108TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 2d Session 108–730 

TO IMPROVE ACCESS TO PHYSICIANS IN MEDICALLY 

UNDERSERVED AREAS 

OCTOBER 5, 2004.—Committed to the Committee of the Whole House on the State 

of the Union and ordered to be printed 

Mr. SENSENBRENNER, from the Committee on the Judiciary, 

submitted the following 

R E P O R T 

[To accompany H.R. 4453] 

[Including Committee Cost Estimate] 

The Committee on the Judiciary, to whom was referred the bill 

(H.R. 4453) to improve access to physicians in medically underserved areas, having considered the same, reports favorably thereon with an amendment and recommends that the bill as amended 

do pass. 

CONTENTS 

Page 

The Amendment ...................................................................................................... 1 

Purpose and Summary ............................................................................................ 2 

Background and Need for the Legislation ............................................................. 2 

Hearings ................................................................................................................... 4 

Committee Consideration ........................................................................................ 4 

Vote of the Committee ............................................................................................. 4 

Committee Oversight Findings ............................................................................... 4 

New Budget Authority and Tax Expenditures ...................................................... 4 

Committee Cost Estimate ....................................................................................... 4 

Performance Goals and Objectives ......................................................................... 5 

Constitutional Authority Statement ...................................................................... 5 

Section-by-Section Analysis and Discussion .......................................................... 5 

Changes in Existing Law Made by the Bill, as Reported ..................................... 6 

Markup Transcript .................................................................................................. 7 

THE AMENDMENT

The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

2 

1See Immigration and Nationality Act § 212(e)(iii). 

SECTION 1. MODIFICATION OF VISA REQUIREMENTS WITH RESPECT TO INTERNATIONAL 

MEDICAL GRADUATES. 

(a) EXTENSION OF DEADLINE.— 

(1) IN GENERAL.—Section 220(c) of the Immigration and Nationality Technical Corrections Act of 1994 (8 U.S.C. 1182 note) (as amended by section 11018 

of Public Law 107–273) is amended by striking ‘‘2004.’’ and inserting ‘‘2006.’’. 

(2) EFFECTIVE DATE.—The amendment made by paragraph (1) shall take effect as if enacted on May 31, 2004. 

(b) EXEMPTION FROM H–1B NUMERICAL LIMITATIONS.—Section 214(l)(2)(A) of 

the Immigration and Nationality Act (8 U.S.C. 1184(l)(2)(A)) is amended by adding 

at the end the following: ‘‘The numerical limitations contained in subsection 

(g)(1)(A) shall not apply to any alien whose status is changed under the preceding 

sentence, if the alien obtained a waiver of the 2-year foreign residence requirement 

upon a request by an interested Federal agency or an interested State agency.’’. 

(c) LIMITATION ON MEDICAL PRACTICE AREAS.—Section 214(l)(1)(D) of the Immigration and Nationality Act (8 U.S.C. 1184(l)(1)(D)) is amended by striking ‘‘agrees 

to practice medicine’’ and inserting ‘‘agrees to practice primary care or specialty 

medicine’’. 

(d) EXEMPTION FROM GEOGRAPHIC LIMITATIONS.—Section 214(l)(1)(D) of the Immigration and Nationality Act (8 U.S.C. 1184(l)(1)(D)), as amended by subsection (c), 

is further amended— 

(1) by striking ‘‘except that,’’ and all that follows through the period at the 

end and inserting ‘‘except that—’’; and 

(2) by adding at the end the following: 

‘‘(i) in the case of a request by the Department of Veterans Affairs, the 

alien shall not be required to practice medicine in a geographic area designated by the Secretary; and 

‘‘(ii) in the case of a request by an interested State agency, the head 

of such State agency determines that the alien is to practice medicine under 

such agreement in a facility that serves patients who reside in one or more 

geographic areas so designated by the Secretary of Health and Human 

Services (without regard to whether such facility is within such a designated geographic area), and the grant of such waiver would not cause the 

number of the waivers granted on behalf of aliens for such State for a fiscal 

year (within the limitation described in subparagraph (B)) in accordance 

with the conditions of this clause to exceed 5.’’. 

PURPOSE AND SUMMARY

H.R. 4453 would extend and modify the program whereby aliens 

who participate in medical residencies in the United States on exchange program visas (known as ‘‘J’’ visas) do not have to leave the 

U.S. at the conclusion of their residencies to reside abroad for 2 

years if they agree to practice medicine for 3 years in an area designated by the Secretary of Health and Human Services (‘‘HHS’’) 

as having a shortage of health care professionals. 

BACKGROUND AND NEED FOR THE LEGISLATION

I. BACKGROUND

Aliens who participate in medical residencies in the United 

States on ‘‘J’’ exchange program visas must generally leave the 

U.S. at the conclusion of their residencies to reside abroad for 2 

years before they can be eligible for permanent residence or status 

as ‘‘H-1B’’ or ‘‘L’’ visa nonimmigrants.1 The intent behind this policy is to encourage American-trained foreign doctors to return home 

to improve health conditions and advance the medical profession in 

their native countries. 

In 1994, Congress created a waiver (until June 1, 1996) of the 

2-year foreign residence requirement when a state department of 

public health requested it for a foreign doctors who committed to 

3 

2See the Immigration and Nationality Technical Corrections Act, Pub. L. No. 103–416, § 220 

(1994). 3See the Illegal Immigration Reform and Immigrant Responsibility Act, Pub. L. No. 104–208, 

§ 622 (1996). 4See the 21st Century Department of Justice Appropriations Authorization Act, Pub. L. No. 

107–273, § 11018 (2002). Section 11018 incorporated the language of H.R. 4858, which was reported by the House Judiciary Committee on June 24, 2002, and passed the House on June 25, 

2002. 5See INA § 212(e). 6See INA § 214(l)(1). 7See The American Competitiveness in the Twenty-First Century Act of 2000, Pub L. No. 

106–313, § 114 (2000). The H-1B quota is now 65,000 each fiscal year. See INA § 214(g)(1)(A). 

practicing medicine for no less than 3 years in a geographic area 

or areas designated by the Secretary of HHS as having a shortage 

of health care professionals.2 The number of foreign doctors who 

could receive the waiver was limited to 20 per state. In 1996, Congress extended the waiver to June 1, 2002.3 In 2002, Congress extended the waiver until June 1, 2004.4 At the same time, the numerical limitation on waivers was increased to 30 per state. 

The waiver requirements are as follows: the Secretary of Homeland Security may authorize a waiver upon the request of an interested U.S. government agency or a director of a state department 

of public health (or its equivalent) as in the public interest 5 if: 

1) in the case of an alien who is otherwise contractually obligated to return to a foreign country, the government of such 

country furnishes the U.S. government with a statement in 

writing that it has no objection to a waiver, 

2) the alien demonstrates a bona fide offer of full-time employment at a health facility or health care organization and that 

employment has been determined by the Secretary of Homeland Security to be in the public interest, 

3) the alien agrees to begin employment within 90 days of receiving the waiver, and agrees to continue to work for not less 

than 3 years (unless the Secretary determines that extenuating 

circumstances exist, such as closure of the facility or hardship 

to the alien, which would justify a lesser period of employment 

at such facility or organization, in which case the alien must 

demonstrate another bona fide offer of employment at a health 

care facility or health care organization for the remainder of 

the 3 year period), and 

4) the alien agrees to practice medicine for the 3 year period 

only in the geographic area or areas which are designated by 

the Secretary of HHS as having a shortage of health care professionals (except in the case of a request by the Department 

of Veterans Affairs or in the case of a request by an interested 

Federal agency to employ the alien full-time in medical research or training).6

II. THE BILL AS REPORTED

H.R. 4453 as introduced would have extended the waiver for a 

year and continued the practice of allowing foreign doctors receiving a waiver to receive H-1B nonimmigrant status regardless of the 

annual H-1B visa quota.7 At the full Committee markup, Representatives Hostettler and Jackson Lee offered an amendment in 

the nature of a substitute that would extend the program until 

June 1, 2006, specify that the H-1B cap exemption would apply to 

4 

doctors whether they were sponsored by a state or Federal agency, 

allow foreign doctors receiving a waiver to work in medically-underserved areas in either primary care or specialty medicine, and 

allow five of each state’s 30 waivers to go to doctors that would 

practice medicine in areas not designated by the Secretary of 

Health and Human Services as having a shortage of health care 

professionals, if the doctors receiving the waivers would practice in 

facilities that serve patients who reside in areas designated by the 

Secretary as having a shortage of health care professionals. The 

Committee adopted the Hostettler-Jackson Lee amendment in the 

nature of a substitute, and the bill as reported reflects that text. 

HEARINGS

No hearings were held in the Committee on the Judiciary on 

H.R. 4453. 

COMMITTEE CONSIDERATION

On June 3, 2004, the Subcommittee on Immigration, Border Security, and Claims met in open session and ordered favorably reported the bill H.R. 4453, without amendment, by a voice vote, a 

quorum being present. On September 30, 2004, the Committee met 

in open session and ordered favorably reported the bill H.R. 4453, 

with an amendment, by a voice vote, a quorum being present. 

VOTE OF THE COMMITTEE

In compliance with clause 3(b) of rule XIII of the Rules of the 

House of Representatives, the Committee notes that there were no 

recorded votes during the Committee’s consideration of H.R. 4453. 

COMMITTEE OVERSIGHT FINDINGS

In compliance with clause 3(c)(1) of rule XIII of the Rules of the 

House of Representatives, the Committee reports that the findings 

and recommendations of the Committee, based on oversight activities under clause 2(b)(1) of rule X of the Rules of the House of Representatives, are incorporated in the descriptive portions of this report. 

NEW BUDGET AUTHORITY AND TAX EXPENDITURES

Clause 3(c)(2) of rule XIII of the Rules of the House of Representatives is inapplicable because this legislation does not provide new 

budgetary authority or increased tax expenditures. 

COMMITTEE COST ESTIMATE

In compliance with clause 3(d)(2) of rule XIII of the Rules of the 

House of Representatives, the Committee believes that the bill will 

have no significant cost for the current fiscal year, and no significant cost for the next five fiscal years. The Committee did not receive any estimates of the costs of this legislation from any other 

government agency as outlined in clause 3(d)(2)(B) of rule XIII. The 

bill does not authorize programs so the Committee cannot provide 

a comparison with relevant programs under current law as outlined in clause 3(d)(2)(C) of rule XIII. 

5 

PERFORMANCE GOALS AND OBJECTIVES

The Committee states that pursuant to clause 3(c)(4) of rule XIII 

of the Rules of the House of Representatives, H.R. 4453 would extend and modify the program whereby aliens who participate in 

medical residencies in the United States on ‘‘J’’ exchange program 

visas do not have to leave the U.S. at the conclusion of their 

residencies to reside abroad for 2 years if they agree to practice 

medicine for 3 years in an area designated by the Secretary of 

Health and Human Services as having a shortage of health care 

professionals. This would increase the availability of doctors in 

these underserved areas. 

CONSTITUTIONAL AUTHORITY STATEMENT

Pursuant to clause 3(d)(1) of rule XIII of the Rules of the House 

of Representatives, the Committee finds the authority for this legislation in article I, § 8 of the Constitution. 

SECTION-BY-SECTION ANALYSIS AND DISCUSSION

The following discussion describes the bill as reported by the 

Committee. 

Section 1. Modification of Visa Requirements with Respect to International Medical Graduates. 

Subsection 1(a) would amend § 220(c) of the Immigration and Nationality Technical Corrections Act of 1994 to extend until June 1, 

2006, the program under which aliens who participate in medical 

residencies in the United States on ‘‘J’’ exchange program visas do 

not have to leave the U.S. at the conclusion of their residencies to 

reside abroad for 2 years if they agree to practice medicine for 3 

years in an area designated by the Secretary of HHS as having a 

shortage of health care professionals. This change shall take effect 

as if enacted on May 31, 2004. 

Subsection 1(b) would amend § 214(l)(2)(A) of the Immigration 

and Nationality Act to provide that the 65,000 annual H-1B visa 

numerical limitation shall not apply to any alien who has obtained 

a waiver of the 2 year foreign residence requirement upon a request by an interested Federal agency or an interested state agency. 

Subsection 1(c) would amend § 214(l)(1)(D) of the Immigration 

and Nationality Act to clarify that an alien participating in the 

waiver program can practice primary care or specialty medicine. 

Subsection (d) would amend § 214(l)(1)(D) of the Immigration and 

Nationality Act to provide that for up to five of a state’s 30 yearly 

waivers, the head of an interested state agency may determine that 

the alien may practice medicine in a facility that serves patients 

who reside in one or more geographic areas designated by the Secretary of the Department of HHS as having a shortage of health 

care professionals without regard to whether such facility is within 

such a designated geographic area. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

6 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italics, 

existing law in which no change is proposed is shown in roman): 

SECTION 220 OF THE IMMIGRATION AND NATIONALITY 

TECHNICAL CORRECTIONS ACT OF 1994 

SEC. 220. WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT 

WITH RESPECT TO INTERNATIONAL MEDICAL GRADUATES. 

(a) * * * 

* * * * * * * 

(c) EFFECTIVE DATE.—The amendments made by this section 

shall apply to aliens admitted to the United States under section 

101(a)(15)(J) of the Immigration and Nationality Act, or acquiring 

such status after admission to the United States, before, on, or 

after the date of enactment of this Act and before June 1, ø2004.¿ 

2006. 

SECTION 214 OF THE IMMIGRATION AND 

NATIONALITY ACT 

ADMISSION OF NONIMMIGRANTS

SEC. 214. (a) * * * 

* * * * * * * 

(l)(1) In the case of a request by an interested State agency, 

or by an interested Federal agency, for a waiver of the 2-year foreign residence requirement under section 212(e) on behalf of an 

alien described in clause (iii) of such section, the Attorney General 

shall not grant such waiver unless— 

(A) * * * 

* * * * * * * 

(D) in the case of a request by an interested Federal agency (other than a request by an interested Federal agency to 

employ the alien full-time in medical research or training) or 

by an interested State agency, the alien øagrees to practice 

medicine¿ agrees to practice primary care or specialty medicine 

in accordance with paragraph (2) for a total of not less than 

3 years only in the geographic area or areas which are designated by the Secretary of Health and Human Services as 

having a shortage of health care professionals, øexcept that, in 

the case of a request by the Department of Veterans Affairs, 

the alien shall not be required to practice medicine in a geographic area designated by the Secretary.¿ except that— 

(i) in the case of a request by the Department of Veterans Affairs, the alien shall not be required to practice 

medicine in a geographic area designated by the Secretary; 

and 

(ii) in the case of a request by an interested State agency, the head of such State agency determines that the alien 

is to practice medicine under such agreement in a facility 

that serves patients who reside in one or more geographic 

7 

areas so designated by the Secretary of Health and Human 

Services (without regard to whether such facility is within 

such a designated geographic area), and the grant of such 

waiver would not cause the number of the waivers granted 

on behalf of aliens for such State for a fiscal year (within 

the limitation described in subparagraph (B)) in accordance with the conditions of this clause to exceed 5. 

(2)(A) Notwithstanding section 248(2), the Attorney General may change the status of an alien who qualifies under this 

subsection and section 212(e) to that of an alien described in 

section 101(a)(15)(H)(i)(b). The numerical limitations contained 

in subsection (g)(1)(A) shall not apply to any alien whose status 

is changed under the preceding sentence, if the alien obtained 

a waiver of the 2-year foreign residence requirement upon a request by an interested Federal agency or an interested State 

agency. 

* * * * * * * 

MARKUP TRANSCRIPT

BUSINESS MEETING 

THURSDAY, SEPTEMBER 30, 2004 

HOUSE OF REPRESENTATIVES, 

COMMITTEE ON THE JUDICIARY, 

Washington, DC. 

The Committee met, pursuant to notice, at 10:05 a.m., in Room 

2141, Rayburn House Office Building, Hon. F. James Sensenbrenner, Jr. [Chairman of the Committee] presiding. 

[Intervening business.] 

Chairman SENSENBRENNER. The next item on the agenda is the 

adoption of H.R. 4453, the ‘‘Access to Rural Physicians Improvement Act of 2004.’’ The Chair recognizes the gentleman from Indiana, Mr. Hostettler, the Chairman of the Subcommittee on Immigration, Border Security, and Claims for a motion. 

Mr. HOSTETTLER. And, Mr. Chairman, the Subcommittee on Immigration, Border Security, and Claims reports favorably the bill, 

H.R. 4453, and moves its favorable recommendation to the full 

House. 

Chairman SENSENBRENNER. Without objection, the bill will be 

considered as read and open for amendment at any point. The 

Chair recognizes the gentleman from Indiana to strike the last 

word. 

[The bill, H.R. 4453, follows:] 

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Mr. HOSTETTLER. Thank you, Mr. Chairman. Today we are marking up Terry Moran’s bill, H.R. 4453, the Access to Rural Physicians Improvement Act of 2004. Aliens who participate in medical 

residencies in the United States on J exchange program visas must 

generally leave the U.S. after the completion of their residencies to 

reside abroad for 2 years. After this foreign residency they can be 

eligible for permanent residence or status as H-1B or L visa nonimmigrants. The intent behind the policy is to encourage American 

trained foreign doctors to return home to improve health conditions 

and advance the medical profession in their native countries. 

In 1994, Congress created a waiver of the 2-year foreign residence requirement. State departments of health, public health may 

request a waiver for foreign doctors to commit to practicing medicine for no less than 3 years in geographic areas designated by the 

Secretary of Health and Human Services as having a shortage of 

health care professionals. The number of foreign doctors who could 

receive the waiver was limited to 20 per State. 

In 1996, Congress extended the waiver to June 1, 2002. In 2002, 

Congress extended the waiver until June 2004. At the same time 

the numerical limitation on waivers was increased to 30 per State. 

The waiver has proven to be an important means of ensuring quality medical care in areas of the United States with physician shortages. 

H.R. 4453, as introduced by Mr. Moran, as approved by the Immigration, Border Security, and Claims Subcommittee would extend the waiver until 1 year after the bill’s date of enactment. I 

plan to have the Subcommittee utilize that time frame to investigate the impact of foreign students and residents on comparable 

Americans before deciding on the longer term status of the program. 

Ms. Jackson Lee and I have agreed to offer a substitute amendment that will extend the program until June 2006 and give the 

Committee a bit more time to consider the issue. A number of organizations have proposed that States be able to utilize their waivers 

in locations not designated as physician shortage areas by the Department of Health and Human Services. Not surprisingly, HHS is 

very much opposed to such proposals. I was hesitant to eliminate 

this requirement for all waivers without a hearing. The substitute 

that Ms. Jackson Lee and I will offer will allow each State to place 

five of the doctors it sponsors each year in areas not designated by 

HHS as physician shortage areas. The Committee will then have 

a year and a half to examine this pilot program and decide whether 

to extend it to the entire waiver program. 

I urge my colleagues to support H.R. 4453 and to support my and 

Ms. Jackson Lee’s substitute amendment. 

Chairman SENSENBRENNER. The gentlewoman from Texas, Ms. 

Jackson Lee. 

Ms. JACKSON LEE. I thank the Chairman very much, and I thank 

the Chairman of the Subcommittee and his cooperation and working with me on the upcoming amendment to the Access to Rural 

Physicians Improvement Act of 2004, H.R. 4453. In our hearings of 

course it was certainly determined and acknowledged that the utilization of the J-1 visas to assist with physicians in rural communities is pivotal. In fact, it is a key element to good health in America. I would not want to say to our rural communities throughout 

12 

America today that we were not allowing good strong professional 

physicians to be able to come into the community to provide good 

health care. 

The Chairman and myself have agreed from the beginning that 

the J-1 visa waiver program for doctors in underserved areas 

should be continued. But we have had, as I have indicated, significant differences of opinions over the details of extending the program. I wanted a 5-year program, which Members of the Senate 

joined me in, and also greater flexibility in dealing with the State 

health departments. I am gratified, however, that we are willing 

and collaborating on a compromise that will provide a 2-year extension and as well give some flexibility. Aliens who attend medical 

school in the United States on J exchange program visas generally 

must leave the country afterwards and reside abroad for 2 years 

before they can apply for another visa on some other basis such as 

an H-1B visa or an L visa. 

In 1994, Congress created a temporary waiver of the 2-year foreign residence requirement. It applied to foreign doctors who would 

commit to practicing medicine for no less than 3 years in a geographic area designated by the Secretary of Health and Human 

Services as having a shortage of health care professionals. This 

program has been successful for 10 years in bringing highly qualified physicians to medically underserved areas. It is sunsetting on 

June 1 of this year. 

The first physician recommended for a waiver in Texas was a 

doctor Maria Camacho, a pediatric internist. Her services to the 

residents of Harlingen in Cameron County provide a level of health 

care to children that was previously unable in that country. It is 

extremely important that she happens to be of course bilingual. Additionally, she serves on the faculty of the Valley Regional Academic Health Center to train new physicians. 

Dr. K.M. Moorthi is a nephrologist who was recommended for a 

waiver to serve at a facility in Pecos, Texas in Reeves County. He 

works at a brand new dialysis center. Patients requiring dialysis 

three times per week in that part of Texas used to have to travel 

more than 70 miles each way for treatments. Now it is available 

in this area. 

Where else throughout the Nation do we find those same circumstances? The Gateway Community Clinic in Laredo is a federally qualified health center on the Texas-Mexico border. It obtained 

a J-1B waiver for Dr. Garcia-Cavazos. This doctor is a 

rheumatologist who provides specialty services to a patient population without regard to their insurance status or their ability to 

pay. The Access to Rural Physicians Improvement Act would authorize a 1-year extension of the waiver. 

Our amendment, which is in the nature of a substitute, would 

provide a 2-year extension. It also has a pilot flexibility provision 

which would allow a State agency to place a doctor in an area that 

has not been designated as underserved if the doctor will nevertheless serve patients from an underserved area. This exception is limited to five doctors in each State. I would venture to say that every 

Member of Congress, House and Senate, would be impacted positively by this compromise amendment, and I am gratified to be 

able to offer it and to support it. 

13 

Under the Access to Rural Physicians Improvement Act H-1B 

doctors who receive the waiver to serve at a State facility do not 

count towards the annual H-1B cap. Our amendment makes the 

same provision for H-1B doctors who serve at a Federal facility. 

The amendment also permits Federal J-1 visa waivers to apply to 

specialists in addition to the primary care physicians. 

I would urge my colleagues to support the underlying legislation 

with the amendment, and I would venture to say that this amendment will contribute to positive health care in America. With that, 

I yield back and I thank the Chairman. 

Chairman SENSENBRENNER. Without objection, all Members’ 

opening statements will appear in the record at this point. 

[The prepared statement of Ms. Jackson Lee follows:] 

PREPARED STATEMENT OF THE HONORABLE SHEILA JACKSON LEE, A REPRESENTATIVE

IN CONGRESS FROM THE STATE OF TEXAS, AND RANKING MEMBER, SUBCOMMITTEE

ON IMMIGRATION, BORDER SECURITY, AND CLAIMS

I want to thank my distinguished colleague, the gentleman from Indiana, Mr. 

Hostettler, for working with me on this amendment to the Access to Rural Physicians Improvement Act of 2004, H.R. 4453. Although we have agreed from the beginning that the J-1 visa waiver program for doctors in underserved areas should 

be continued, we have had significant differences of opinion over the details of extending the program. I appreciate Mr. Hostettler’s willingness to negotiate a compromise that can be moved forward as a bipartisan bill. 

Aliens who attend medical school in the United States on J exchange program 

visas generally must leave the country afterwards and reside abroad for two years 

before they can apply for another visa on some other basis, such as an H-1B or an 

L visa. In 1994, Congress created a temporary waiver of the two-year foreign residence requirement. It applied to foreign doctors who would commit to practicing 

medicine for no less than three years in a geographic area designated by the Secretary of Health and Human Services as having a shortage of health care professionals. This program has been successful for ten years in bringing highly qualified 

physicians to medically underserved areas. It sunsetted on June 1st of this year. 

The first physician recommended for a waiver in Texas was Dr. Maria Camacho, 

a Pediatric Intensivist. Her services to the residents of Harlingen in Cameron County provide a level of health care to children that was previously unavailable in that 

county. Additionally, she serves on the faculty of the Valley Regional Academic 

Health Center to train new physicians. 

Dr. K. M. Moorthi is a Nephrologist who was recommended for a waiver to serve 

at a facility in Pecos, Texas, in Reeves County. He works at a brand new dialysis 

center. Patients requiring dialysis 3 times per week in that part of Texas used to 

have to travel more than 70 miles each way for the treatments. Now it is available 

in Pecos. 

The Gateway Community Clinic in Laredo is a Federally Qualified Health Center 

on the Texas-Mexico border. It obtained a J-1 waiver for Dr. Rogelio GarciaCavazos. This doctor is a Rheumatologist who provides specialty services to a patient population without regard to their insurance status or their ability to pay. 

The Access to Rural Physicians Improvement Act would authorize a one-year extension of the waiver. Our amendment, which is in the nature of a substitute, would 

provide a two-year extension. It also has a pilot flexibility provision which would 

allow a state agency to place a doctor in an area that has not been designated as 

underserved if the doctor will nevertheless serve patients from an underserved area. 

This exception is limited to five doctors in each state. 

Under the Access to Rural Physicians Improvement Act, H-1B doctors who receive 

the waiver to serve at a state facility do not count towards the annual H-1B cap. 

Our amendment makes the same provision for H-1B doctors who serve at a federal 

facility. The amendment also permits federal J-1 visa waivers to apply to specialists 

in addition to primary care physicians. 

I urge you to vote for this amendment. Thank you. 

Chairman SENSENBRENNER. Are there amendments? The gentleman from Indiana has the substitute. 

Mr. HOSTETTLER. Mr. Chairman, I have a substitute at the desk. 

Chairman SENSENBRENNER. The Clerk will report the substitute. 

14 

The CLERK. Amendment in the nature of a substitute to H.R. 

4453 offered by Mr. Hostettler of Indiana and Ms. Jackson Lee of 

Texas. 

[The amendment in the nature of a substitute follows:] 

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Chairman SENSENBRENNER. Without objection, the substitute is 

considered as read and open for amendment at any point. The 

Chair recognizes the gentleman from Indiana, Mr. Hostettler. 

Mr. HOSTETTLER. Mr. Chairman, I thank you, and as we said 

earlier, Mr. Chairman, H.R. 4453, introduced by Representative 

Moran, extends the J visa for foreign residency waiver program 

until 1 year after the bill’s date of enactment. On June 3, 2004, the 

bill was approved by the Subcommittee on Immigration, Border Security and Claims by a voice vote. This substitute that Ms. Jackson 

Lee and I are offering would accomplish the following: 

First, the substitute would extend the waiver until June 1, 2006. 

This will give the Subcommittee adequate time to fully explore all 

the issues involved with foreign medical students and foreign medical residents. 

Second, the substitute would allow foreign doctors receiving a 

waiver to receive H-1B status regardless of the annual H-1B visa 

quota, whether they are sponsored by a State or Federal agency. 

Third, the substitute would explicitly allow foreign doctors receiving a waiver to work in medically underserved areas in either 

primary care or specialty medicine. A number of State public 

health agencies have utilized the waiver program to meet needs for 

specialty care providers, and the substitute recognizes this practice. 

Fourth, the substitute will allow five of each States 30 waiver recipients to practice medicine in areas not designated by the Secretary of Health and Human Services as having a shortage of 

health care professional, if the doctors receiving the waivers will 

practice in facilities that serve patients who reside in areas designated by the Secretary as having a shortage of health care professionals. The Subcommittee will review the operation of this program to ensure not only that the goal of the waivers is maintained; 

that is, serving the underserved, but also to determine the impact 

on American citizens who by very definition, at least 30 in each 

State, 30 per State spots, slots in medical schools must be, by definition of the result of this, the presence of this program, must be 

denied to American citizens for the purpose of practicing medicine. 

And so in the interim time we will not only be looking at the situation as it seeks to serve those that are in underserved areas, but 

obviously the impact on American citizens and their ability to attend medical school. 

On that, Mr. Chairman, I yield back the balance of my time. 

Chairman SENSENBRENNER. The question is on the adoption. 

Ms. JACKSON LEE. Chairman. 

Chairman SENSENBRENNER. The gentlewoman from Texas. 

Ms. JACKSON LEE. Thank you very much, Mr. Chairman. As the 

Chairman mentioned, of the Subcommittee, this is a compromise. 

I would simply—I will be including most of my statement into the 

record, but I do want to make the point that this is a very, very 

well respected program and a well-needed program. I hope after we 

have had a successful study of this program in the 2-year extension 

we will be able to implement a J-1 visa program that will allow a 

5-year program continuously. These are physicians who in most instances adhere to their visa time frame. They will return back to 

their nation of origin, but more importantly, they serve a very vital 

need in the battle for good health care in America to underserved 

19 

areas, and I believe it is crucial that this program continue with 

a 5-year program and the flexibility for the States. 

The compromise I accept and support, and I ask my colleagues 

to support the amendment in the nature of a substitute of myself 

and Mr. Hostettler. 

I would yield back. 

Chairman SENSENBRENNER. Are there amendments to the 

amendment in the nature of a substitute? If there are none, the 

question is on agreeing to the amendment in the nature of a substitute offered by the gentleman from Indiana, Mr. Hostettler. 

Those in favor will say aye. Opposed, no. The ayes appear to have 

it. The ayes have it, and the amendment in the nature of a substitute is agreed to. 

A reporting quorum is present. The question occurs on the motion to report the bill H.R. 4453 favorably, as amended. All in favor 

will say aye. Opposed, no. The ayes appear to have it. The ayes 

have it and the motion to report favorably is adopted. 

Without objection, the bill will be reported favorably to the 

House in the form of a single amendment in the nature of a substitute incorporating the amendment adopted here today. Without 

objection, the Chairman is authorized to move to go to conference 

pursuant to House rules. Without objection, the staff is directed to 

make any technical and conforming changes, and all Members will 

be given 2 days as provided by the House rules in which to submit 

additional, dissenting, supplemental, or minority views. 

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