible waivers for physicians to work outside of designated underserved
areas.

Overall, a little less than half (46 percent) of the waivers requested by
states and federal agencies in fiscal year 2005 were for physicians to
practice exclusively primary care, while a slightly smaller proportion (39
percent) were for physicians to practice exclusively nonprimary care (see
fig. 4). A small proportion of waiver requests (5 percent) were for
physicians to practice both primary and nonprimary care--for example, for
individual physicians to practice both internal medicine and cardiology.
An additional 7 percent of waiver requests in fiscal year 2005 were for
physicians to practice psychiatry.

^28In our May 2006 testimony on preliminary findings ( [23]GAO-06-773T ),
we reported that ARC, DRA, and HHS requested waivers for physicians to
practice in 15 states in fiscal year 2005. Our final analysis of agency
data determined that these agencies requested waivers for physicians to
practice in 14 states that year (see app. II).

Figure 4: Practice Specialties of Physicians for Whom States and Federal
Agencies Requested J-1 Visa Waivers, Fiscal Year 2005

Notes: Percentages are based on 956 waivers requested by 52 states and 56
waivers requested by three federal agencies in fiscal year 2005. Puerto
Rico and the U.S. Virgin Islands requested no waivers that year.
Psychiatry is reported separately from primary care and nonprimary care
specialties because some states and federal agencies consider primary care
to include psychiatry while others do not.

States and federal agencies differed, however, in the proportion of
waivers they requested for physicians to practice primary versus
nonprimary care (see fig. 5). Less than 50 percent of the waivers
requested by states in fiscal year 2005 were for physicians to practice
exclusively primary care, compared with 80 percent of those requested by
federal agencies.

Figure 5: J-1 Visa Waivers Requested by States and Federal Agencies, by
Practice Specialty, Fiscal Year 2005

Notes: Percentages are based on 956 waivers requested by 52 states and 56
waivers requested by three federal agencies in fiscal year 2005. Puerto
Rico and the U.S. Virgin Islands requested no waivers that year.
Psychiatry is reported separately from primary care and nonprimary care
specialties because some states and federal agencies consider primary care
to include psychiatry while others do not.

Nearly all of the states and DRA reported that their fiscal year 2005
policies allowed them to request waivers for physicians to practice
nonprimary care.^29 Twenty-seven of these states, however, reported
placing some limits on such requests, including limiting the number of
requests for physicians to practice nonprimary care or restricting the
number of hours a physician could practice a nonprimary care specialty.
Even with these limitations, the number of waivers requested for
physicians to practice nonprimary care increased among both states and
federal agencies over the 3-year period beginning in fiscal year 2003.
Overall, requests for physicians to practice exclusively nonprimary care
increased from about 300 (28 percent) in fiscal year 2003 to nearly 400
(39 percent) in fiscal year 2005. States and federal agencies reported
requesting waivers in fiscal year 2005 for physicians to practice more
than 40 nonprimary care specialties (e.g., anesthesiology) and
subspecialties (e.g., pediatric cardiology); the most common of these were
anesthesiology, cardiology, and pulmonology (the study and treatment of
respiratory diseases).

^29See appendix II for states' and federal agencies' responses to selected
survey questions, including their policies for requesting waivers.

Regarding practice settings, more than three-quarters of the waivers
requested by states in fiscal year 2005 were for physicians to practice in
hospitals (37 percent) and private practices (41 percent) (see fig. 6).^30
In addition, 16 percent were for physicians to practice in federally
qualified health centers (facilities that provide primary care services in
underserved areas) and rural health clinics (facilities that provide
outpatient primary care services in rural areas). Although the largest
proportion of waivers that states requested was for physicians to work in
private practices, more than 80 percent of the states and all three
federal agencies reported that their fiscal year 2005 policies required
the facilities where waiver physicians work--regardless of practice
setting--to accept some patients who are uninsured or covered by Medicaid.

^30Data on practice settings were not available for all federal agencies.
ARC, which requested 36 waivers in fiscal year 2005 (more than half of all
federally requested waivers that year), reported that it does not track
waiver physicians' practice settings. (See app. II for available data on
practice settings reported by federal agencies.)

Figure 6: 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 requested no
waivers that year.

Overall, about half of all waiver requests in fiscal year 2005 were for
physicians to practice in areas that respondents considered rural,
although the proportions differed between states' and federal agencies'
requests. States' waiver requests in fiscal year 2005, which accounted for
the vast majority of total requests that year, were about equally divided
between those for physicians to work in areas respondents considered rural
and those they considered nonrural. Federal agencies' waiver requests were
mostly (93 percent) for physicians to work in areas considered rural (see
fig. 7).

Figure 7: Proportion of J-1 Visa Waivers Requested by States and Federal
Agencies for Physicians to Practice in Rural and Nonrural Areas, Fiscal
Year 2005

Note: Percentages are based on 956 waivers requested by 52 states and 56
waivers requested by three federal agencies in fiscal year 2005. Puerto
Rico and the U.S. Virgin Islands requested no waivers that year.

Most of the waivers requested by states and federal agencies in fiscal
year 2005 were for physicians to practice in HPSAs. While federal
regulations generally permit states and federal agencies to request
waivers for physicians to work in HPSAs or MUA/Ps, about a quarter of the
states and two federal agencies (ARC and HHS) had policies in place in
fiscal year 2005 that limited at least some types of physicians to
practicing in HPSAs. Overall, more than three-quarters (77 percent) of
waivers requested by states and federal agencies in fiscal year 2005 were
for physicians to work in facilities located in HPSAs, and 16 percent were
for physicians to work in facilities located in MUA/Ps that were outside
of HPSAs. Additionally, less than half of the states (23 states) reported
taking advantage of the option to request flexible waivers--those for
physicians to work in facilities that, while located outside of
HHS-designated underserved areas, treat patients residing in underserved
areas. Requests for flexible waivers in fiscal year 2005, the first year
such waivers were allowed, accounted for 7 percent of all waiver requests
that year.

Most States and Federal Agencies Reported That They Conducted Monitoring
Activities

Most states and federal agencies reported that they conducted monitoring
activities to help ensure that physicians were meeting their agreements to
work in underserved areas. Although monitoring is not explicitly required
of states and federal agencies that request waivers, more than 85 percent
of states and two of the three federal agencies that requested waivers in
any fiscal year from 2003 through 2005 reported that they conducted at
least one monitoring activity in fiscal year 2005. These activities
included actions to help determine, for example, whether physicians were
working in the locations for which their waivers were requested or whether
they were treating the intended patients, such as those who were uninsured
or covered by Medicaid. The most common monitoring activity--reported by
40 states, ARC, and DRA--was to require periodic reports from physicians
or employers (see fig. 8). For example, some states and federal agencies
required written reports submitted once or twice a year that included
information such as the number of hours waiver physicians worked or the
number of patients for whom Medicaid claims were submitted. States and
federal agencies that requested waivers also reported that they monitored
waiver physicians through regular communications with employers and
physicians, such as through phone calls, and through site visits to waiver
physicians' practice locations. In addition, a small number of states
reported conducting other monitoring activities. For example, one state
official said the state's J-1 visa waiver program used Medicaid data to
confirm that waiver physicians were treating patients covered by Medicaid.

Figure 8: Monitoring Activities That States and Federal Agencies
Requesting J-1 Visa Waivers Reported Conducting in Fiscal Year 2005

Note: Our surveys asked states and federal agencies that requested waivers
whether they conducted any of these specific activities in fiscal year
2005 to help ensure that physicians were meeting their waiver agreements.
Data are for the 53 states and three federal agencies that requested
waivers in any fiscal year from 2003 through 2005. Puerto Rico did not
request waivers during this period.

Although most states and federal agencies reported conducting at least one
monitoring activity, the number of monitoring activities varied. Ten
states and DRA reported conducting at least four different activities,
while six states and HHS--together accounting for about 13 percent of
waiver requests in fiscal year 2005--reported that they did not conduct
any monitoring activities in fiscal year 2005. Four of the six states that
reported they did not conduct monitoring activities reported requesting
more than 25 waivers in each of fiscal years 2003 through 2005.

States and federal agencies reported identifying relatively few incidents
in fiscal years 2003 through 2005 in which physicians were not meeting
their waiver agreements.^31 These incidents included cases in which the
physician was not working in the practice specialty or at the facility
specified in his or her waiver agreement, was not seeing the intended
patients, or did not serve the entire 3-year employment contract. The most
common issue cited was physicians' transferring to another location or
employer without the approval of the state or federal agency that
requested their waivers.^32 In addition, several states reported that they
had identified cases in which waiver physicians never reported to work.
Officials from these states cited examples in which physicians simply
failed to appear at the practice sites and did not contact the state that
had made the waiver requests on the physicians' behalf. According to
states and federal agencies that reported identifying any incidents,
physicians were not solely responsible in all cases in which they did not
meet their waiver agreements. Some state officials provided examples of
employers who directed physicians to work in locations other than those
for which their waivers were requested, including locations outside of
underserved areas.

States and federal agencies that requested waivers reported that they use
a variety of practices to prevent or respond to cases of physicians' not
meeting their waiver agreements (see fig. 9). For example, 38 states and
HHS reported that it is their practice to bar employers who are
responsible for problems involving waiver physicians from consideration
for future J-1 visa waiver physician placements, either temporarily or
permanently. Forty states and two federal agencies reported that it is
their practice to inform USCIS if they identify physicians who are not
meeting their waiver agreements. Physicians not meeting their waiver
agreements would again be subject to the 2-year foreign residence
requirement and would need to return to their home country or country of
last legal residence before they could apply for an immigrant visa,
permanent residence, or certain nonimmigrant work visas. USCIS officials
said that reports of physicians not meeting their waiver agreements have
been relatively rare. Some states and federal agencies that requested
waivers also reported that they require physicians' contracts to stipulate
fees to be imposed if the physicians fail to meet their waiver agreements.
These requirements include, for example, liquidated damages clauses, which
set a particular amount that physicians agree to pay employers if the
physicians break their employment contracts. Other practices that states
reported included reporting problems with waiver physicians to state
medical boards.

^31States and federal agencies reported identifying a total of 81
incidents of physicians not meeting their waiver agreements in fiscal
years 2003 through 2005; we did not independently verify these incidents.
We estimated that at the end of fiscal year 2005, more than 3,000 waiver
physicians were working in underserved areas.

^32Most of the states and the one federal agency that reported identifying
physicians who had transferred without their approval had policies or
guidelines requiring physicians seeking transfers to notify or obtain
approval from their J-1 visa waiver programs in addition to obtaining the
required approval from USCIS.

Figure 9: States' and Federal Agencies' Practices to Help Ensure
Physicians Meet Their Waiver Agreements

Note: Our surveys asked states and federal agencies that requested waivers
whether they use any of these specific practices to help ensure that
physicians meet their waiver agreements. Data are for the 53 states and
three federal agencies that requested waivers in any fiscal year from 2003
through 2005. Puerto Rico did not request waivers during this period.

States cited a number of factors affecting their ability to monitor or
take other actions that they believed could help them ensure that
physicians meet their waiver agreements. More than one-quarter of the
states reported that funding and staffing constraints limited their
ability to carry out monitoring activities.^33 For example, four states
commented that time and staff constraints limited their ability to conduct
visits to physicians' practice sites. Several states noted that they have
little or no authority to take actions that would help ensure that
physicians meet their waiver agreements. For example, one state commented
that beyond reporting physicians who do not meet their waiver agreements
to USCIS, it has no authority over waiver physicians. In addition, a few
states noted that their ability to effectively monitor physicians is
limited by the fact that they are not notified when USCIS grants waivers
or approves transfers. Consequently, states may not know with certainty
which physicians USCIS has authorized to work in, or move to or from,
their states.^34 One federal agency (ARC) cited two factors that
positively affected its ability to help ensure that physicians meet their
waiver agreements: the liquidated damages clauses for violating employment
agreements that ARC requires to be in physicians' employment contracts,
and site visits by staff of ARC's Office of Inspector General. According
to a senior ARC official, these unannounced visits have occasionally
resulted in the discovery of physicians working at sites other than those
at which the physicians were authorized to work. The official commented
that the visits have also had a deterrent effect.

^33Six states and DRA reported charging application fees ranging from $200
to $2,000 in fiscal year 2005 to help fund their J-1 visa waiver programs.
Our survey results showed no statistically significant relationship
between charging application fees and the number of monitoring activities
conducted.

HHS Lacks Data to Account for Waiver Physicians in Its Efforts to Address
Physician Shortages

Although the use of J-1 visa waivers remains a major means of providing
physicians to practice in underserved areas, HHS does not have the
information needed to account for waiver physicians in its efforts to
address physician shortages. Without such information, when considering
where to place NHSC physicians, HHS has no systematic means of knowing
whether the needs of a HPSA are already being met through waiver
physicians. Our analysis indicates that some states could have had more
waiver and NHSC physicians practicing primary care in HPSAs than HHS
identified as needed, while other states were below HHS's identified need.
Although data were not available to determine the number of waiver
physicians practicing primary care specifically in HPSAs, our analysis
showed that in seven states the estimated number of waiver physicians
practicing primary care in all locations (including HPSAs, MUA/Ps, and
nondesignated areas), combined with the number of NHSC physicians
practicing primary care in HPSAs at the end of fiscal year 2005, exceeded
the number of physicians HHS identified as needed to remove the primary
care HPSA designations in the state.^35 In six of these seven states, the
estimated number of primary care waiver and NHSC physicians exceeded by at
least 20 percent the number needed to remove primary care HPSA
designations. Meanwhile, in each of 25 states, the estimated number of
primary care waiver and NHSC physicians was less than half of the state's
identified need for primary care physicians.

^34According to USCIS officials, as of September 2006, the agency did not
notify states and federal agencies when it approved waiver and transfer
requests. The officials said that the agency was working with the
Department of State to develop a system to do so and expected such a
system to be in place in fiscal year 2007.

The lack of information on waiver physicians could also affect HHS's
efforts to revise how it designates primary care HPSAs and other
underserved areas. Multiple federal programs use HHS's primary care HPSA
designation system to allocate resources or provide benefits, but as we
have reported, the designation system does not account for all primary
care providers practicing in underserved areas, including waiver
physicians.^36 Specifically, waiver physicians practicing primary care in
an area are not counted in the ratio of population to primary care
physicians, one of the factors used to determine whether an area may be
designated as a primary care HPSA. HHS has been working on a proposal--in
process since 1998--to revise the primary care HPSA designation system,
which would, among other things, account for waiver physicians, according
to HHS officials. HHS officials acknowledged, however, that the department
lacked complete data on waiver physicians, needed to implement such a
provision.^37

Recognizing the lack of a comprehensive database with information on J-1
visa waiver physicians and other international medical graduates,^38 HHS
in 2003 contracted with ECFMG--the organization that sponsors all foreign
physicians with J-1 visas participating in graduate medical education--to
assess the feasibility of developing a database that would provide access
to information on the U.S. practice locations of, populations served by,
and other information about international medical graduates. ECFMG
completed the study and in 2004 submitted a draft report to HHS that
included recommendations. As of September 2006, a final report had not
been published.

^35See appendix I for detailed information on this analysis. Data were not
available to determine the areas (HPSA, MUA/P, or nondesignated areas)
where waiver physicians were practicing primary care at the end of fiscal
year 2005.

^36See GAO, Health Care Shortage Areas: Designations Not a Useful Tool for
Directing Resources to the Underserved, [24]GAO/HEHS-95-200 (Washington,
D.C.: Sept. 8, 1995).

^37In October 2006, we recommended that the Secretary of Health and Human
Services complete and publish the proposal to revise the HPSA designation
system and address the shortcomings that have been identified. See GAO,
Health Professional Shortage Areas: Problems Remain with Primary Care
Shortage Area Designation System, [25]GAO-07-84 (Washington, D.C.: Oct.
24, 2006). In commenting on that report, HHS agreed with this
recommendation.

^38International medical graduates are physicians who completed their
medical education in schools outside the United States and Canada; they
include U.S. citizens and permanent residents as well as foreign
nationals.

Conclusions

The use of J-1 visa waivers remains a major means of placing physicians in
underserved areas of the United States, supplying even more physicians to
these areas than NHSC programs. Although thousands of physicians practice
in underserved areas through the use of J-1 visa waivers, comprehensive
data on their overall numbers, practice locations, and practice
specialties are not routinely collected and maintained by HHS. Only by
surveying states and federal agencies that requested waivers were we able
to collect information for this report. Having comprehensive data on
waiver physicians could help HHS more effectively target the placement of
NHSC physicians and implement proposed changes to designating underserved
areas.

Recommendation for Executive Action

To better account for physicians practicing in underserved areas through
the use of J-1 visa waivers, we recommend that the Secretary of Health and
Human Services collect and maintain data on waiver physicians--including
information on their numbers, practice locations, and practice
specialties--and use this information when identifying areas experiencing
physician shortages and placing physicians in these areas.

Agency Comments and our Evaluation

We provided a draft copy of this report to the five federal agencies that
are involved with waivers for physicians to practice in underserved areas:
ARC, DRA, HHS, the Department of Homeland Security, and the Department of
State. We received written comments on the draft report from HHS (see app.
III). HHS concurred with our recommendation that data should be collected
and maintained to track waiver physicians. HHS noted that the department
had also discussed, internally, tracking other physicians who are working
under H-1B visas, stating that this would allow a more complete accounting
of the actual number of physicians providing care in underserved areas.
HHS commented that the department's goal is to assure that the limited
resources of the J-1 visa waiver program and other programs addressing
areas and populations with limited access to health care professionals are
targeted most effectively and that the availability of complete data on
these additional providers would enhance the data used to identify such
shortage areas.

HHS also commented that the draft report may have overstated, to a degree,
the "oversupply" of physicians in some states. HHS acknowledged that we
made important adjustments in our analysis for physicians practicing
nonprimary care and psychiatry. The department, however, expressed concern
that our calculations did not address the fact that some J-1 visa waiver
placements are not in HPSAs, referring to our finding that 23 percent of
waivers requested in fiscal year 2005 were for physicians to practice
outside of HPSAs. We believe that applying this percentage to our analysis
would be inappropriate for several reasons. First, this percentage
pertained to waiver physicians practicing all specialties, including
primary care, nonprimary care, and psychiatry, while our analysis focused
on physicians practicing primary care. Further, the 23 percent figure
represents waivers requested in only one fiscal year (fiscal year 2005),
while our analysis covered waivers requested in 3 fiscal years. In
addition, fiscal year 2005 was the only year in our analysis in which
states could request waivers for physicians to practice in nondesignated
areas. In our draft report, we did not use the term "oversupply," but we
acknowledge that our report should clearly specify the limitations in the
data used in our analysis. To do so, we clarified the text describing our
methodology and results.

We also received technical comments from HHS and the Department of
Homeland Security's USCIS, which we incorporated as appropriate. Three
agencies--ARC, DRA, and Department of State--said that they did not have
comments on the draft report.

We are sending copies of this report to the Secretary of Health and Human
Services, the Secretary of Homeland Security, the Secretary of State, the
Federal Co-chair of ARC, the Federal Co-chairman of DRA, and appropriate
congressional committees. We will also provide copies to others upon
request. In addition, the report is available at no charge on the GAO Web
site at http://www.gao.gov .

If you or your staff members have any questions about this report, please
contact me 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 report. GAO staff who made major contributions to this
report are listed in appendix IV.

Leslie G. Aronovitz Director, Health Care

Appendix I: Physician Need and Number of Primary Care Waiver and National
Health Service Corps Physicians, by State

This appendix presents the following information for each state as of the
end of fiscal year 2005: (1) the number of primary care physicians the
Department of Health and Human Services (HHS) identified as needed to
remove primary care health professional shortage area (HPSA) designations,
(2) our estimate of the number of J-1 visa waiver physicians practicing
primary care, (3) the number of National Health Service Corps (NHSC)
physicians practicing primary care, and (4) primary care waiver and NHSC
physicians as a percentage of the HHS-identified need.

To determine the need for primary care physicians in each state, we used
the number of physicians HHS reported as needed to remove primary care
HPSA designations in the state, a measurement used by HHS to identify the
need for physicians. Specifically, we used summary data from HHS's Health
Resources and Services Administration on the number of additional
full-time equivalent (FTE) primary care physicians needed to remove
primary care HPSA designations in the state as of September 30, 2005. HHS
determines the number of additional full-time primary care physicians
needed to remove primary care HPSA designations for geographic areas,
population groups, and facilities. For geographic areas, HHS's threshold
for the ratio of population to primary care physicians is 3,500 to 1 (or
3,000 to 1 under special circumstances); for population groups, it is
3,000 to 1; for facilities that are state or federal correctional
institutions, it is 1,000 to 1.^1 In calculating the ratio of population
to primary care physicians, HHS does not take into account waiver
physicians and most NHSC physicians. In addition to HPSAs, waiver
physicians may also practice in designated medically underserved areas or
populations (MUA/P). HHS does not, however, have a similar measure of the
number of physicians needed in MUA/Ps.^2

To determine the number of NHSC physicians practicing primary care in
HPSAs in each state as of September 30, 2005, we used data obtained from
the Health Resources and Services Administration on the number of primary
care physicians practicing through the NHSC Scholarship, NHSC Loan
Repayment, and NHSC Ready Responder programs.^3 NHSC physicians are
required to practice in HPSAs.

^1Certain facilities, including all federally qualified health centers and
certain rural health clinics, are not required to meet a specific ratio of
population to primary care physicians for primary care HPSA designation.
Because data were not available to identify which waiver and NHSC
physicians were working in these facility HPSAs, these physicians were
included in physician counts for this analysis.

^2HHS has been working on a proposal to revise the MUA/P designation
system. As of September 2006, this proposal was in the department's
clearance process.

Although data are not available on the number of physicians granted J-1
visa waivers and practicing primary care in underserved areas at any given
time, we estimated this number using data on waivers requested by states
and by three federal agencies--the Appalachian Regional Commission (ARC),
the Delta Regional Authority (DRA), and HHS. We estimated the number of
waiver physicians practicing primary care in each state as of September
30, 2005, by using the number of waivers requested in fiscal years 2003
through 2005 for such physicians. This number represents the number of
primary care physicians expected to be fulfilling the minimum 3-year
employment contract at the end of fiscal year 2005 or who had waivers in
process to do so.^4 Our estimate includes all waiver physicians practicing
primary care in the state (including those practicing in HPSAs, MUA/Ps,
and nondesignated areas). Data were not available to distinguish waiver
physicians practicing primary care in HPSAs from those practicing in
MUA/Ps or nondesignated areas.^5

Table 1 shows the estimated number of waiver and NHSC physicians
practicing primary care at the end of fiscal year 2005 and the number of
physicians needed to remove primary care HPSA designations in each state.

^3A total of 499 physicians practicing in the states through two other
NHSC programs--the State Loan Repayment and Community Scholarship
programs--were not included in the total number of NHSC physicians for
this analysis because, according to HHS officials, they are already
counted as physicians practicing in HPSAs when HHS identifies the number
of additional primary care physicians required to remove HPSA
designations.

^4Physicians for whom waivers were requested to practice both primary and
nonprimary care (e.g., physicians who practiced both internal medicine and
cardiology) were counted as 0.5 FTE. We excluded from our analysis
1,051waivers requested in fiscal years 2003 through 2005 for physicians to
practice exclusively nonprimary care. We also excluded 256 waivers
requested during that time for physicians to practice psychiatry because
psychiatrists are not included in physician counts for primary care HPSAs.

^5Data were not available to determine the areas (HPSA, MUA/P, or
nondesignated area) where physicians whose waivers were requested in
fiscal years 2003-2005 were practicing primary care. For all physicians
whose waivers were requested in fiscal year 2005--including those
requested to practice primary care, nonprimary care or psychiatry--we
found that 77 percent worked in facilities located in HPSAs, 16 percent
worked in MUA/Ps that were not also in HPSAs, and 7 percent worked outside
of HPSAs and MUA/Ps.

Table 1: Physicians Needed and Number of Primary Care Waiver and NHSC
Physicians, by State, as of September 30, 2005

                                                                     Primary 
                                                                        care 
                                                                  waiver and 
                              Estimated                     Total       NHSC 
                              number of                 number of physicians 
                  Physicians primary care                 primary       as a 
                   needed to    waiver       Number of       care percentage 
              remove primary physicians^b primary care waiver and         of 
                   care HPSA                      NHSC       NHSC physicians                                 
State         designations^a        State physicians^c physicians     needed       ARC   DRA       HHS Total 
Alabama                  218         20.0          8.0                            28.0    40      68.0 31.2% 
Alaska                    29          0.5                                          0.5     9       9.5  32.8 
Arizona                  272         69.0                                1.0      70.0    58     128.0  47.1 
Arkansas                  71         26.0                     5.0                 31.0     6      37.0  52.1 
California               816         73.0                                4.0      77.0    72     149.0  18.3 
Colorado                 144          9.5                                          9.5    35      44.5  30.9 
Connecticut               57            d                                1.0         d    15         d     d 
Delaware                  12         27.0                                         27.0    10      37.0 308.3 
District of                                                                                                  
Columbia                  35          8.0                                          8.0    40      48.0 137.1 
Florida                  774         74.0                                9.0      83.0   105     188.0  24.3 
Georgia                  347         53.5          6.0                            59.5    53     112.5  32.4 
Guam                       5          0.5                                          0.5     0       0.5  10.0 
Hawaii                    16          6.5                                          6.5     8      14.5  90.6 
Idaho                     58          1.0                                2.0       3.0    19      22.0  37.9 
Illinois                 404         78.0                     3.0        1.0      82.0    75     157.0  38.9 
Indiana                  107         47.0                                2.0      49.0    20      69.0  64.5 
Iowa                      58         33.0                                         33.0    11      44.0  75.9 
Kansas                    98         29.0                                         29.0    11      40.0  40.8 
Kentucky                  99         48.5         41.0        1.0                 90.5    11     101.5 102.5 
Louisiana                161         30.5                     3.0                 33.5    15      48.5  30.1 
Maine                     24         19.5                                         19.5    19      38.5 160.4 
Maryland                  79         45.5          1.0                   2.0      48.5    23      71.5  90.5 
Massachusetts             60         37.0                                         37.0    36      73.0 121.7 
Michigan                 274         72.0                                3.0      75.0    63     138.0  50.4 
Minnesota                 73         36.0                                         36.0    13      49.0  67.1 
Mississippi              173         31.0         11.0       10.5        1.0      53.5    24      77.5  44.8 
Missouri                 356         12.0                     4.0        3.0      19.0    67      86.0  24.2 
Montana                   56          4.0                                          4.0    15      19.0  33.9 
Nebraska                  17          9.0                                          9.0     2      11.0  64.7 
Nevada                    95         52.0                                         52.0    10      62.0  65.3 
New Hampshire             17          6.5                                          6.5     5      11.5  67.6 
New Jersey                28          5.0                                          5.0     8      13.0  46.4 
New Mexico               130         34.0                                         34.0    32      66.0  50.8 
New York                 325         26.0          7.0                   5.0      38.0    79     117.0  36.0 
North                                                                                                        
Carolina                 143         31.0          1.0                            32.0    38      70.0  49.0 
North Dakota              33         17.0                                         17.0     3      20.0  60.6 
Ohio                     144         25.0         13.0                            38.0    30      68.0  47.2 
Oklahoma                  69          9.0                                1.0      10.0    13      23.0  33.3 
Oregon                    45         31.5                                         31.5    24      55.5 123.3 
Pennsylvania             173         16.0          4.0                            20.0    50      70.0  40.5 
Puerto Rico              263                                                       0.0     9       9.0   3.4 
Rhode Island              12         51.0                                         51.0     9      60.0 500.0 
South                                                                                                        
Carolina                 117         26.0                                1.0      27.0    36      63.0  53.8 
South Dakota             104          8.0                                          8.0     2      10.0   9.6 
Tennessee                149         43.0          5.0        6.0        1.0      55.0    31      86.0  57.7 
Texas                    664         33.0                               19.0      52.0    63     115.0  17.3 
U.S. Virgin                                                                                                  
Islands                    2          1.0                                          1.0     1       2.0 100.0 
Utah                      66          4.5                                          4.5    23      27.5  41.7 
Vermont                    2          1.0                                          1.0     1       2.0 100.0 
Virginia                 106         38.5                                         38.5    22      60.5  57.1 
Washington               146         49.0                                1.0      50.0    33      83.0  56.8 
West Virginia             58          8.0          7.0                            15.0    16      31.0  53.4 
Wisconsin                126         58.0                                         58.0    23      81.0  64.3 
Wyoming                   27          3.0                                          3.0    12      15.0  55.6 
Total                  7,937    1,477.5^e        104.0       32.5       57.0 1,670.0^e 1,448 3,103.0^e 39.1e 

Sources: GAO survey of states, 2005; data provided by ARC, DRA, and HHS;
Health Resources and Services Administration.

Note: Data are presented in terms of FTE physicians.

aThe number of additional FTE physicians HHS identified as needed as of
September 30, 2005, to remove primary care HPSA designations in the state.

bThe estimated number of primary care waiver physicians practicing in
HPSAs, MUA/Ps, and nondesignated areas as of September 30, 2005. Data were
not available to distinguish waiver physicians practicing primary care in
HPSAs from those practicing in MUA/Ps or nondesignated areas. Physicians
for whom waivers were requested to practice both primary and nonprimary
care (e.g., physicians who practiced both internal medicine and
cardiology) were counted as 0.5 FTE.

cThe number of primary care NHSC physicians practicing in primary care
HPSAs as of September 30, 2005.

dData were not available to estimate the number of waiver physicians
practicing primary care in Connecticut or to make associated calculations.

eTotal does not include waiver physicians who may have been practicing
primary care in Connecticut.

Appendix II: States' and Federal Agencies' Requests for J-1 Visa Waivers

This appendix summarizes states' and federal agencies' responses to
selected questions from GAO's surveys, as well as data obtained from ARC,
DRA, and HHS on their waiver requests by state. The following tables
present data on the number of waivers states and federal agencies
requested in each of fiscal years 2003 through 2005, in total (table 2),
by federal agency (table 3), by practice specialty (table 4), and by
practice setting (table 5). We also present data on states' and federal
agencies' policies for requesting waivers (table 6).

Table 2: J-1 Visa Waivers Requested by States and Federal Agencies for
Physicians to Practice in Underserved Areas, by State, Fiscal Years 2003
through 2005

                                    Number of waivers requested
                   2003             2004                2005                  
                     Federal          Federal               Federal     Total 
State         State agencies   State agencies        State agencies 2003-2005 
Alabama                   18       3       19            3   24   4        71          
Alaska                     5                1      6                                   
Arizona                   30       1       30                30            91          
Arkansas                  30  30               5  29  1 95                             
California                30       3       30 30   1 94                                
Colorado                  11                3  5  19                                   
Connecticut               27       1       30 26  84                                   
Delaware                  21  21  16   58                                              
District of                                                                            
Columbia                   3   9   3   15                                              
Florida                   30      10       30 30 100                                   
Georgia                   30       5       30            1   28  94                    
Guam                           1   2    3                                              
Hawaii                     2   1   4    7                                              
Idaho                              2    1   3                                          
Illinois                  28       3       30 30   1 92                                
Indiana                   27       1       30 30   1 89                                
Iowa                      30  30  28   88                                              
Kansas                    14  26  17   57                                              
Kentucky                  30      25       30           13   30   9       137          
Louisiana                 15       2       13            1   10  41                    
Maine                     29  18  25   72                                              
Maryland                  15       3       22 29  69                                   
Massachusetts             28  30  30   88                                              
Michigan                  30       1       30            2   30  93                    
Minnesota                 30                  15                           21       66 
Mississippi               19       5          17              7            18 14    80 
Missouri                  30       2          30              4            30  3    99 
Montana                    2                   1                            2        5 
Nebraska                  15                   7                           13       35 
Nevada                    26                  18                           13       57 
New Hampshire              6                  11                           15       32 
New Jersey                 2                   1                            2        5 
New Mexico                29                  27                           29       85 
New York                  30       5          30              3            30  8   106 
North                                                                                  
Carolina                  10                  11                           16  1    38 
North Dakota              11                  13                            6       30 
Ohio                      30       7          30              5            30  7   109 
Oklahoma                           1          17                           12       30 
Oregon                    20                  19                           22       61 
Pennsylvania              13       7          16                           22       58 
Puerto Rico                                                                            
Rhode Island              30                  30                           30       90 
South                                                                                  
Carolina                  30       1          26                           21       78 
South Dakota              10                   6                            6       22 
Tennessee                 21       4          27              6            12  3    73 
Texas                     30      10          30              8            30  1   109 
U.S. Virgin                                                                            
Islands                    1                                                         1 
Utah                       4                   6                            5       15 
Vermont                                        1                            2        3 
Virginia                  17                  13                           19       49 
Washington                30       2          30                           28       90 
Wisconsin                 29                  23                           12       64 
West Virginia             22       4          14              2            18  2    62 
Wyoming                    3                   3                            4       10 
Total                    983     108         965             60           956 56 3,128 

Sources: GAO survey of states, 2005; data provided by ARC, DRA, and HHS.

Note: A blank cell indicates that no waivers were requested.

Table 3: J-1 Visa Waivers Requested by Federal Agencies for Physicians to
Practice in Underserved Areas, by State, Fiscal Years 2003 through 2005

                        Number of waivers requested
                     2003         2004          2005
State          ARC DRA HHS  ARC DRA HHS  ARC DRA   HHS
Alabama                3            3           4      
Arizona                       1                        
Arkansas                               5           1   
California                    3                      1 
Connecticut                   1                        
Florida                      10                        
Georgia                5            1                  
Idaho                         2                        
Illinois                  2   1                    1   
Indiana                       1                      1 
Kentucky              25           13           8  1   
Louisiana                 2            1               
Maryland               1      2                        
Michigan                      1            2           
Mississippi            4  1         4  2   1    5  9   
Missouri                  1   1        3   1       2 1 
New York                      5     3           8      
North Carolina                                  1      
Ohio                   7            5           7      
Oklahoma                      1                        
Pennsylvania           7                               
South Carolina                1                        
Tennessee              2  1   1     3  3        1  2   
Texas                        10            8         1 
Washington                    2                        
West Virginia          4            2           2      
Total                 58  7  43    34 14  12   36 16 4 

Sources: Data provided by ARC, DRA, and HHS.

Notes: Only states where federal agencies requested waivers in any fiscal
year from 2003 through 2005 are shown; federal agencies requested no
waivers for other states. A blank cell indicates that no waivers were
requested.

Table 4: J-1 Visa Waivers Requested by States and Federal Agencies for
Physicians to Practice in Underserved Areas, by Practice Specialty, Fiscal
Years 2003 through 2005

                                     Number of waivers requested (percentage)
States                             2003      2004           2005
Exclusively primary care             525    (53)    462  (48)    424  (44) 
Exclusively nonprimary care          302    (31)    356  (37)    390  (41) 
Both primary and nonprimary care      49     (5)     35   (4)     49   (5) 
Psychiatry^a                          80     (8)     82   (8)     67   (7) 
No answer                             27     (3)     30   (3)     26   (3) 
Total                                983   (100)    965 (100)    956 (100) 
Federal agencies                                                           
Exclusively primary care              93    (86)     55  (92)     45  (80) 
Exclusively nonprimary care            0     (0)      1   (2)      2   (4) 
Both primary and nonprimary care       0     (0)      0   (0)      1   (2) 
Psychiatry^a                          15    (14)      4   (7)      8  (14) 
No answer                              0     (0)      0   (0)      0   (0) 
Total                                108   (100)     60 (100)     56 (100) 
States and federal agencies                                                
combined                                                                   
Exclusively primary care             618    (57)    517  (50)    469  (46) 
Exclusively nonprimary care          302    (28)    357  (35)    392  (39) 
Both primary and nonprimary care      49     (4)     35   (3)     50   (5) 
Psychiatry^a                          95     (9)     86   (8)     75   (7) 
No answer                             27     (2)     30   (3)     26   (3) 
Total                              1,091   (100)  1,025 (100)  1,012 (100) 

Sources: GAO survey of states, 2005; GAO survey of federal agencies, 2005.

Note: Percentages may not add to 100 because of rounding.

aPsychiatry is reported separately from primary care and nonprimary care
specialties because some states and federal agencies consider primary care
to include psychiatry while others do not.

Table 5: J-1 Visa Waivers Requested by States and Federal Agencies for
Physicians to Practice in Underserved Areas, by Practice Setting, Fiscal
Years 2003 through 2005

                                     Number of waivers requested (percentage)
States                            2003     2004       2005
Federally qualified health center       91   (9)     97  (10)    101  (11) 
Rural health clinic                     50   (5)     39   (4)     45   (5) 
Hospital                               261  (27)    296  (31)    353  (37) 
Private individual or group                                                
practice                               486  (49)    452  (47)    394  (41) 
Other settings                          35   (4)     51   (5)     33   (3) 
No answer                               60   (6)     30   (3)     30   (3) 
Total                                  983 (100)    965 (100)    956 (100) 
Federal agencies^a                                                         
Federally qualified health center        6   (6)      6  (10)      3   (5) 
Rural health clinic                      3   (3)     11  (18)      7  (13) 
Hospital                                 4   (4)      6  (10)      6  (11) 
Private individual or group                                                
practice                                34  (31)      3   (5)      4   (7) 
Other settings                           3   (3)      0   (0)      0   (0) 
No answer                               58  (54)     34  (57)     36  (64) 
Total                                  108 (100)     60 (100)     56 (100) 
States and federal agencies                                                
combined                                                                   
Federally qualified health center       97   (9)    103  (10)    104  (10) 
Rural health clinic                     53   (5)     50   (5)     52   (5) 
Hospital                               265  (24)    302  (29)    359  (35) 
Private individual or group                                                
practice                               520  (48)    455  (44)    398  (39) 
Other settings                          38   (3)     51   (5)     33   (3) 
No answer                              118  (11)     64   (6)     66   (7) 
Total                                1,091 (100)  1,025 (100)  1,012 (100) 

Sources: GAO survey of states, 2005; GAO survey of federal agencies, 2005.

Note: Percentages may not add to 100 because of rounding.

aData on practice settings are for DRA and HHS; "no answer" represents
waivers requested by ARC, which reported that it does not track waiver
physicians' practice settings.

Table 6: States' and Federal Agencies' Policies for Requesting J-1 Visa
Waivers, Fiscal Year 2005

              Facilities                                                            
                where                                                               
                waiver                                                              
              physicians                                                            
                 work                                                               
               required                                                             
              to accept                                                             
                 some                                          Requests   Requests  
               patients                           Nonprimary     for        for     
               who are   Nonprimary  Nonprimary      care      primary   nonprimary 
              uninsured     care        care      physicians     care       care    
              or covered physicians  physicians    eligible   physicians physicians 
                  by        not     eligible with   without   limited to limited to 
State          Medicaid   eligible  limitations^a limitations  HPSAs^b     HPSAs    
Alabama           X                       X                       X                 
Alaska                                                 X                            
Arizona           X                       X                                         
Arkansas          X                                    X                            
California                   X                                               c      
Colorado          X                                    X                            
Connecticut                                            X                            
Delaware          X                                    X                            
District of       X                                    X                            
Columbia                                                                            
Florida                                   X                                         
Georgia           X                       X                                         
Guam              X                                    X          X          X      
Hawaii            X                       X                                         
Idaho             X          X                                               c      
Illinois                                  X                       X                 
Indiana           X                                    X                            
Iowa              X                                    X                            
Kansas            X                       X                                         
Kentucky          X                                    X                            
Louisiana         X                       X                                         
Maine             X                                    X                            
Maryland          X                       X                                         
Massachusetts     X          X                                                      
Michigan          X                   J-1 Visa                    X                 
                                     Waivers for                                    
                                    Physicians X                                    
                                      J-1 Visa                                      
                                     Waivers for                                    
                                     Physicians                                     
                                      J-1 Visa                                      
                                     Waivers for                                    
                                     Physicians                                     
                                      J-1 Visa                                      
                                     Waivers for                                    
                                     Physicians                                     
                                      J-1 Visa                                      
                                     Waivers for                                    
                                     Physicians                                     
                                      J-1 Visa                                      
                                     Waivers for                                    
                                     Physicians                                     
                                      J-1 Visa                                      
                                     Waivers for                                    
                                     Physicians                                     
Minnesota         X                                    X                            
Mississippi       X                       X                       X                 
Missouri          X                                    X          X          X      
Montana           X                       X                                         
Nebraska          X                       X                                         
Nevada            X                       X                                         
New Hampshire     X                       X                                         
New Jersey        X                       X                       X          X      
New Mexico        X                       X                       X                 
New York          X                                    X                            
North             X                       X                       X          X      
Carolina                                                                            
North Dakota                                           X                            
Ohio              X                                    X          X          X      
Oklahoma          X                       X                                         
Oregon            X                                    X                            
Pennsylvania      X                                    X                            
Rhode Island      X                                    X                            
South             X                                    X                            
Carolina                                                                            
South Dakota      X                                    X                            
Tennessee                                 X                                         
Texas                                     X                       X                 
Utah              X                                    X          X          X      
Vermont           X                       X                                         
Virginia          X                       X                                         
Washington        X                       X                                         
Wisconsin         X                       X                                         
West Virginia     X                                    X                            
Wyoming           X                       X                       X          X      
Federal                                                                             
agency                                                                              
ARC               X          X                                    X          c      
DRA               X                                    X                            
HHS               X          X                                    X          c      

Sources: GAO survey of states, 2005; GAO survey of federal agencies, 2005.

Note: Responses are for the 52 states and three federal agencies that
requested any waivers in fiscal year 2005. Puerto Rico and the U.S. Virgin
Islands requested no waivers that year.

aExamples of limitations provided in the survey question included policies
limiting the number of nonprimary care physicians allowed and the number
of practice hours allowed in a specialty outside primary care.

bHPSAs are health professional shortage areas, as designated by the
Secretary of Health and Human Services under section 332 of the Public
Health Service Act (42 U.S.C. S 254e).

cCalifornia, Idaho, ARC, and HHS reported that their fiscal year 2005
policies did not allow them to request waivers for physicians to practice
nonprimary care.

Appendix III: Comments from the Department of Health and Human Services

Appendix IV: Contact and Acknowledgments

GAO Contact

Leslie G. Aronovitz, (312) 220-7600 or [email protected]

Acknowledgments

In addition to the contact named above, Kim Yamane, Assistant Director;
Ellen W. Chu; Jill Hodges; Julian Klazkin; Linda Y.A. McIver; and Perry
Parsons made key contributions to this report.

Related GA Related GAO Products

Health Professional Shortage Areas: Problems Remain with Primary Care
Shortage Area Designation System. [28]GAO-07-84 . Washington, D.C.:
October 24, 2006.

Foreign Physicians: Preliminary Findings on the Use of J-1 Visa Waivers to
Practice in Underserved Areas. [29]GAO-06-773T . Washington, D.C.: May 18,
2006.

State Department: Stronger Action Needed to Improve Oversight and Assess
Risks of the Summer Work Travel and Trainee Categories of the Exchange
Visitor Program. [30]GAO-06-106 . Washington, D.C.: October 14, 2005.

Health Workforce: Ensuring Adequate Supply and Distribution Remains
Challenging. [31]GAO-01-1042T . Washington, D.C.: August 1, 2001.

Health Care Access: Programs for Underserved Populations Could Be
Improved. [32]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. [33]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. [34]GAO/HEHS-95-200 . Washington, D.C.:
September 8, 1995.

(290485)

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www.gao.gov/cgi-bin/getrpt?GAO-07-52 .

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and methodology, click on the link above.

For more information, contact Leslie G. Aronovitz at (312) 220-7600 or
[email protected].

Highlights of [42]GAO-07-52 , a report to congressional requesters

November 2006

FOREIGN PHYSICIANS

Data on Use of J-1 Visa Waivers Needed to Better Address Physician
Shortages

Many U.S. communities face difficulties attracting physicians. To address
this problem, states and federal agencies have turned to foreign
physicians who have just completed graduate medical education in the
United States under J-1 visas. Ordinarily, these physicians must return
home after completing their programs, but this requirement can be waived
at the request of a state or federal agency if the physician agrees to
practice in an underserved area. In 1996, GAO reported that J-1 visa
waivers had become a major source of physicians for underserved areas but
were not well coordinated with Department of Health and Human Services
(HHS) programs for addressing physician shortages.

GAO was asked to examine (1) the number of waivers requested by states and
federal agencies; (2) waiver physicians' practice specialties, settings,
and locations; and (3) the extent to which waiver physicians are accounted
for in HHS's efforts to address physician shortages. GAO surveyed states
and federal agencies about waivers they requested in fiscal years
2003-2005 and reviewed HHS data.

[43]What GAO Recommends

GAO recommends that the Secretary of Health and Human Services collect and
maintain data on waiver physicians and use these data when identifying
areas experiencing physician shortages and placing physicians in these
areas. HHS concurred with GAO's recommendation.

The use of J-1 visa waivers remains a major means of providing physicians
to practice in underserved areas of the United States. More than 1,000
waivers were requested in each of fiscal years 2003 through 2005 by states
and three federal agencies--the Appalachian Regional Commission, the Delta
Regional Authority, and HHS. At the end of fiscal year 2005, the estimated
number of physicians practicing in underserved areas through J-1 visa
waivers exceeded the number practicing there through the National Health
Service Corps (NHSC)--HHS's primary mechanism for addressing physician
shortages. In contrast to a decade ago, when federal agencies requested
the vast majority of waivers, states have become the primary source of J-1
visa waiver requests, accounting for 90 percent or more of waiver requests
in fiscal years 2003 through 2005.

States and federal agencies requested waivers for physicians to work in a
variety of practice specialties, settings, and locations. In fiscal year
2005, a little less than half of the waiver requests were for physicians
to practice exclusively primary care. More than three-quarters of the
waiver requests were for physicians to work in hospitals or private
practices, and about half were for physicians to practice in rural areas.

HHS does not have the information needed to account for waiver physicians
in its efforts to address physician shortages. Without such information,
when considering where to place NHSC physicians, HHS has no systematic
means of knowing if an area's needs are already being met by waiver
physicians.

J-1 Visa Waivers Requested by States and Federal Agencies, Calendar Year
1995 and Fiscal Years 2003 through 2005

Note: "States" refers to entities eligible to request waivers under the
authority granted to states, including the 50 states, the District of
Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands.

References

Visible links
  18. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-97-26
  19. http://www.gao.gov/cgi-bin/getrpt?GAO-06-773T
  20. http://www.gao.gov/cgi-bin/getrpt?GAO-06-773T
  21. http://www.gao.gov/cgi-bin/getrpt?GAO-06-106
  22. http://www.gao.gov/cgi-bin/getrpt?GAO-06-773T
  23. http://www.gao.gov/cgi-bin/getrpt?GAO-06-773T
  24. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-95-200
  25. http://www.gao.gov/cgi-bin/getrpt?GAO-07-84
  28. http://www.gao.gov/cgi-bin/getrpt?GAO-07-84
  29. http://www.gao.gov/cgi-bin/getrpt?GAO-06-773T
  30. http://www.gao.gov/cgi-bin/getrpt?GAO-06-106
  31. http://www.gao.gov/cgi-bin/getrpt?GAO-01-1042T
  32. http://www.gao.gov/cgi-bin/getrpt?GAO/T-HEHS-00-81
  33. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-97-26
  34. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-95-200
  42. http://www.gao.gov/cgi-bin/getrpt?GAO-07-52
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