United States Government Accountability Office

GAO Report to Congressional Requesters

FOREIGN 

PHYSICIANS 

Data on Use of J-1 

Visa Waivers Needed 

to Better Address 

Physician Shortages 

November 2006 

 

GAO-07-52 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

November 2006

FOREIGN PHYSICIANS

Data on Use of J-1 Visa Waivers Needed 

Highlights of GAO-07-52, a report to to Better Address Physician Shortages 

congressional requesters 

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. 

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. 

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

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. 
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 

Page i GAO-07-52 J-1 Visa Waivers for Physicians
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 

Page ii GAO-07-52 J-1 Visa Waivers for Physicians
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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Page iii GAO-07-52 J-1 Visa Waivers for Physicians
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 

 1

In 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. 

2

8 U.S.C. §§ 1182(e), 1184(l)(1)(D). 

3

In 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.” 

Page 1 GAO-07-52 J-1 Visa Waivers for Physicians
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

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. 

 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 report. 

6

See GAO, Foreign Physicians: Preliminary Findings on the Use of J-1 Visa Waivers to 

Practice in Underserved Areas, GAO-06-773T (Washington, D.C.: May 18, 2006). 

Page 2 GAO-07-52 J-1 Visa Waivers for Physicians
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 

 7

The 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. §1101(a)(36). 

8

ARC 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. 

9

DRA 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. 

Page 3 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

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. 

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 

Results in Brief 

 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 GAO-06-773T. 

Page 4 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

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

 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. 

Page 5 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

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. 

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 

Background 

 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. § 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 6 GAO-07-52 J-1 Visa Waivers for Physicians
visas took part in U.S. graduate medical education programs during 

academic year 2004–05. 

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

 158 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). 

168 U.S.C. §§ 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, § 220, 108 Stat. 4305, 4319. 

18Pub. L. No. 87-256, § 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. 

Page 7 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

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. § 1184(l)(1)(D)(iii).

22Pub. L. No. 108-441, § 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.

Page 8 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

Page 9 GAO-07-52 J-1 Visa Waivers for Physicians
Figure 1: Process to Apply for and Obtain a J-1 Visa Waiver for a Physician to Work 

in an Underserved Area 

Physician

Submits J-1 visa waiver application to Department of State to obtain case number

Secures bona fide offer of employment from U.S. health care facility for minimum of 3 years

Department of State

Processes physician’s application, reviews state’s or federal agency’s waiver request, and makes

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

Services (USCIS)

Department of Homeland Security, USCIS

Reviews recommendation, grants waiver of the 2-year foreign residence requirement, and notifies

physician of waiver approval

Reviews and approves employer’s petition for physician to obtain H-1B status

Physician

Fulfills minimum 3-year employment contract

Physician

Leaves the United States or applies for permanent residence, continued H-1B status, or other 

nonimmigrant status

Waiver process

Physician

Completes graduate medical education on J-1 visa

State

Submits waiver request to Department

of State

• May request waivers for up to 30 

physicians per year

• Five of the 30 waivers may be for 

physicians to work in facilities that, while 

located outside of HHS-designated 

underserved areas, treat patients residing 

in underserved areas

Federal agencya

Submits waiver request to Department 

of State

• No numerical limits on waivers

• Physicians must work in 

HHS-designated underserved areas

Physician, employer, or both

Apply to state or federal agency to request a J-1 visa waiver on physician’s behalf

Source: GAO.

or

a

Waivers 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. 

Page 10 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

Page 11 GAO-07-52 J-1 Visa Waivers for Physicians
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

Waivers Remain a 

Major Means for 

Providing Physicians 

to Underserved Areas 

 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. 

Page 12 GAO-07-52 J-1 Visa Waivers for Physicians
Figure 2: J-1 Visa Waivers Requested by States and Federal Agencies, Calendar 

Year 1995 and Fiscal Years 2003 through 2005 

0

200

400

600

800

1,000

1,200

1,400

Federal agencies

States

2003 2004 2005 a 1995 

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

89

1,285

983

108

965

60

956

56

1,374

1,091

1,025 1,012

Number of waiver requests

Year

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. 

a

In our May 2006 testimony on preliminary findings (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). 

Page 13 GAO-07-52 J-1 Visa Waivers for Physicians
Figure 3: J-1 Visa Waivers Requested by States, Fiscal Year 2005 

Sources: GAO survey of states, 2005 (data); 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

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. 

Page 14 GAO-07-52 J-1 Visa Waivers for Physicians
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

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. 

Waivers Were

Requested for 

Physicians to Work in 

a Variety of Practice 

Specialties, Settings, 

and Locations 

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 (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). 

Page 15 GAO-07-52 J-1 Visa Waivers for Physicians
Figure 4: Practice Specialties of Physicians for Whom States and Federal Agencies 

Requested J-1 Visa Waivers, Fiscal Year 2005 

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

Both primary and nonprimary care

Exclusively nonprimary care

3%

No answer

Psychiatry

Exclusively primary care

7%

5%

39%

46%

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. 

Page 16 GAO-07-52 J-1 Visa Waivers for Physicians
Figure 5: J-1 Visa Waivers Requested by States and Federal Agencies, by Practice 

Specialty, Fiscal Year 2005

0

10

20

30

40

50

60

70

80

90

100

States

Federal agencies

Both Psychiatry No answer

primary care and

nonprimary care

Exclusively

nonprimary care

Exclusively

primary care

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

Percentage of waivers requested

44

41

5 7

3

80

4 2

14

0

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. 

 29See appendix II for states’ and federal agencies’ responses to selected survey questions, 

including their policies for requesting waivers.

Page 17 GAO-07-52 J-1 Visa Waivers for Physicians
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). 

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.) 

Page 18 GAO-07-52 J-1 Visa Waivers for Physicians
Figure 6: 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 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). 

Page 19 GAO-07-52 J-1 Visa Waivers for Physicians
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 

0 20 40 60 80 100

Nonrural areas

Rural areas

Federal agencies

States

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

Percentage of waivers requested

7

50

93

50

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 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 

Most States and 

Federal Agencies 

Reported That They 

Conducted 

Monitoring Activities 

Page 20 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

Page 21 GAO-07-52 J-1 Visa Waivers for Physicians
Figure 8: Monitoring Activities That States and Federal Agencies Requesting J-1 

Visa Waivers Reported Conducting in Fiscal Year 2005 

0 5 10 15 20 25 30 35 40 45

Federal agencies

States

Other monitoring activities

Conducted periodic site visits

Monitored through regular

communication with physicians

Monitored through regular

communication with employers

Required periodic reports by

physicians or employers

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

Activity

Number of states and federal agencies

21

40

19

18

9

2

1

1

2

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 

Page 22 GAO-07-52 J-1 Visa Waivers for Physicians
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

 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. 

Page 23 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

Figure 9: States’ and Federal Agencies’ Practices to Help Ensure Physicians Meet 

Their Waiver Agreements 

0 5 10 15 20 25 30 35 40 45

Federal agencies

States

Other

Require contracts to stipulate that

physicians who violate contracts be

required to pay damages to employers

Permanently or temporarily

disqualify noncompliant employers

from further placements

Report noncompliant

physicians to USCIS

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

Practice

Number of states and federal agencies

40

38

9

7

2

1

2

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 

 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. 

Page 24 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

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 

HHS Lacks Data to 

Account for Waiver 

Physicians in Its 

Efforts to Address 

Physician Shortages 

 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.

Page 25 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

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

 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, 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, 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. 

Page 26 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

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. 

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. 

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 

Conclusions 

Recommendation for 

Executive Action 

Agency Comments 

and our Evaluation 

Page 27 GAO-07-52 J-1 Visa Waivers for Physicians
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. 

Page 28 GAO-07-52 J-1 Visa Waivers for Physicians
If you or your staff members have any questions about this report, please 

contact me 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 report. GAO staff who made major contributions to this 

report are listed in appendix IV. 

Leslie G. Aronovitz 

Director, Health Care 

Page 29 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix I: Physician Need and Number of 

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

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 

 1

Certain 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. 

2

HHS 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. 

Page 30 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix I: Physician Need and Number of 

Primary Care Waiver and National Health 

Service Corps Physicians, by State 

Loan Repayment, and NHSC Ready Responder programs.3 NHSC 

physicians are required to practice in HPSAs. 

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. 

 3

A 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. 

4

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. 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. 

5

Data 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.

Page 31 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix I: Physician Need and Number of 

Primary Care Waiver and National Health 

Service Corps Physicians, by State 

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

Estimated number of primary care 

waiver physiciansb

State 

Physicians 

needed to

remove 

primary care 

HPSA 

designationsa

State ARC DRA HHS Total

Number of 

primary care 

NHSC 

physiciansc

 

Total number 

of primary 

care waiver 

and NHSC 

physicians 

Primary care 

waiver and

NHSC 

physicians 

as a 

percentage

of physicians 

needed

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 d1.0 d15 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

Page 32 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix I: Physician Need and Number of 

Primary Care Waiver and National Health 

Service Corps Physicians, by State 

Estimated number of primary care 

waiver physiciansb

State 

Physicians 

needed to

remove 

primary care 

HPSA 

designationsa

State ARC DRA HHS Total

Number of 

primary care 

NHSC 

physiciansc 

Total number 

of primary 

care waiver 

and NHSC 

physicians 

Primary care 

waiver and

NHSC 

physicians 

as a 

percentage

of physicians 

needed

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 1,477.5e104.0 32.5 57.0 1,670.0e1,448 3,103.0e39.1e

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. 

a

The number of additional FTE physicians HHS identified as needed as of September 30, 2005, to 

remove primary care HPSA designations in the state. 

b

The 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. 

Page 33 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix I: Physician Need and Number of 

Primary Care Waiver and National Health 

Service Corps Physicians, by State 

c

The number of primary care NHSC physicians practicing in primary care HPSAs as of 

September 30, 2005. 

d

Data were not available to estimate the number of waiver physicians practicing primary care in 

Connecticut or to make associated calculations. 

e

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

Page 34 GAO-07-52 J-1 Visa Waivers for Physicians
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 

State State 

Federal 

agencies State

Federal 

agencies State 

Federal 

agencies

Total

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

Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

Page 35 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

Number of waivers requested

2003 2004 2005 

State State 

Federal 

agencies State

Federal 

agencies State 

Federal 

agencies

Total

2003–2005

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. 

Page 36 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

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. 

Page 37 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

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)

Psychiatrya80 (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) 

Psychiatrya15 (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)

Psychiatrya95 (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. 

a

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. 

Page 38 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

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 agenciesa

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. 

a

Data 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. 

Page 39 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

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

State 

Facilities where 

waiver 

physicians work 

required to

accept some 

patients who are 

uninsured or

covered by

Medicaid 

Nonprimary 

care 

physicians 

not eligible 

Nonprimary 

care physicians 

eligible with

limitationsa

Nonprimary 

care physicians 

eligible without 

limitations 

Requests for 

primary care 

physicians 

limited to

HPSAsb

Requests for 

nonprimary care 

physicians 

limited to 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 Columbia X X 

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 X X

Minnesota X X

Mississippi X X X

Missouri X X X X

Montana X X

Nebraska X X

Nevada X X

Page 40 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

State 

Facilities where 

waiver 

physicians work 

required to

accept some 

patients who are 

uninsured or

covered by

Medicaid 

Nonprimary 

care 

physicians 

not eligible 

Nonprimary 

care physicians 

eligible with

limitationsa

Nonprimary 

care physicians 

eligible without 

limitations 

Requests for 

primary care 

physicians 

limited to

HPSAsb

Requests for 

nonprimary care 

physicians 

limited to HPSAs

New Hampshire X X 

New Jersey X X X X

New Mexico X X X

New York X X

North Carolina X X X X

North Dakota X 

Ohio X X X X

Oklahoma X X

Oregon X X

Pennsylvania X X

Rhode Island X X

South Carolina X X

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. 

a

Examples 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. 

Page 41 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix II: States’ and Federal Agencies’ 

Requests for J-1 Visa Waivers 

b

HPSAs 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. § 254e). 

c

California, Idaho, ARC, and HHS reported that their fiscal year 2005 policies did not allow them to 

request waivers for physicians to practice nonprimary care. 

Page 42 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix III: Comments from the Appendix III: Comments from the Department of Health and Human Services 

Department of Health and Human Services 

Page 43 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix III: Comments from the 

Department of Health and Human Services 

Page 44 GAO-07-52 J-1 Visa Waivers for Physicians
Appendix IV: Contact and Acknowledgments 

Page 45 GAO-07-52 

Appendix IV: Contact and Acknowledgments 

GAO Contact Leslie G. Aronovitz, (312) 220-7600 or aronovitzl@gao.gov

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. 

Acknowledgments 

 J-1 Visa Waivers for Physicians
Related GAO Products 

Page 46 GAO-07-52 

Related GAO Products 

Health Professional Shortage Areas: Problems Remain with Primary 

Care Shortage Area Designation System. 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. 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. 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. 

(290485) J-1 Visa Waivers for Physicians
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U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, D.C. 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

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