United States Government Accountability Office

GAO Testimony

Before the Subcommittee on Immigration, 

Border Security, and Claims, Committee 

on the Judiciary, House of Representatives

FOREIGN PHYSICIANS

Preliminary Findings on the 

Use of J-1 Visa Waivers to 

Practice in Underserved 

Areas 

Statement of Leslie G. Aronovitz 

Director, Health Care 

For Release on Delivery

Expected at 2:00 p.m. EDT

Thursday, May 18, 2006

GAO-06-773T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 18, 2006

FOREIGN PHYSICIANS

Preliminary Findings on the Use of J-1 

Visa Waivers to Practice in Underserved 

Areas 

Highlights of GAO-06-773T, a testimony 

before the Subcommittee on Immigration, 

Border Security, and Claims, Committee 

on the Judiciary, House of 

Representatives 

Many U.S. communities face

difficulties attracting physicians to 

meet their health care needs. To

address this problem, states and 

federal agencies have turned to

foreign physicians who have just 

completed their graduate medical

education in the United States

under J-1 visas. Ordinarily, these 

physicians are required to return

home after completing their

education, but this requirement can 

be waived at the request of a state

or federal agency if the physician 

agrees to practice in, or work at a

facility that treats residents of, an

underserved area. In 1996, GAO

reported that J-1 visa waivers had 

become a major means of

providing physicians for 

underserved areas, with over 1,300

requested in 1995. Since 2002, each 

state has been allotted 30 J-1 visa

waivers per year, but some states 

have expressed interest in more. 

GAO was asked to report on its 

preliminary findings from ongoing 

work on (1) the number of J-1 visa

waivers requested by states and 

federal agencies and (2) states’

views on the 30-waiver limit and on 

their willingness to have unused 

waiver allotments redistributed.

Such redistribution would require 

legislative action. 

GAO surveyed the 50 states, the 

District of Columbia, 3 U.S. insular 

areas—the 54 entities that are 

considered states for purposes of

requesting J-1 visa waivers—and 

federal agencies about waivers they

requested in fiscal years 2003–05. 

The use of J-1 visa waivers remains a major means of placing physicians in 

underserved areas of the United States. States and federal agencies reported

requesting more than 1,000 waivers in each of the past 3 years. In contrast to 

a decade ago, states are now the primary source of waiver requests for 

physicians to practice in underserved areas, accounting for more than 90 

percent of such waiver requests in fiscal year 2005. The number of waivers 

individual states requested that year, however, varied considerably. For 

example, about one-quarter of the states requested the maximum of 30 

waivers, while slightly more than a quarter requested 10 or fewer.

Regarding the annual limit on waivers, about 80 percent of the states—

including many of those that requested the annual limit or close to it—

reported the 30-waiver limit to be adequate for their needs. About 13 percent

reported that this limit was less than adequate. Of the 44 states that did not 

always request the limit, 25 reported that they would be willing to have their 

unused waiver allotments redistributed, at least under certain 

circumstances. In contrast, another 14 states reported that they would not be 

willing to have their unused waiver allotments redistributed. These states 

cited concerns such as the possibility that physicians seeking waivers would 

wait until a redistribution period opened and apply to practice in preferred 

locations in other states. 

States’ Requests for J-1 Visa Waivers for Physicians to Practice in Underserved Areas, 

Fiscal Year 2005

Sources: GAO survey of states (data), 2005; copyright © Corel Corp., all rights reserved (map).

1 to 10 11 to 20 21 to 29 30

NH

MA

RI

CT

NJ

DE

MD

DC

PA

OR

NV

ID

MT

WY

UT

AZ NM

CO

ND

SD

NE

TX

KS

OK

MN

IA

MO

AR

LA

IL

MS

IN

KY

TN

AL

FL

GA

SC

NC

VA

OH

MI

CA

WA

WI NY

VT ME

WV

HI

AK

Note: Guam requested two J-1 visa waivers in fiscal year 2005; Puerto Rico and the U.S. Virgin 

Islands requested no waivers that year. 

www.gao.gov/cgi-bin/getrpt?GAO-06-773T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Leslie G. 

Aronovitz at (312) 220-7600 or 

aronovitzl@gao.gov. 
Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today as you consider the states’ authority to 

request J-1 visa waivers for foreign physicians to practice in underserved 

areas1

 of the United States. As you know, many communities throughout 

the country—including rural and low-income urban areas—experience 

difficulties in attracting physicians to meet their health care needs. To 

address this problem, states and federal agencies have turned to foreign 

physicians who have just completed their graduate medical education in

the United States. Many of these foreign physicians entered the United 

States on temporary visas, called J-1 visas, and are ordinarily required to 

return to their home country or country of last legal residence for 2 years 

when they complete their graduate medical education. This foreign 

residence requirement, however, can be waived by the Department of 

Homeland Security in certain circumstances, including at the request of a 

state or federal agency if the physician agrees to practice in an

underserved area for at least 3 years.2

 By law, up to 30 J-1 visa waivers per 

year can be granted in response to each state’s requests—regardless of the 

state’s size or need for physicians.3

 There is no limit in the number of J-1 

visa waivers that may be granted in response to federal agencies’ requests. 

In 1996, we reported that the number of J-1 visa waivers requested by 

states and federal agencies for physicians to work in underserved areas 

had risen dramatically—from 70 in 1990 to more than 1,300 in 1995—and 

that requesting waivers had become a major means of providing 

physicians for underserved areas. We estimated that, in 1995, the number 

of waiver physicians practicing in underserved areas exceeded the number 

of physicians practicing there through the National Health Service Corps 

(NHSC) programs—the Department of Health and Human Services’ (HHS) 

primary mechanism for addressing shortages of physicians and other 

 1

In this statement, we use the term “underserved areas” to refer to (1) areas, population 

groups within areas, and facilities with shortages of health care professionals or (2) areas 

or population groups with shortages of health care services. The Department of Health and 

Human Services has established specific criteria for identifying these areas, which are 

described in more detail later in this statement. 

2

Throughout this statement, we refer to a waiver of the 2-year foreign residence 

requirement as a “J-1 visa waiver” or “waiver.” 

3

8 U.S.C. §§ 1182(e), 1184(l)(1)(B). States may request waivers for foreign physicians who 

enter the United States before June 1, 2006, under a J-1 visa for graduate medical education 

or who acquired such status after admission. 8 U.S.C. § 1182 note. 

Page 1 GAO-06-773T
primary care health professionals.4

 We reported that slightly over half of 

these waiver physicians practiced internal medicine, and many also had 

medical subspecialties. Further, more than one-third of the waiver 

physicians practiced in nonprofit community and migrant health centers, 

while nearly one-fourth were in private practices. We also noted that 

controls for ensuring that these physicians met the terms of their waiver 

agreements were somewhat weak.5

 In the 10 years since our earlier report, 

the Department of Agriculture and the Department of Housing and Urban 

Development—which together requested more than 80 percent of the J-1 

visa waivers for physicians in 1995—decided to stop doing so. 

You and others have expressed an interest in determining how J-1 visa 

waivers are being used to place physicians in underserved areas. We were 

also asked to report on one option that has been raised as a possible 

means to accommodate those states that have expressed an interest in 

having more than 30 waivers granted at their request each year—the 

possibility of redistributing some states’ unused waiver allotments. My 

remarks today are based on preliminary findings from our ongoing work 

and will focus on (1) the number of waivers requested by states in relation 

to the number requested by federal agencies; (2) practice specialties and

settings of physicians whose waivers were requested by states; (3) states’ 

activities to monitor compliance with waiver agreements; and (4) states’ 

views on both the adequacy of the annual limit of 30 J-1 visa waivers per 

state and on having unused waiver allotments redistributed, which would 

require legislation. 

To address these issues, we administered a Web-based survey to the 

entities eligible to request J-1 visa waivers for physicians under the 

authority granted to the states—the 50 states, the District of Columbia, 

Puerto Rico, Guam, and the U.S. Virgin Islands (hereafter referred to as 

“states”).6

 We sent the survey to the official in each state authorized to sign 

 4

NHSC 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. 

5

See GAO, Foreign Physicians: Exchange Visitor Program Becoming Major Route to

Practicing in U.S. Underserved Areas, GAO/HEHS-97-26 (Washington, D.C.: Dec. 30, 1996), 

and “Related GAO Products” at the end of this statement. 

6

8 U.S.C. §1101(a)(36). We also sent a mail survey to the three federal agencies that 

requested waivers for physicians to practice in underserved areas in fiscal years 2003 

through 2005. These included the Appalachian Regional Commission, the Delta Regional 

Authority, and the Department of Health and Human Services. 

Page 2 GAO-06-773T
waiver requests or to his or her designee. The survey asked for 

information on states’ J-1 visa waiver requests7

 for fiscal years 2003 

through 2005 and on their views on the adequacy of the 30-waiver limit and 

having their unused waiver allotments redistributed.8

 We received a 

100 percent response rate. We reviewed the surveys for internal 

consistency and followed up with respondents to resolve discrepancies 

and clarify responses; however, we did not verify the accuracy of the 

responses. We also reviewed relevant laws, regulations, and documents, 

and interviewed officials involved in reviewing and granting waivers at the 

Departments of State and Homeland Security. We also interviewed 

officials at HHS and the Educational Commission for Foreign Medical 

Graduates—the private, nonprofit organization that sponsors foreign 

physicians as exchange visitors for graduate medical education. We shared 

facts included in this statement with officials at the Department of State,

the Department of Homeland Security, and HHS and made changes as 

appropriate. We conducted our work from August 2005 through May 2006 

in accordance with generally accepted government auditing standards. 

In summary, we found that the use of J-1 visa waivers remains a major 

means of placing physicians in underserved areas of the United States, 

with more than 1,000 waivers requested in each of the past 3 years for 

physicians to practice in nearly every state. In fiscal year 2005, states made 

more than 90 percent of these waiver requests. About 44 percent of the 

states’ waiver requests were for physicians to practice exclusively primary

care,9

 while about 41 percent were for physicians to practice exclusively 

nonprimary care specialties, such as anesthesiology or cardiology. 

Regarding practice settings, more than three-fourths of the states’ waiver 

requests were for physicians to work in hospitals or private practices. 

While states do not have explicit responsibility for monitoring physicians’ 

compliance with their waiver agreements, most states reported that they

had conducted some monitoring activities, such as requiring periodic 

reports on patients treated and conducting site visits to the practice 

 7

While comprehensive data on the number of J-1 visa waivers granted at the request of 

states do not exist, the federal agencies responsible for reviewing and granting state waiver 

requests indicated that, after review for compliance with statutory requirements and 

security issues, nearly all are recommended and approved. 

8

We did not ask states for their views on other options to accommodate states that would 

like more than 30 waivers granted at their request each year. 

9

For the purposes of this report, we define primary care to include family practice, internal

medicine, obstetrics/gynecology, and pediatrics. 

Page 3 GAO-06-773T
locations. Six states—which together accounted for about 

13 percent of all state waiver requests in fiscal year 2005—reported that 

their states had not conducted any monitoring activities that year. Finally, 

regarding the states’ authority to request waivers, about 80 percent of the 

states—including many of the states that requested the annual limit or 

close to it—reported the 30-waiver limit was adequate for their needs. 

About 13 percent, however, reported that this limit was less than adequate. 

Of the 44 states that did not always request the limit, 25 reported that they

would be willing to have their unused waiver allotments redistributed, at 

least under certain circumstances, if authorized by law. In contrast, 

another 14 states reported that they would not be willing to have their 

unused waiver allotments redistributed. These states cited concerns such 

as the possibility that physicians seeking waivers would wait until a 

redistribution period opened and apply to practice in preferred locations 

in other states. 

Many foreign physicians who enter U.S. graduate medical education 

programs do so as participants in the Department of State’s Exchange 

Visitor Program—an educational and cultural exchange program aimed at 

increasing mutual understanding between the peoples of the United States 

and other countries. Participants in the Exchange Visitor Program enter 

the United States with J-1 visas.10 More than 6,100 foreign physicians with 

J-1 visas took part in U.S. graduate medical education programs during 

academic year 2004–05. This number was about 40 percent lower than a 

Background 

 10In addition to foreign physicians seeking to pursue graduate medical education, other 

categories of exchange visitors include professors and research scholars, short-term

scholars, trainees, college and university students, teachers, secondary school students,

specialists, international visitors, government visitors, camp counselors, au pairs, and 

summer work travel. See generally 22 C.F.R. pt. 62. Exchange visitors in these other 

categories are subject to the 2-year foreign residence requirement under certain 

circumstances. See 8 U.S.C. § 1182(e)(i), (ii). For more information on the Exchange Visitor 

Program, see GAO, State Department: Stronger Action Needed to Improve Oversight and

Assess Risks of the Summer Work Travel and Trainee Categories of the Exchange Visitor 

Program, GAO-06-106 (Washington, D.C.: Oct. 14, 2005). 

Page 4 GAO-06-773T
decade earlier, when about 10,700 foreign physicians with J-1 visas were in 

U.S. graduate medical education programs.11

Physicians participating in graduate medical education on J-1 visas are 

required to return to their home country or country of last legal residence 

for at least 2 years before they may apply for an immigrant visa, permanent 

residence, or certain nonimmigrant work visas.12 They may, however, 

obtain a waiver of this requirement from the Department of Homeland 

Security at the request of a state or federal agency, if the physician has 

agreed to practice in, or work at a facility that treats residents of, an 

underserved area for at least 3 years.13

States were first authorized to request J-1 visa waivers on behalf of foreign 

physicians in October 1994.14 Initially, states were authorized to request 

waivers for up to 20 physicians each fiscal year; in 2002, the annual limit 

was increased to 30 waivers per state.15 Physicians who receive waivers 

may work in various practice settings, including federally funded health

centers and private hospitals, and they may practice both primary care and 

 11The reasons for this decline are not completely understood. Foreign physicians also enter 

the United States for graduate medical education using other visa types, such as H-1B

visas—temporary work visas for foreign nationals employed in certain specialty 

occupations. These other visa types may require the physician to meet additional statutory

or regulatory requirements, such as evidence that the physician has a license to practice 

medicine in a particular state. Reliable data are not available on the extent to which these 

other visa types are used. 

128 U.S.C. § 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. § 1258(2). 

138 U.S.C. §§ 1182(e), 1184 (l)(1)(D). Physicians may also obtain a waiver at the request of

the Department of Veterans Affairs (VA) if the physician has agreed to practice at a VA 

facility for at least 3 years. To obtain a waiver to practice in an underserved area or at a VA 

facility, such employment must also be determined by the Department of Homeland 

Security to be in the public interest. Physicians with J-1 visas may also obtain a waiver of 

the 2-year foreign residence requirement if the Department of Homeland Security 

determines that their departure from the United States would create an exceptional 

hardship for the physician’s U.S. citizen or permanent resident spouse or child or if the

return to the physician’s home country or country of last residence would subject the 

physician to persecution because of race, religion, or political opinions.

14Pub. L. No. 103-416, § 220, 108 Stat. 4305, 4319. Federal agencies were first authorized to

request J-1 visa waivers for physicians in graduate medical education in 1961. Pub. L. No. 

87-256, § 109(c), 75 Stat. 527, 534. 

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

Page 5 GAO-06-773T
nonprimary care specialties.16 States and federal agencies may impose 

additional limitations on their programs beyond federal statutory 

requirements, such as limiting the number of requests they will make for 

physicians to practice nonprimary care specialties. 

Obtaining a J-1 visa waiver through a state request involves multiple steps. 

A physician must first secure a bona fide offer of employment from a 

health care facility that is located in, or that treats residents of, an 

underserved area. The physician, the prospective employer, or both then 

submit an application to a state to request the waiver. The state submits a 

request for the waiver to the Department of State. If the Department of 

State recommends the waiver, it forwards its recommendation to the 

Department of Homeland Security’s U.S. Citizenship and Immigration 

Services (USCIS). USCIS is responsible for making the final determination 

and notifying the physician when a waiver is granted. According to 

officials involved in recommending and approving waivers at the 

Department of State and USCIS, after review for compliance with 

statutory requirements and security issues, nearly all states’ waiver 

requests are recommended and approved. Once physicians are granted 

waivers, they must work at the site specified in their waiver applications

for a minimum of 3 years.17 During this period, although states do not have 

explicit responsibility for monitoring physicians’ compliance with the 

terms and conditions of their waivers, states may conduct monitoring 

activities at their own initiative. 

For purposes of J-1 visa waivers, HHS has specified two types of 

underserved areas in which waiver physicians may practice: health 

professional shortage areas (HPSAs) and medically underserved areas and

populations (MUA/Ps).18 In general, HPSAs are areas, population groups 

within areas, or facilities that HHS has designated as having a shortage of 

primary care health professionals and are identified on the basis of, among 

 16States and federal agencies requesting waivers for nonprimary care physicians are 

required to demonstrate a shortage of health care professionals able to provide services in 

that medical specialty for the patients who would be served by that physician, based on

their own criteria. 8 U.S.C. § 1184(l)(1)(D)(iii). 

17Physicians may obtain approval from USCIS to transfer to another facility or location 

when extenuating circumstances exist, such as when the physician’s assigned facility 

closes. 

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

Page 6 GAO-06-773T
other factors, the ratio of population to primary care physicians.19 MUA/Ps

are areas or populations that HHS has designated as having shortages of 

health care services and are identified using several factors in addition to 

the availability of primary care providers.20 In 2004, Congress gave states 

the flexibility to use up to 5 of their 30 waiver allotments each year—

which we call “flexible waivers”—for physicians to work in facilities that 

serve patients who reside in a HPSA or MUA/P, regardless of the facilities’

location.21

No one federal agency is responsible for managing or tracking states’ and 

federal agencies’ use of J-1 visa waivers to place physicians in underserved

areas. Further, no comprehensive data are available on the total number of 

waivers granted for physicians to practice in underserved areas. HHS’s 

Health Resources and Services Administration is the primary federal 

agency responsible for improving access to health care services, both in 

terms of designating underserved areas and in administering programs—

such as the NHSC programs—to place physicians and other providers in 

them. However, HHS’s oversight of waiver physicians practicing in 

underserved areas has generally been limited to those physicians for 

whom HHS has requested J-1 visa waivers. 

J-1 visa waivers continue to be a major means of supplying physicians to 

underserved areas in the United States, with states and federal agencies 

reporting that they requested more than 1,000 waivers in each of fiscal 

years 2003 through 2005. We estimated that, at the end of fiscal year 2005,

the number of physicians practicing in underserved areas through the use 

Waivers Remain a 

Major Means for 

Providing Physicians, 

and States Request 

Most Waivers 

 19HHS’s Health Resources and Services Administration (HRSA) designates geographic 

areas, specific population groups within an area, or specific facilities as HPSAs. Separate

designations exist for primary care and for other health care fields, such as mental health. 

For primary care HPSAs, designation is based in part on the basis of the ratio of population

to the number of primary care physicians but may also include other factors such as health

care resources available in neighboring areas. See http://bhpr.hrsa.gov/shortage 

/hpsacrit.htm, downloaded May 15, 2006. 

20HRSA designates areas and populations as MUA/Ps. See http://bhpr.hrsa.gov/shortage 

/muaguide.htm, downloaded May 15, 2006. 

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

Page 7 GAO-06-773T
of J-1 visa waivers was roughly one and a half times the number practicing 

there through NHSC programs.22

In contrast to our findings a decade ago, states are now the primary source 

of waiver requests for physicians to practice in underserved areas. In fiscal 

year 2005, more than 90 percent of the waiver requests for physicians were 

initiated by the states, compared with fewer than 10 percent in 1995.23 (See 

fig. 1.) Every state except Puerto Rico and the U.S. Virgin Islands reported 

requesting waivers for physicians in fiscal year 2005, for a total of 956 

waiver requests. In 1995—the first full year that states had authority to 

request waivers—nearly half of the states made a total of 89 waiver 

requests. 

 22Data are not available on the number of waiver physicians practicing in underserved areas 

at any given time. We estimated that number by totaling the number of waiver requests in 

each of fiscal years 2003 through 2005–which would represent the physicians expected to 

be fulfilling their 3-year practice period or who had waivers in process to do so. We

compared that number with the number of NHSC physicians practicing in underserved 

areas as of September 30, 2005. 

23In 1995, up to 20 waivers per year could be granted in response to each state’s requests, so 

the maximum number of waivers that could be granted that year in response to the 54 

states’ requests was 1,080. Since 2002, the maximum number has been 50 percent higher, so 

the maximum number of waivers that can be granted annually in response to the 54 states’ 

requests has been 1,620.

Page 8 GAO-06-773T
Figure 1: States’ and Federal Agencies’ Requests for J-1 Visa Waivers for 

Physicians 

0

200

400

600

800

1,000

1,200

1,400

Federal agencies

States

1995 2003 2004 2005 

Sources: GAO/HEHS-97-26; GAO survey of states, 2005; GAO survey of federal agencies, 2005.

89

1,285

983

110

965

60

956

56

1,374

1,093

1,025 1,012

Number of waiver requests

Years

Note: Data apply to calendar year 1995 and fiscal years 2003 through 2005. In 1995, up to 20 

waivers per year could be granted in response to each state’s requests. Since 2002, the annual limit 

has been 30 waivers per state. 

During the past decade, the two federal agencies that requested the most 

waivers for physicians to practice in underserved areas in 1995—the 

Department of Agriculture and the Department of Housing and Urban 

Development—have discontinued their programs.24 These federal agencies 

together requested more than 1,100 waivers for physicians to practice in 47 

states in 1995, providing a significant source of waiver physicians for some 

states. For example, these federal agencies requested a total of 149 

waivers for physicians to practice in Texas, 134 for New York, and 105 for

Illinois in 1995. In fiscal year 2005, the three federal agencies that 

requested waivers for physicians to practice in underserved areas—the 

Appalachian Regional Commission, the Delta Regional Authority, and 

 24The Department of Housing and Urban Development stopped requesting waivers for 

physicians in 1996; the Department of Agriculture stopped its program in 2002. 

Page 9 GAO-06-773T
HHS—requested a total of 56 waivers for physicians to practice in 15

states.25

With diminished federal participation, states now obtain waiver physicians 

primarily through the 30 waivers they are allotted each year. The number 

of waivers states actually requested, however, varied considerably among

the states in fiscal years 2003 through 2005. For example, in fiscal year 

2005, about one-quarter of the states requested the maximum of 30 

waivers, while slightly more than a quarter requested 10 or fewer (see fig. 

2). Collectively, the 54 states requested 956 waivers, or roughly 60 percent 

of the maximum of 1,620 waivers that could have been granted at their 

request. 

 25The number of waivers requested by these agencies for physicians to practice in each of

the 15 states ranged from 1 request for each of 6 states to 14 requests for Mississippi. 

Page 10 GAO-06-773T
Figure 2: States’ Requests for J-1 Visa Waivers for Physicians to Practice in Underserved Areas, Fiscal Year 2005 

Sources: GAO survey of states (data), 2005; copyright © Corel Corp., all rights reserved (map).

1 to 10

11 to 20

21 to 29

30

PA

OR

NV

ID

MT

WY

UT

AZ NM

CO

ND

SD

NE

TX

KS

OK

MN

IA

MO

AR

LA

IL

MS

IN

KY

TN

AL

FL

GA

SC

NC

VA

OH

NH

MA

RI MI

CA

WA

WI NY

ME

VT

WV

HI

NJ

DE

MD

DC

AK

CT

Note: Guam requested two waivers in fiscal year 2005; Puerto Rico and the U.S. Virgin Islands 

requested no waivers that year. 

Page 11 GAO-06-773T
Of the waivers states requested in fiscal year 2005, about 44 percent were 

for physicians to practice exclusively primary care, while about 41 percent 

were for physicians to practice exclusively in nonprimary care specialties, 

such as anesthesiology or cardiology. An additional 7 percent were for 

physicians to practice psychiatry.26 A small proportion of requests 

(5 percent) were for physicians to practice both primary and nonprimary 

care—for example, for individual physicians who practice both internal 

medicine and cardiology (see fig. 3).

Figure 3: Specialties Practiced by Physicians for Whom States Requested J-1 Visa

Waivers, Fiscal Year 2005 

States Requested 

Waivers for 

Physicians to Work 

in a Variety of 

Practice Specialties 

and Settings 

Source: GAO survey of states, 2005.

Exclusively primary care

Exclusively nonprimary care

3%

No answer

Psychiatry

Both primary care and nonprimary care

44%

7%

41%

5%

Note: Percentages are based on 956 waivers requested by 52 states in fiscal year 2005. Puerto Rico

and the U.S. Virgin Islands did not request waivers that year. Psychiatry is reported as a separate 

medical specialty because some states’ J-1 visa waiver programs have requirements for psychiatrists 

that differ from those for other physicians. 

 26Psychiatry is reported as a separate medical specialty because some states’ J-1 visa 

waiver programs have requirements for psychiatrists that differ from those for other

physicians. For example, a state might require psychiatrists seeking J-1 visa waivers to 

practice in areas that HHS has designated as mental health HPSAs. 

Page 12 GAO-06-773T
More than 90 percent of the states that requested waivers in fiscal year 

2005 reported that, under their policies in place that year, nonprimary care 

physicians were eligible to apply for waiver requests. Some of these states 

limited these requests. For example, some states restricted the number of 

hours a physician could practice in a nonprimary care specialty. Further, 

two states reported that they accepted applications from, and requested 

waivers for, primary care physicians only. 

Regarding practice settings, more than three-fourths of the waivers 

requested by states in fiscal year 2005 were for physicians to practice in

hospitals and private practices, including group practices. In addition, 

16 percent were for physicians to practice in federally qualified health

centers—facilities that provide primary care services in underserved 

areas—or rural health clinics—facilities that provide outpatient primary 

care services in rural areas (see fig. 4). More than 80 percent of the states 

requesting waivers in fiscal year 2005 reported requiring facilities where 

the physicians worked—regardless of practice setting—to accept some 

patients who were uninsured or covered by Medicaid.27

 27Authorized under title XIX of the Social Security Act, Medicaid is the joint federal-state 

program that finances health care for certain low-income individuals. 

Page 13 GAO-06-773T
Figure 4: Practice Settings of Physicians for Whom States Requested J-1 Visa 

Waivers, Fiscal Year 2005 

Source: GAO survey of states, 2005.

Federally qualified health center

Private practice

3%

No answer

Rural health clinic

Hospital

3%

Other

5%

11%

41%

37%

Note: Percentages are based on 956 waivers requested by 52 states in fiscal year 2005. Puerto Rico

and the U.S. Virgin Islands did not request waivers that year. 

Although states do not have explicit responsibility for monitoring 

physicians’ compliance with the terms and conditions of their waivers, in 

fiscal year 2005, more than 85 percent of the states reported conducting at 

least one monitoring activity. The most common activity—reported by 40 

states—was to require periodic reports by the physician or the employer 

(see table 1). Some states required these reports to specify the number of 

hours the physician worked or the types of patients—for example, 

whether they were uninsured—whom the physician treated. 

Most States Reported 

Conducting Some 

Monitoring Activities 

Page 14 GAO-06-773T
Table 1: Monitoring Activities States Reported Conducting in Fiscal Year 2005 

Activity 

Number of states 

conducting

activity 

Percentage of

states conducting 

activity

Required periodic reports by the physician or

employer 40 75

Monitored through regular communication with 

employers 21 40

Monitored through regular communication with 

physicians 19 36

Conducted periodic site visits 18 34

Other 9 17

Source: GAO survey of states, 2005. 

Note: Reported activities are for the 53 states that requested any waivers in fiscal years 2003 through 

2005. Puerto Rico did not request waivers during that period. 

Not all states that requested waivers conducted monitoring activities. Six 

states, which collectively accounted for about 13 percent of all state 

waiver requests in fiscal year 2005, reported that they conducted no 

monitoring activities in that year. 

The majority of the states reported that the annual limit of 30 waivers per 

state was at least adequate to meet their needs for J-1 visa waiver 

physicians. When asked about their needs for additional waiver 

physicians, however, 11 states reported needing more. Furthermore, of the 

44 states that did not request their 30-waiver limit in each of fiscal years 

2003 through 2005, more than half were willing, at least under certain 

circumstances, to have their unused waiver allotments redistributed to 

other states in a given year. Such redistribution would require legislation. 

Fourteen states reported that they would not be willing to have their 

states’ unused waiver allotments redistributed. 

Most States Reported 

That the Annual Limit 

Was Adequate but 

Reported Differing 

Views on Having 

Allotments 

Redistributed 

Page 15 GAO-06-773T
About 80 percent of the states reported that the annual limit of 30 waivers 

per state was adequate or more than adequate to meet their needs for J-1 

visa waiver physicians. However, 13 percent of the states reported that the 

30-waiver limit was less than adequate (see fig. 5). 

Figure 5: States’ Views on the Adequacy of the Annual Limit of 30 J-1 Visa Waivers 

for Physicians, 2005 

Most States Reported That 

the Annual Waiver Limit 

Was Adequate, While Some 

Reported the Need for 

More 

Source: GAO survey of states, 2005.

Less or much less than adequate

More or much more than adequate

Too early to tell, don’t know, or no answer

Adequate

6%

13%

37%

44%

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

Among the 16 states that requested 29 or 30 waivers in fiscal year 2005, 10 

states reported that the annual limit was at least adequate for their needs.

The other 6 states that requested all or almost all of their allotted waivers 

that year reported that the 30-waiver limit was less than adequate. 

As mentioned earlier, states can use up to 5 of their waiver allotments for 

physicians to work in facilities located outside of HPSAs and MUA/Ps, as 

long these facilities serve patients who live in these underserved areas. 

While we inquired about states’ views on the adequacy of the annual limit

on these flexible waivers, fewer than half of the states reported requesting

flexible waivers in fiscal year 2005—the first year they were authorized to 

do so. When asked about the annual limit of 5 flexible waivers, half of the 

states (27 states) reported that this limit was at least adequate, but nearly

one-third (17 states) did not respond or reported that they were unsure of 

their need for flexible waivers. The remaining 10 states reported that the 

Page 16 GAO-06-773T
annual limit of 5 flexible waivers was less than adequate (see fig. 6). Of 

these 10 states, 8 had also reported that the annual limit of 30 waivers per 

state was at least adequate for their needs, suggesting that some states 

may be more interested in increasing the flexibility with which waivers 

may be used than in increasing the overall number of waivers each year.

Figure 6: States’ Views on the Adequacy of the Annual Limit of Five Flexible J-1 

Visa Waivers for Physicians to Practice Outside of HPSAs or MUA/Ps, 2005 

Source: GAO survey of states, 2005.

Less or much less than adequate

More or much more than adequate

Too early to tell, don’t know, or no answer

Adequate

31%

19%

19%

31%

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

In addition to commenting on the adequacy of the annual waiver limits, 

states estimated their need for additional physicians under their J-1 visa 

waiver programs. Specifically, 11 states (20 percent) estimated needing 

between 5 and 50 more waiver physicians each. Collectively, these 

11 states reported needing 200 more waiver physicians (see table 2). 

Page 17 GAO-06-773T
Table 2: Number of Additional J-1 Visa Waiver Physicians States Estimated Needing

per Year, 2005

State 

Estimated number of waiver physicians 

needed beyond annual limit of 30 

Kentucky 5

Arkansas 10

Iowa 10

Louisiana 10

Massachusetts 10

West Virginia 10

California 20

Michigan 20

Arizona 25

New York 30

Texas 50

Total 200

Source: GAO survey of states, 2005. 

Note: Data are from the 11 states that reported needing additional J-1 visa waiver physicians beyond 

the current annual limit of 30. 

Although 10 states reported requesting the annual limit of 30 waivers in 

each of fiscal years 2003 through 2005, the large majority (44 states) did 

not. When asked to provide reasons why they did not use all 30, many of 

these states reported that they received fewer than 30 applications that 

met their requirements for physicians seeking waivers through their state 

J-1 visa waiver programs. Some states, however, offered further 

explanations, which touched upon difficulties attracting physicians to the 

state, low demand for waiver physicians among health care facilities or 

communities, and mismatches between the medical specialties 

communities needed and those held by the physicians seeking waivers. 

For example: 

• Difficulties attracting waiver physicians: One state commented that the

increase in the annual limit on waivers from 20 to 30 in 2002 opened more 

positions in other states, contributing to a decrease in interest among 

physicians seeking waivers to locate in that state. Two states suggested 

that because they had no graduate medical education programs or a low 

number of them, fewer foreign physicians were familiar with their states, 

affecting their ability to attract physicians seeking J-1 visa waivers. 

• Low demand for waiver physicians: Many states noted low demand for 

foreign physicians among health care facilities or communities in the 

Page 18 GAO-06-773T
states. Two of these states commented that they had relatively few 

problems recruiting U.S. physicians. Another state commented that health

care facilities—particularly small facilities and those located in rural 

areas—may be reluctant to enter into the required 3-year contracts with 

waiver physicians because of their own budget uncertainties.

• Lack of physicians with needed specialties: One state commented that 

most communities in the state need physicians trained in family medicine 

and that few physicians with J-1 visas have that training. Similarly, another 

state noted a lack of demand among the health care facilities in the state 

for the types of medical specialties held by physicians seeking waivers. 

In response to a question about whether they had observed any significant 

changes in the number of physicians seeking J-1 visa waivers, 15 states 

reported seeing less interest from physicians, or fewer applications, since 

2001. Some states suggested that the decline might be due to an overall

reduction in the number of physicians with J-1 visas who were in graduate

medical education programs. Three states mentioned the possibility that 

more physicians may be opting to participate in graduate medical 

education on an H-1B visa, which does not have the same foreign 

residence requirement as a J-1 visa. 

Of the 44 states that did not use all of their waiver allotments in each of 

fiscal years 2003 through 2005, slightly over half (25 states) reported that

they would be willing, at least under certain circumstances, to have their 

unused waiver allotments redistributed to other states. In contrast, about 

one-third of the states with unused waiver allotments (14 states) reported 

that they would not be willing to have their unused waiver allotments 

redistributed. (See table 3 and, for further details on states’ responses, see 

app. I.) 

States’ Views Differed on 

Having Unused Waiver 

Allotments Redistributed 

Page 19 GAO-06-773T
Table 3: Views Reported by States with Unused Waiver Allotments on Their 

Willingness to Have Them Redistributed, 2005. 

Willingness to have their unused waiver 

allotments redistributed 

Number of 

states 

Total number of

unused waiver 

allotments in fiscal 

year 2005 

Willing 11 161

Willing under certain circumstances 14 237

Not willing 14 200

No opinion 2 23

Don’t know/no answer 3 43

Total 44 664

Source: GAO survey of states, 2005. 

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

years 2003 through 2005. 

The 14 states that reported they would be willing under certain

circumstances to have their unused waiver allotments redistributed listed 

a variety of conditions under which they would be willing to do so, if 

authorized by law. These conditions centered around the timing for 

redistribution, the approach for redistribution, and the possibility for 

compensation. 

• Timing of redistribution: Seven states reported that their willingness to 

have their unused waiver allotments redistributed depended in part on 

when the redistribution would occur in a given year. Their comments 

suggested concerns about states being asked to give up unused waiver 

allotments before having fully determined their own needs for them. For 

example, three states reported that they would be willing to release at 

least a portion of their unused waiver allotments midway through the 

fiscal year. One state reported that it would be willing to have its unused 

waiver allotments redistributed once the state reached an optimal 

physician-to-population ratio. Finally, two states specified that states 

benefiting from any redistribution should be required to use the 

redistributed waivers within the same fiscal year.

• Approach for redistribution: Three states reported that their willingness 

to have their unused waiver allotments redistributed depended on how the 

redistribution would be accomplished. Two states reported a willingness 

to do so if the allotments were redistributed on a regional basis—such as 

among midwestern or southwestern states. Another state reported that it 

would be willing to have its unused waiver allotments redistributed to 

states with high long-term vacancy rates for physicians. This state was also 

Page 20 GAO-06-773T
willing to have its unused waiver allotments redistributed in emergency 

relief situations, such as Hurricane Katrina’s aftermath, to help attract 

physicians to devastated areas. 

• Possibility for compensation: Two states stated that they would be 

willing to have their unused waiver allotments redistributed if they were 

somehow compensated. One state remarked that it would like more 

flexible waiver allotments, equal to the number of unused waiver 

allotments that were redistributed. The other state did not specify the form 

of compensation. 

• Other issues: One state commented that it would be willing to have its 

unused waiver allotments redistributed as long as redistribution did not 

affect the number of waivers it could request in future years. Another state 

responded that any provision to have unused waiver allotments 

redistributed would need to be pilot-tested for 2 years so that its effect 

could be evaluated. 

The 14 states that reported that they would not be willing to have their 

unused waiver allotments redistributed to other states cited varied 

concerns. Several states commented that, because of physicians’ location 

preferences and differences in states’ J-1 visa waiver program 

requirements, a redistribution of unused waiver allotments could possibly 

reduce the number of physicians seeking waivers to practice in certain 

states. 

• Physician location preferences: Three states commented that physicians 

seeking J-1 visa waivers might wait until a redistribution period opened so

that they could apply for waivers to practice in preferred states. As one 

state put it, if additional waivers were provided to certain states, a 

physician might turn down the “number 15 slot” in one state to accept the

“number 40 slot” in another. This concern was also raised by four states 

that reported they were willing to have their unused waiver allotments 

redistributed under certain circumstances; two of these states specifically

mentioned the possible negative impact that redistribution could have on

rural areas. 

• Differences in state program requirements: One state commented that 

until state requirements for waivers were made consistent among states, 

having unused waiver allotments redistributed would benefit states with 

more lenient requirements or force states with more stringent 

requirements to change their policies. While this state did not specify what

it considered to be stringent or lenient requirements, substantial 

differences in state programs do exist. For example, some states restrict 

their waiver requests solely to primary care physicians, while others place 

no limits on the number of allotted waivers they request for nonprimary 

care physicians. In another example, four states require 4- or 5-year 

Page 21 GAO-06-773T
contracts for all physicians or for physicians in certain specialties. One 

state commented that if it lost an unused waiver allotment to a state with 

more lenient requirements, it would have given away to another state a 

potential resource that it had denied its own communities. 

Mr. Chairman, this concludes my prepared statement. I will be happy to 

answer any questions that you or Members of the Subcommittee may have. 

For information regarding this testimony, please contact Leslie G. 

Aronovitz at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this statement. Kim Yamane, Assistant Director; Ellen W. Chu; 

Jill Hodges; Julian Klazkin; Linda Y.A. McIver; and Perry G. Parsons made 

key contributions to this statement. 

Contact and 

Acknowledgments 

Page 22 GAO-06-773T
Page 23 GAO-06-773T

Number of waivers states 

reported requesting in each

fiscal year 

State 2003 2004 2005

Views on adequacy of

annual limit of 30 

waivers 

Views on adequacy of

annual limit of 5 flexible

waivers 

Willingness to have 

unused waiver 

allotments redistributed

to other states 

Alabama 18 19 24 Adequate Adequate Yes

Alaska 5 0 1 Adequate Adequate Yes, under certain

circumstances

Arizona 30 30 30 Adequate Adequate a

Arkansas 30 30 29 Less than adequate Don’t know Yes 

California 30 30 30 Much less than adequate No answer a

Colorado 11 3 5 Much more than

adequate 

Much more than 

adequate 

Don’t know 

Connecticut 27 30 26 More than adequate No answer Yes 

Delaware 21 21 16 Adequate Adequate Yes, under certain

circumstances

District of 

Columbia 

3 9 3 More than adequate Less than adequate Yes 

Florida 30 30 30 Adequate No answer a

Georgia 30 30 28 Adequate More than adequate Yes 

Guam 0 1 2 Much more than

adequate 

Much more than 

adequate 

Yes 

Hawaii 2 1 4 More than adequate More than adequate Yes, under certain 

circumstances

Idaho 0 0 1 More than adequate More than adequate No 

Illinois 28 30 30 Adequate Too early to tell No 

Indiana 27 30 30 Adequate Adequate No

Iowa 30 30 28 Less than adequate Too early to tell Yes, under certain 

circumstances

Kansas 14 26 17 Adequate Adequate Yes, under certain

circumstances

Kentucky 30 30 30 Adequate Less than adequate a

Louisiana 15 13 10 Too early to tell Adequate No 

Maine 29 18 25 More than adequate Adequate No 

Maryland 15 22 29 Adequate Adequate Yes, under certain

circumstances

Massachusetts 28 30 30 Less than adequate No answer No answer 

Michigan 30 30 30 Less than adequate Less than adequate a

Minnesota 30 15 21 Adequate Too early to tell Yes 

Mississippi 19 17 18 Adequate Less than adequate No 

Appendix I: State Responses to Selected 

Survey Questions 
Number of waivers states 

reported requesting in each

fiscal year 

State 2003 2004 2005

Views on adequacy of

annual limit of 30 

waivers 

Views on adequacy of

annual limit of 5 flexible

waivers 

Willingness to have 

unused waiver 

allotments redistributed

to other states 

Missouri 30 30 30 More than adequate Much more than

adequate 

a

Montana 2 1 2 More than adequate Adequate Yes, under certain 

circumstances

Nebraska 15 7 13 Adequate Adequate Yes, under certain

circumstances

Nevada 26 18 13 Adequate Adequate No

New Hampshire 6 11 15 Much more than

adequate 

Less than adequate Yes, under certain 

circumstances

New Jersey 2 1 2 Much more than 

adequate 

Adequate Yes, under certain 

circumstances

New Mexico 29 27 29 Adequate Adequate Yes

New York 30 30 30 Less than adequate Too early to tell a

North Carolina 10 11 16 More than adequate More than adequate No 

North Dakota 11 13 6 More than adequate Much less than adequate Yes, under certain 

circumstances

Ohio 30 30 30 Adequate Much more than

adequate 

a

Oklahoma 0 17 12 More than adequate Less than adequate No 

Oregon 20 19 22 Adequate Too early to tell Yes, under certain 

circumstances

Pennsylvania 13 16 22 More than adequate Too early to tell No 

Puerto Rico 0 0 0 Much more than

adequate 

Much more than 

adequate 

Yes 

Rhode Island 30 30 30 Adequate Too early to tell a

South Carolina 30 26 21 Adequate Adequate No

South Dakota 10 6 6 Much more than

adequate 

Too early to tell No 

Tennessee 21 27 12 Adequate Too early to tell No 

Texas 30 30 30 Much less than adequate Adequate a

Utah 4 6 5 Much more than

adequate 

Don’t know Yes 

Vermont 0 1 2 Adequate Less than adequate Yes 

Virgin Islands 1 0 0 Too early to tell More than adequate Yes, under certain 

circumstances

Virginia 17 13 19 No answer Much less than adequate No opinion 

Washington 30 30 28 Adequate Too early to tell Yes, under certain 

circumstances

West Virginia 22 14 18 Adequate Adequate No opinion

Page 24 GAO-06-773T
Number of waivers states 

reported requesting in each

fiscal year 

State 2003 2004 2005

Views on adequacy of

annual limit of 30 

waivers 

Views on adequacy of

annual limit of 5 flexible

waivers 

Willingness to have 

unused waiver 

allotments redistributed

to other states 

Wisconsin 29 23 12 More than adequate Too early to tell Don’t know 

Wyoming 3 3 4 Much more than

adequate 

Much less than adequate No 

Source: GAO survey of states, 2005. 

a

States that requested 30 waivers in each of fiscal years 2003 through 2005 were not asked about

their willingness to have unused waiver allotments redistributed to other states. 

Page 25 GAO-06-773T
Page 26 GAO-06-773T

Related GAO Products 

State Department: Stronger Action Needed to Improve Oversight and 

Assess Risks of the Summer Work Travel and Trainee Categories of the 

Exchange Visitor Program. GAO-06-106. Washington, D.C.: October 14,

2005. 

Health Workforce: Ensuring Adequate Supply and Distribution Remains

Challenging. GAO-01-1042T. Washington, D.C.: August 1, 2001. 

Health Care Access: Programs for Underserved Populations Could Be 

Improved. GAO/T-HEHS-00-81. Washington, D.C.: March 23, 2000. 

Foreign Physicians: Exchange Visitor Program Becoming Major Route 

to Practicing in U.S. Underserved Areas. GAO/HEHS-97-26. Washington,

D.C.: December 30, 1996.

Health Care Shortage Areas: Designations Not a Useful Tool for 

Directing Resources to the Underserved. GAO/HEHS-95-200. Washington,

D.C.: September 8, 1995. 

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