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PHYSICIANS FOR UNDERSERVED AREAS ACT

HEARING

BEFORE THE

SUBCOMMITTEE ON IMMIGRATION, 

BORDER SECURITY, AND CLAIMS

OF THE

COMMITTEE ON THE JUDICIARY 

HOUSE OF REPRESENTATIVES

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

ON

H.R. 4997

MAY 18, 2006

Serial No. 109–111

Printed for the use of the Committee on the Judiciary

(

Available via the World Wide Web: http://judiciary.house.gov 

(II)

COMMITTEE ON THE JUDICIARY 

F. JAMES SENSENBRENNER, JR., Wisconsin, Chairman 

HENRY J. HYDE, Illinois 

HOWARD COBLE, North Carolina 

LAMAR SMITH, Texas 

ELTON GALLEGLY, California 

BOB GOODLATTE, Virginia 

STEVE CHABOT, Ohio 

DANIEL E. LUNGREN, California 

WILLIAM L. JENKINS, Tennessee 

CHRIS CANNON, Utah 

SPENCER BACHUS, Alabama 

BOB INGLIS, South Carolina 

JOHN N. HOSTETTLER, Indiana 

MARK GREEN, Wisconsin 

RIC KELLER, Florida 

DARRELL ISSA, California 

JEFF FLAKE, Arizona 

MIKE PENCE, Indiana 

J. RANDY FORBES, Virginia 

STEVE KING, Iowa 

TOM FEENEY, Florida 

TRENT FRANKS, Arizona 

LOUIE GOHMERT, Texas 

JOHN CONYERS, JR., Michigan 

HOWARD L. BERMAN, California 

RICK BOUCHER, Virginia 

JERROLD NADLER, New York 

ROBERT C. SCOTT, Virginia 

MELVIN L. WATT, North Carolina 

ZOE LOFGREN, California 

SHEILA JACKSON LEE, Texas 

MAXINE WATERS, California 

MARTIN T. MEEHAN, Massachusetts 

WILLIAM D. DELAHUNT, Massachusetts 

ROBERT WEXLER, Florida 

ANTHONY D. WEINER, New York 

ADAM B. SCHIFF, California 

LINDA T. SA ́ NCHEZ, California 

CHRIS VAN HOLLEN, Maryland 

DEBBIE WASSERMAN SCHULTZ, Florida

PHILIP G. KIKO, General Counsel-Chief of Staff 

PERRY H. APELBAUM, Minority Chief Counsel 

SUBCOMMITTEE ON IMMIGRATION, BORDER SECURITY, AND CLAIMS

JOHN N. HOSTETTLER, Indiana, Chairman

STEVE KING, Iowa 

LOUIE GOHMERT, Texas 

LAMAR SMITH, Texas 

ELTON GALLEGLY, California 

BOB GOODLATTE, Virginia 

DANIEL E. LUNGREN, California 

JEFF FLAKE, Arizona 

BOB INGLIS, South Carolina 

DARRELL ISSA, California 

SHEILA JACKSON LEE, Texas 

HOWARD L. BERMAN, California 

ZOE LOFGREN, California 

LINDA T. SA ́ NCHEZ, California 

MAXINE WATERS, California 

MARTIN T. MEEHAN, Massachusetts

GEORGE FISHMAN, Chief Counsel 

ART ARTHUR, Counsel 

ALLISON BEACH, Counsel 

CINDY BLACKSTON, Professional Staff 

NOLAN RAPPAPORT, Minority Counsel 

(III)

C O N T E N T S 

MAY 18, 2006

OPENING STATEMENT 

Page 

The Honorable John N. Hostettler, a Representative in Congress from the 

State of Indiana, and Chairman, Subcommittee on Immigration, Border 

Security, and Claims ............................................................................................ 1

The Honorable Sheila Jackson Lee, a Representative in Congress from the 

State of Texas, and Ranking Member, Subcommittee on Immigration, Border Security, and Claims ..................................................................................... 2

WITNESSES 

The Honorable Jerry Moran, a Representative in Congress from the State 

of Kansas 

Oral Testimony ..................................................................................................... 6

Prepared Statement ............................................................................................. 8

Mr. Edward Salsberg, Director, Center for Workforce Studies, Association 

of American Medical Colleges 

Oral Testimony ..................................................................................................... 9

Prepared Statement ............................................................................................. 12

Mr. John B. Crosby, J.D., Executive Director, The American Osteopathic 

Association 

Oral Testimony ..................................................................................................... 48

Prepared Statement ............................................................................................. 49

Ms. Leslie G. Aronovitz, Director, Health Care, United States Government 

Accountability Office 

Oral Testimony ..................................................................................................... 58

Prepared Statement ............................................................................................. 60

APPENDIX 

MATERIAL SUBMITTED FOR THE HEARING RECORD

Prepared Statement of the Honorable Sheila Jackson Lee, a Representative 

in Congress from the State of Texas, and Ranking Member, Subcommittee 

on Immigration, Border Security, and Claims ................................................... 99

Prepared Statement of the Honorable Kent Conrad, a U.S. Senator from 

the State of North Dakota ................................................................................... 100

Prepared Statement of Gregory Siskind, Chairman, National Health Care 

Access Coalition .................................................................................................... 106

Letter to the Honorable Sheila Jackson Lee from Connie Berry, Manager, 

Texas Primary Care Office .................................................................................. 119

(1)

PHYSICIANS FOR UNDERSERVED AREAS ACT 

THURSDAY, MAY 18, 2006

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON IMMIGRATION,

BORDER SECURITY, AND CLAIMS, 

COMMITTEE ON THE JUDICIARY, 

Washington, DC.

The Subcommittee met, pursuant to notice, at 2:04 p.m., in Room 

2141, Rayburn House Office Building, the Honorable John N. 

Hostettler (Chairman of the Subcommittee) presiding. 

Mr. HOSTETTLER. The Subcommittee will come to order. 

Good afternoon. Today’s hearing will examine H.R. 4997, the 

‘‘Physicians for Underserved Areas Act.’’ This legislation is sponsored by Congressman Jerry Moran, who has joined us today as a 

witness. 

H.R. 4997 makes permanent the J-1 visa waiver program for 

physicians who agree to work in underserved areas—sometimes referred to as the ‘‘Conrad program’’ after the original author of the 

program, Senator Kent Conrad. 

Under current law, foreign doctors may come to the United 

States to complete their residency training. Many do so using the 

J-1 visa, which is for cultural exchange and training programs. 

One of the requirements for physicians who use the J visa is that 

the participant return to his or her country for 2 years upon completion of the training program in the United States. The purpose 

of this foreign residency requirement is to encourage Americantrained physicians to return to their country and improve medical 

conditions there. 

Since 1994, Congress has waived the 2-year foreign residency requirements for physicians who agree to work in an underserved 

area of the United States as designated by the Department of 

Health and Human Services. Each State receives 30 such waivers 

per year. 

The waiver program allows States to recruit physicians to areas 

that may be considered unattractive to American physicians. Many 

communities that might otherwise have no access to medical services now have physicians nearby as a result of this program. It also 

responds to an overall shortage of physicians in the United States, 

a shortage that seems to be growing. 

While today’s hearing will address legislation to reauthorize a 

visa program for foreign physicians, I believe Congress must also 

focus on other ways to address the physician shortage. First, I am 

interested to hear from our witnesses today what is being done to 

increase the capacity of medical training programs here in the 

2

United States. Educating more physicians here at home is one obvious way we can alleviate the shortage. 

I’m also interested in the expansion of programs, such as the National Health Services Corps, which provides incentives for U.S. 

physicians to work in underserved areas. 

In looking at the J-1 visa waiver program, we must keep in mind 

the intent behind the 2-year foreign residency requirement. We 

want to make sure that we aren’t facilitating ‘‘brain drain’’ from 

countries that desperately need well-trained medical personnel. 

In its 2006 World Health Report, the World Health Organization 

cited the migration of health care workers from poorer countries to 

richer countries as a major problem whose ‘‘consequences can be 

measured in lives lost.’’

J visas are designed to allow foreigners to participate in exchange and training programs here in the U.S. and then take those 

skills back to their home country. But right now, a significant portion of these physicians are staying here in the United States. 

Another factor that is complicating the training goal of the J-1 

visa program is that foreign physicians are now using the H-1B 

visa to come to the U.S. for their residencies. Physicians who come 

to the U.S. on an H-1B visa for the residency training are not required to return to their home country for 2 years. 

As a result, foreign physicians prefer to use the H-1B and fewer 

are using the J-1 visa. With fewer physicians using the J-1 program, there are fewer available physicians to participate in the J1 waiver program to work in underserved areas, and there are also 

fewer physicians returning to needier countries. 

I believe we need to closely examine this disparity in treatment 

and consider a uniform policy for foreign physicians who receive 

training in the U.S. The J-1 visa waiver program may be helpful 

in getting physicians to underserved areas, but it is, hopefully, a 

temporary fix to a much larger problem. 

I am hopeful that this Committee and other Committees of jurisdiction will work to find ways to educate and train greater numbers of American physicians and reduce our reliance on foreign 

physicians. 

At this time, the Chair recognizes the gentlelady from Texas, the 

Ranking Member of the Subcommittee, Ms. Jackson Lee, for purposes of an opening statement. 

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

I appreciate this hearing. I appreciate the witnesses. And you 

have certainly crafted or laid the parameters down that it is complex, but it’s a good program. 

And the legislation that my friend and colleague Mr. Moran has, 

has great merit because we do know that there are certain concerns that you’ve expressed that I join you in. We don’t want to 

have a brain drain of some of our developing nations all over the 

world. In fact, we want to be partners in good health care. 

But at the same time, we want to ensure the normal flow of talented physicians in underserved areas, and I might say, with a 

State as big as Texas, we’re already asking for an increase or a 

need that would cover the vast State—vast areas of our State. 

So we know that we have to find a way to answer your concerns 

to discern the purpose of the utilization of other visas versus the 

3

J-1. We have to address the question of overstays, and I might say 

we have to address the question of training more American doctors, 

helping our Nation’s medical schools, and providing resources for 

nurses in America, and training and teachers. 

But I do believe that this is a valuable program, and I’m delighted that the GAO is present, Mr. Chairman, because I do want 

to acknowledge, as you well know, that Senator Conrad and myself 

asked for a GAO study to assess where we are in this program and 

how we can make it effective. And I look forward to your testimony. 

I mentioned, again, the legislation of Congressman Jerry Moran 

that was introduced just recently, H.R. 4997. And specifically, it 

would make the J-1 visa program permanent. 

The J visa is used for one of the educational cultural exchange 

programs that has become a gateway for foreign medical graduates 

to gain admission to the United States as non-immigrants for the 

purpose of graduate medical education training. The visa that most 

of these physicians enter under is the J-1 non-immigrant visa. 

And let me just say this. I had the opportunity to speak before 

the National Convention of Indo-American Physicians and Pakistan 

Physicians. They are what the oath that they take represents. 

They’re healers. They want to do what is right. 

But I tell you, one of the number-one issues was what was happening to the J-1 visa because they wanted to use it in a positive 

sense. And I made a commitment in a legislative manner, which 

is to say that this Congress would take the J-1 visa program seriously and know of their interest and passion. 

One of the doctors in particular was Dr. Kudir, who has formerly 

served—or has served as the leadership of the Pakistan-American 

doctors. But they wanted it to be constructive. And they are participants in making the J-1 visa work, not to abuse it. And I think we 

should engage physicians and those who participate in this program to make it work. 

The physicians who participate in the J-1 visa programs are required to return to their home country for a period of at least 2 

years before they can apply for another non-immigrant visa or legal 

permanent resident status, unless they’re granted a waiver of this 

requirement. 

In 1994, Senator Kent Conrad established a new basis for waiver 

of this requirement with an amendment to the Immigration and 

Nationality Act. It was known as then as the Conrad State 20 program. It permitted each State to obtain waivers for 20 physicians 

by establishing that they were needed in health professional shortage areas known as HPSAs. 

On November 2, 2002, the Conrad 20 program was extended to 

2004, and the number of waivers available to the States were increased to 30. This program, which is now referred to as the 

‘‘Conrad 30’’ or ‘‘State 30’’ program, expired on June 1, 2004. 

On December 3, 2004, it was reinstated and extended to June 1, 

2006. That is why we’re here today, which is only a few weeks from 

now. Congressman Moran’s Physicians for Underserved Areas Act 

would eliminate the need for future extensions by making the program permanent. 

4

And I might say because of the recounting of the yearly or every 

other year extension, it might make sense that we have the parameters and the strictures or the structure of the program such that 

we can address the permanent aspect of it. 

When the Conrad 30 Program was established in 1994, most of 

those studying the supply of physicians in the United States were 

concerned about the distribution of physicians, as opposed to the 

total number of doctors being trained. It is now generally recognized that we’re facing a severe physician shortage. The Health 

Policy Institute eliminates—estimates that the shortage could grow 

to as much as 200,000 by 2020, an astounding possibility in view 

of the fact that the physician population in the United States currently is only about 800,000. 

And might I say that I am not bragging about this catastrophe, 

it is one. Obviously, we have to do something outside the jurisdiction of this Committee with our Nation’s medical schools, the encouragement of physicians or medical students, and certainly 

health care in America. 

But given where we are today, this is a needed program. The 

failure to forecast this severe physician shortage may explain why 

from 1980 until last year no new medical schools opened in the 

United States. According to the Health Policy Institute, the United 

States needs to produce an extra 10,000 physicians per year over 

the next decade and a half in order to meet the demands of the 

country. 

This number assumes that the number of foreign-educated physicians will remain constant. We might need to have ‘‘hug a physician’’ day in America. 

Senator Conrad and I have asked the General Accountability Office to do a survey of State views on the Conrad 30 program. All 

50 States filled out a GAO questionnaire and promptly returned it 

to the GAO. One of the GAO investigators will testify about the results of that survey, and so I’ll look forward to that. 

Approximately 80 percent of the States reported that the annual 

limit of 30 waivers per State is inadequate. Only 13 percent reported that it is inadequate. Excuse me. I’m sorry. Eighty percent 

of the States reported that the annual limit of 30 waivers per State 

is adequate, and only 13 percent said it was inadequate. 

Eleven States estimated that they need between 5 and 50 more 

waiver physicians, which would total 200 more waiver physicians. 

Forty-four States did not use all of their allotted, and the total of 

the unused waivers for the year was 664, which is one of my views 

of being able to move some of the waivers from State to State. 

The J-1 visa program has been in effect now for more than a decade. In addition to being a good source of additional physicians, it 

ensures that additional physicians will go where they are most 

needed, health professional shortage areas in both rural and urban 

settings. 

I can assure you, Mr. Chairman and to this Committee, that it 

is important for us to have this hearing, but more importantly, to 

take it seriously and to address the concerns of our States, but also 

Americans who need good health care. 

And I look forward to admitting certain letters, but I will hold 

them for the witnesses’ testimony, and I believe that, together, we 

5

can make this program effective and provide the good health care 

for all Americans. 

With that, I yield back. 

Mr. HOSTETTLER. I thank the gentlelady. 

The Chair will now introduce members of our panel of witnesses. 

The Honorable Jerry Moran began his career in public service in 

the Kansas State Senate, serving 8 years in that body, including 

2 years as majority leader. As the representative in Congress of 

Kansas’s 1st District, which has more hospitals than any congressional district in the country, Mr. Moran has been a leading advocate for health care reform, rural health care in particular. 

Congressman Moran has been supportive of community health 

care centers and has introduced additional measures, such as the 

Community Pharmacy Preservation Act, which seeks to keep smalltown pharmacies open and accessible. 

His efforts in Congress have earned Mr. Moran the top legislative award from the National Rural Health Association. He is the 

sponsor of the bill H.R. 4997, the legislation that this panel is discussing today. 

Edward S. Salsberg began his career in public health in 1984 at 

the New York State Department of Public Health, where he served 

as a bureau director. In 1996, Mr. Salsberg left the department to 

found the Center for Health Workforce Studies at the School of 

Public Health of the University at Albany of the State University 

of New York, where he served as its executive director. 

Mr. Salsberg has authored and co-authored numerous reports on 

the health care workforce and has spoken throughout the country 

on the topic. He currently serves as director of the Center for 

Workforce Studies at the Association of American Medical Colleges. 

John B. Crosby became the executive director of the American 

Osteopathic Association in May 1997. Prior to joining the AOA, he 

spent 6 years at the American Medical Association as senior vice 

president for health policy, where he was actively involved with 

policy development and strategic planning. 

He currently serves on the board of directors of the Chicago 

Health Policy Research Council and the Health Care Quality Alliance in Washington, D.C. Mr. Crosby has worked on health care 

issues for both the private and public sectors since 1977. He has 

served in positions at think tanks, trade associations, and on Capitol Hill. 

Leslie G. Aronovitz began her service to the U.S. Government Accountability Office at GAO’s Atlanta office in 1974. Before working 

on health and income security issues, Ms. Aronovitz was an assistant director in GAO’s Accounting and Financial Management Division. There, she directed much of GAO’s work on the quality of audits performed by public accountants. This work led to important 

changes in the way the accounting profession engaged in self-monitoring. 

Ms. Aronovitz has served as director of GAO’s health care team 

for the past 15 years. Among her numerous responsibilities as director of the team is research on health professions shortages. 

Gentlemen and lady, we appreciate your presence here today, 

and you will notice we have the light system, and we ask—and 

6

without objection, your entire written testimony will be made a 

part of the record. 

If you can keep within that 5 minutes as much as possible, we 

will give an opportunity for the panel to ask questions. 

Congressman Moran, you are recognized. 

TESTIMONY OF THE HONORABLE JERRY MORAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF KANSAS 

Mr. MORAN. Mr. Chairman, thank you very much. Thank you for 

the privilege of appearing before your Subcommittee today. 

I appreciate your comments and am pleased to support your effort to broaden the inquiry about increasing the availability of 

health care professionals across the country. I appreciate Ms. Jackson Lee and her efforts; we were engaged as allies the last time 

this program was reauthorized in 2002. 

I’ve been a Member of Congress now for a decade. Much of my 

focus in Washington has been about access to health care. I represent one of the most rural districts in the country. My largest 

community is a population about 45,000. 

I represent three quarters of the geography of Kansas, and you 

are correct. We have 75 hospitals in the congressional district, 

more than any congressional district in the Nation. 

My constituents drive long distances to access health care. They 

are elderly, generally, and income levels are—would be below the 

national average. I have been engaged in the Rural Health Care 

Coalition and its efforts since coming to Congress and have served 

as its chairman for a number of years. 

My colleague in co-sponsoring this bill, Mr. Pomeroy, the gentleman from North Dakota, is the co-chairman of the Rural Health 

Care Coalition today. 

This issue is one that I think matters so much. In fact, I believe 

that health care is the number-one domestic issue we face in the 

country today. And it is about access, but it’s also about affordability. 

And I have been involved in the J-1 visa program since coming 

to Congress. Many of the physicians who serve, who provide health 

care services to my constituents, are J-1 visa doctors. 

And you were right in your recitation of the history. This has—

came about, this program came about in 1994. We’ve also had a 

companion Federal J-1 visa program. And surprising to me and 

perhaps to others, Kansas was not a participant in the J-1 visa program on the State level until 2002. Prior to that, we relied upon 

the United States Department of Agriculture to provide J-1 visa access through the Federal program. 

And since 2002, when we started the Conrad—now Conrad 30 

program, we have provided 66 physicians to the people of our 

State. The population of America is 25 percent rural, and yet physicians, their practice, only 10 percent of practicing physicians have 

their practice in rural America. So there’s a tremendous shortage. 

Having outlined the rural nature of my district and my focus in 

Congress, I also would like to point out that the J-1 visa program 

is important to urban areas of the country. It is not just a rural 

issue. Many of the core centers of our cities face the same dilemma 

in trying to attract and retain physicians. 

7

It’s been my experience that if you are a physician who is primarily interested in making money, you will not locate in the core 

of a center of a city. You will not locate in rural America because 

the population base, the patient load is generally older. That 

means that Medicare has a significant component of your practice. 

In fact, of the 75 hospitals, many of the hospitals in our congressional district—certainly 60, 70, 80, sometimes even 90 percent of 

the patients that are admitted to our hospitals are on Medicare, 

which means that Medicare is the sole—is nearly the sole provider 

of the revenue necessary to generate income for the hospital or the 

physician. 

And then on top of that, you add Medicaid, which also is a detriment to a physician’s income. Underserved areas exist in this 

country, and they exist for a number of reasons, cultural as well 

as economic. 

This has been a successful program in Kansas since its arrival 

in 2002. I know of a number of communities, and I’ve talked to constituents who tell me that but ‘‘absent that J-1 physician being in 

my community, I would not be alive today.’’

So it’s a matter of economic growth and community development, 

but it is a matter of life and death that people can access a physician, and in many cases, it’s a J-1 visa physician within the confines of their community. 

Rush County Memorial Hospital is located about 25 miles from 

my hometown. Thirty-seven hundred people live in the county. 

They have three J-1 visa physicians. One now, two—a husband and 

wife team, who have now retired. That community has been served 

by J-1 visa physicians for a number of years—decades, in fact—

since the J-1 visa program was—arrived, and they now have a physician who has replaced the two who retired. 

Greensburg, Kansas, population 1,500. For the last 10 years, the 

only physicians they’ve had in the county are J-1 visa physicians. 

In each of these cases, the community has attempted, at least initially, to attract a United States, an American physician without 

success. 

Meade County District Hospital, population of the county is 

about 1,600, 1,700, they made that attempt. Finally were successful 

in obtaining a J-1 visa physician through the waiver program. That 

doctor is now from Romania, has stayed at the hospital for 6 years. 

When he retired and left the community, they attracted a J-1 visa 

physician from the Maldives Islands. 

And finally, the hope—I’m, as you indicated, a supporter of community health care clinics. I think they’re part of access to health 

care. They’re also a part of a way that we can reduce health care 

costs. 

And United Methodist Ministries in Garden City, Kansas, which 

serves a very diverse population, has now been able to attract a J1 visa doctor, originally from Peru, who is bilingual and is arriving 

in August of this year to provide services to those with—really, 

without any insurance, without any financial means. And it’s only 

through this J-1 visa program that this community health clinic 

has been successful in attracting a physician. 

Mr. Chairman, I am an advocate, a supporter, a—just an enthusiastic, and I guess it’s not just—it’s not based upon emotion. It’s 

8

based upon the reality that absent this program, people will not be 

living, communities will not survive, and rural America as well as 

urban America will have one more nail in its coffin. 

So I urge the reauthorization of this program. I’m happy to discuss potential amendments in a way that we can meet the needs 

perhaps of Texas, which has perhaps a greater demand than the 

30 that are allowed, the flexibility to move physicians around the 

country, but also the permanent nature. 

Again, this is an issue that I’ve lived from the beginning of my 

time in Congress, and it would be nice to have a permanent program as compared to us rushing in here always at the last minute, 

trying to get the J-1 visa program reauthorized for a short period 

of time. 

I thank the Chairman and the Ranking Member and the gentleman from California for their attention. 

[The prepared statement of Mr. Moran follows:]

PREPARED STATEMENT OF THE HONORABLE JERRY MORAN, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF KANSAS

I am here today to discuss H.R. 4997, the Physicians for Underserved Areas Act, 

which would reauthorize the J-1 Visa Waiver program. The J-1 Visa Waiver program provides opportunities for graduates of foreign medical schools, who have 

trained in U.S. medical residency programs on the J-1 cultural exchange visa, to 

stay in the United States if they serve for three years in an area that has a health 

professional shortage. These designated health professional shortage areas can occur 

in rural areas as well as urban areas. 

State government agencies may sponsor J-1 physician waiver requests under the 

State 30 program. The State 30 program is designed to provide each State up to 

30 waivers for physicians each year. Each State has been given some flexibility to 

implement its own guidelines, but there are some basic requirements that are common to all State 30 programs. The recruitment process takes into consideration the 

‘fit’ with the practice, the community, and the needs of the physician and family. 

One of my goals is improving access to health care in rural areas. It is extremely 

difficult to recruit health care professionals to places where doctors are few and access to major metropolitan hospitals requires hours of travel. According to the U.S. 

Department of Health and Human Services, while a quarter of the population lives 

in rural areas, only 10 percent of physicians practice there. This definitely highlights the need for the J-1 Visa Waiver program. Today, I would like to highlight 

how this program has benefited my home state of Kansas and the predominately 

rural area which I represent. 

Kansas has been able to recruit 66 physicians to work in underserved areas and 

with underserved populations since 2002. Each year, the interest has grown and 

more and more physicians and hospitals are finding that this match is benefiting 

not only themselves, but the communities which they serve. 

The Rush County Memorial Hospital located in La Crosse, Kansas is responsible 

for providing health care to the 3,700 residents of the county. With a population 

that is primarily elderly, having quality healthcare is a major concern and requirement. 

After advertising and spending countless dollars and resources trying to recruit 

American born, American trained doctors, Rush County Memorial turned to the J1 Visa program to meet their healthcare needs. They have been able to recruit three 

J-1 Visa physicians into the area and would not be able to have top notch healthcare 

without this program. In addition, the physicians have been welcomed into the community and warmly received. One physician has stated that this small Midwestern 

town reminds him of his home community in Egypt and has started to put down 

roots by buying a home and getting involved in community events. The J-1 Visa 

Waiver program has been invaluable to the Rush County Memorial Hospital. 

Greensburg, Kansas is a small, rural community which has had difficulty recruiting physicians in the past. For the last 10 years, their physicians have all been J1 physicians. They have served the community well and have been providing excellent health care. The current J-1 physician manages 3 mid-level practitioners, provides health care to the local assisted living facility and provides care at the mental 

health facility which is located 10 miles from his place of residence. However, he 

9

still finds time to work a booth at the local health fair. For this community, it is 

imperative that the J-1 Visa Waiver program be permanently reauthorized. 

For 15 years, the Meade District Hospital has tried to get an American born, 

American trained physician to move to their rural Southwest Kansas hospital and 

have had no luck. However, through their participation in the J-1 Visa Waiver program, they have been able to attract foreign born physicians for the last 10 years. 

The J-1 Visa program has helped the hospital provide quality care to their patients. 

They had one doctor, originally from Romania, who stayed in the hospital for six 

years and a current doctor from the Maldaise Islands who they anticipate having 

a long term relationship with as well. The J-1 Visa program has been a lifesaver 

to this hospital and the citizens of Meade County. 

Finally, the last success story I will highlight is the story of the United Methodist 

Mexican-American Ministries which is located in Garden City, Kansas. They are 

scheduled to receive their first J-1 Visa doctor in August of this upcoming year. This 

community health clinic provides care for many migrant and immigrant families 

who speak a variety of languages including Spanish, German, and French. The new 

J-1 Visa doctor is originally from Peru and is highly educated, bi-lingual and has 

tremendous references. The private medical community has been supportive of the 

clinic’s efforts to recruit a doctor as the need for medical care is great in this area 

of Kansas. Without the J-1 Visa program, this clinic would not be able to get a physician to treat their patients. 

People deserve quality health care regardless of their location. The J-1 Visa Waiver program is helping many hospitals in my district find qualified physicians for 

their communities and this increases the quality of healthcare overall in Kansas. 

This is a well regarded, well run program that is worthy of permanent reauthorization. The Physicians for Underserved Areas Act is the way to make this happen.

Mr. HOSTETTLER. Thank you, Congressman Moran. 

Even though that I must admit that it is a blessing from time 

to time to see your beaming face in front of this Committee, that 

being said——

Mr. MORAN. Mr. Chairman, I might remind you that I was on 

the steering Committee that allowed you to come to the Judiciary 

Committee. [Laughter.] 

And I appreciate that very much because you were senior to me 

in the House Agriculture Committee, and you allowed me to become a Subcommittee Chairman when you departed. And I’m very 

grateful for your—for your move. 

Mr. HOSTETTLER. And now we know ‘‘the rest of the story.’’

Mr. Salsberg? 

TESTIMONY OF EDWARD SALSBERG, DIRECTOR, CENTER FOR 

WORKFORCE STUDIES, ASSOCIATION OF AMERICAN MEDICAL COLLEGES 

Mr. SALSBERG. Good afternoon, Chairman Hostettler and Ranking Member Jackson Lee and other Members of the Subcommittee. 

My name is Ed Salsberg. I’m the director of the Center for Workforce Studies at the Association of American Medical Colleges. 

AAMC represents all 125 accredited U.S. allopathic medical 

schools, nearly 400 teaching hospitals and health systems, and 94 

academic societies. 

I’ve been asked to address today the likely future supply and demand for physician services and what our medical schools and 

teaching hospitals are doing to assure an adequate supply of physicians to meet America’s needs. 

Let me state at the outset that the AAMC and our members are 

fully committed to assuring an adequate supply of well-trained 

physicians to serve the Nation. Historically, U.S. medical schools 

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cially when those needs have been clearly articulated and supported by Government programs and policies. 

In the 1960’s and 1970’s, the U.S. medical school enrollment doubled in response to a national need and Federal support. In the 

1980’s and 1990’s, allopathic medical schools responded to a series 

of Government reports that clearly expressed concern about a pending surplus. And the schools are now responding to growing evidence about a future shortage, including the recent report by the 

National Council on Graduate Medical Education. 

While we believe our members will respond, we believe more can 

be done, including in terms of Federal support for our efforts. Forecasting future physician supply and demand is extremely difficult. 

We’re trying to look 10, 20 years out into the future, and there are 

just many, many unknowns. 

But based on our current analysis, we believe that the Nation is 

likely to face a significant shortage in the future. That’s really reflecting both factors of supply and demand. 

On the supply side, we know there are 250,000 active physicians 

over the age of 55 that will be approaching age of retirement. We 

know that there are reports of younger physicians not interested in 

working the long hours that physicians did in the past. 

On the demand side, the Nation is growing rapidly, adding 25 

million additional Americans every decade. We know that the elderly will double between 2000 and 2030. That’s critical because 

the elderly use far more services than a younger population. 

And I think also the increasing wealth of the Nation and the expectations of the baby boom generation lead us to conclude the demand for health services, particularly physician services, will be 

rising in the future and that the supply will not be keeping up. 

A comment about international medical school graduates who are 

really a critical source of—component of the physician workforce. 

International medical school graduates represent 25 percent of our 

active physicians in America and 25 percent of the physicians in 

training. 

As you mentioned, we are hearing of growing concerns internationally about the impact of the migration of physicians from less 

developed to more developed countries, and this is an issue of concern. 

The AAMC has recommended a number of actions to better assure an adequate supply of physicians in the coming years. First, 

last February, the association adopted a position of recommending 

that U.S. medical schools increase their enrollment by 15 percent. 

We’re now considering a recommendation to our members that 

they increase enrollment by 30 percent. That would be equal to 

about 5,000 additional graduates each year. We’ve seen some response already, and I’ll come back to that. 

A second important step would be to raise the caps on Medicarefunded GME positions. Our medical schools are beginning to respond, but they’re clearly concerned that in the absence of an increase in the cap on residency positions, that their efforts to increase the physician supply will not lead to that end. 

Third, we reiterated our commitment to the importance of having 

a diverse, culturally diverse physician workforce that reflects the 

Nation. 

11

Fourth, we’ve recommended and feel it’s critical that we expand 

the National Health Service Corps. That really is probably the 

most effective national strategy to assure redistribution of physicians to underserved areas. 

And fifth, we support efforts to expand data collection and analysis on an ongoing basis to assure that the medical community and 

the public are aware of what the future physician workforce needs 

are. 

In that regard, we are concerned with the elimination last year 

of about 50 percent of title 7 funding, one of the only sources of 

funding for medical education, including medical education in rural 

communities. And also eliminated was the support for the national 

center and the regional centers for health workforce data collection. 

Let me just note that the U.S. medical schools are responding. 

More than half of the U.S. allopathic schools have indicated their 

plans or serious consideration for expanding over the next several 

years. We also expect to see five new allopathic schools in the coming years. 

Overall, we see about a 10 percent increase in U.S. medical 

school enrollment in the pipeline now, and we hope to see more. 

I think—in closing, I think U.S. medical schools have begun to 

respond to the calls for an expansion. We could use your support. 

A positive signal from the Federal Government, such as the restoration of title 7 funding, lifting of the Medicare GME caps, and 

expansion of the National Health Service Corps would go a long 

way to inform and support the efforts of U.S. medical schools to expand their capacity. 

I thank you for the opportunity to speak to you today and would 

welcome any questions. 

[The prepared statement of Mr. Salsberg follows:]

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PREPARED STATEMENT OF EDWARD SALSBERG


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Mr. HOSTETTLER. Thank you, Mr. Salsberg. 

Mr. Crosby? 

TESTIMONY OF JOHN B. CROSBY, J.D., EXECUTIVE DIRECTOR, 

THE AMERICAN OSTEOPATHIC ASSOCIATION 

Mr. CROSBY. Thank you very much, Mr. Chairman and Members 

of the Committee. 

The AOA is honored to be here, representing 56,000 osteopathic 

physicians in the United States, and we’re honored to be working 

with Congressman Pomeroy and Congressman Moran on addressing these critical issues of access to health care in rural America 

and other underserved areas. 

Let me make clear at the outset, the AOA is not opposed to H.R. 

4997. We acknowledge the positive results from the J-1 visa and 

Conrad programs, and they’ve helped many rural communities over 

the years. 

What we are concerned about, however, is that policy objectives 

today are not addressing U.S. osteopathic and allopathic medical 

schools and their needs to better meet these critical issues. Let me 

reiterate, the AOA is concerned that U.S. graduate medical education programs are not prepared to meet the physician workforce 

demands of 2020. 

Right now, I’m not going to go over the statistics, but there are 

about 96,000 residency positions in the United States. By the year 

2015, assuming there are still 24,000 PGY-1 programs around, 

M.D.s will need another 20,000 positions than they have today, and 

D.O.s will need another 5,000 positions. 

Mr. Chairman, you mentioned in your remarks that you were interested in what the U.S. medical schools and physician community 

were doing to address these needs. We have—in the osteopathic 

community, since 1991, we have opened up 8 new medical schools, 

and we have 6 additional medical schools on the drawing board as 

we speak. 

Since 1990, osteopathic physicians have grown in number by 67 

percent. We represent 6 percent of all physicians in the United 

States now, 8 percent of the military, and 22 percent of all physicians practicing in rural and underserved parts of the United 

States. 

We have 23 colleges of osteopathic medicine right now. And 

speaking of rural America and underserved areas, some of our newest schools have gone into Appalachia, into the rural West. We’re 

working with Indian health centers, Eskimo populations, and others. 

And our newest school is probably going to be in Harlem, New 

York, to meet the underserved needs of the inner city. So we’re 

very proud of what we have done in terms of making a commitment to rural care. 

There are several things you can do to address U.S. health care 

needs in this regard. First of all, you can assist us in helping to 

expand the class sizes and increase the number of new medical 

schools, as Dr. Salsberg and others have advocated. 

You can focus more attention on training primary care physicians and general surgeons, largely through the Medicare physician 

49

payment system, which right now has a bias against those two 

areas of training and practice. 

You can increase the training capacity in the United States. As 

Dr. Salsberg said, we support the AAMC in eliminating the cap 

from the Balanced Budget Act of 1997, which limits the number of 

residency training programs for U.S. trained physicians as we 

speak today. 

You can provide financial assistance to rural hospitals who would 

like to start up teaching programs. Right now, it takes about 18 

months before you get your first dollar from Medicare if you want 

to start a teaching program. Provide them a loan. Tie it to primary 

care. Target it to rural communities, and you can do a lot to establish new training programs here in the United States. 

And again, as I said, tie it to primary care. You can improve 

graduate medical education training programs that foster training 

in rural settings, particularly nonhospital settings. Congressmen 

Hulshof and Talent have introduced H.R. 4403, the ‘‘Community 

and Rural Medical Residency Preservation Act of 2005.’’ Your support of that legislation would go a long way. 

And expanding scholarship and loan repayment programs to provide incentives for physicians practicing in rural communities 

would go a long way. Provide an annual tax credit equal to the 

amount of interest that they pay on their student loans, and also 

expand the current scholarship and loan repayment program to 

allow physicians to fulfill their commitment to rural communities 

on a part-time basis as well as the full-time basis currently provided by law. 

We are deeply appreciative of your leadership on this critical 

issue. We welcome this opportunity to address these concerns. And 

again, we do not oppose H.R. 4997, but we think you can do a great 

deal to expand training for U.S. educated osteopathic and 

allopathic physicians. 

Thank you very much. 

[The prepared statement of Mr. Crosby follows:]

PREPARED STATEMENT OF JOHN B. CROSBY

Chairman Hostettler, Ranking Member Jackson Lee, and distinguished members 

of the Committee. My name is John Crosby. I am the executive director of the 

American Osteopathic Association (AOA). The AOA, which represents the nation’s 

56,000 osteopathic physicians and 12,000 osteopathic medical students, is honored 

to be here today to discuss a very important issue-access to physicians in rural and 

other underserved communities. We believe that by increasing training and workforce opportunities through recruitment and placement of U.S. trained osteopathic 

physicians you can improve access to physician services in rural communities and 

better address the global health needs by encouraging U.S. trained foreign medical 

graduates to return home to provide care to underserved populations. 

We recognize that many communities face limited access to physicians and physician services. This is especially true in rural communities. We applaud the efforts 

made by state governments, the federal government, Members of Congress, and 

rural communities to increase physician access for their citizens. 

For more than 130 years the AOA and the osteopathic profession have been dedicated to educating and training the future physician workforce. Consistent with our 

mission, we remain committed to producing primary care physicians who will practice in rural and other underserved communities. This mission has been a tenet of 

the profession since it’s founding in the late 1800’s. Today, more than sixty-five percent of all osteopathic physicians practice in a primary care specialty (family medicine, internal medicine, pediatrics, and obstetrics/gynecology). Each year, more than 

65 million patient office visits are made to osteopathic physicians. 

50

Over the past fifteen years we have enjoyed tremendous growth. Since 1990 the 

number of osteopathic physicians has increased sixty-seven percent. Currently, osteopathic physicians represent six percent of the total U.S. physician workforce and 

over eight percent of all military physicians. However, twenty-two percent of osteopathic physicians practice in a designated medically underserved area (MUA) (Map 

1). Throughout our history the osteopathic profession has placed an emphasis on 

primary care and rural service. Our colleges of osteopathic medicine have embraced 

this mission. Through the years, new colleges of osteopathic medicine have been established in some of the nation’s most medically underserved regions (Map 2). 

The issues facing our nation’s rural health care system are complex. We do not 

suggest that there are easy answers, but we do believe that there are policies that 

would increase our ability to meet these needs. The following pages outline several 

recommendations. These recommendations promote the ability of the AOA and our 

allopathic colleagues to meet the needs of rural communities without placing a 

greater dependence upon international medical graduates. Additionally, we believe 

that the implementation of these recommendations will allow the U.S. medical education system to meet its responsibilities of training international physicians who 

will return home and provide quality of care to their citizens. As a result of these 

two missions, we fulfill our joint goal of improving health care for all Americans and 

sharing our expertise with other countries as a means of improving global health. 

INTERNATIONAL MEDICAL GRADUATES

The U.S. health care system is widely recognized as the most advanced in the 

world. The rapid development of new diagnoses and treatments outpaces those in 

other countries. We are the world’s leader in medicine and medical technology. In 

this role, we should share our expertise with the world. For this reason, the AOA 

supports the continued acceptance of international medical graduates (IMGs) into 

the U.S. graduate medical education system. By training international physicians, 

we can improve the health care delivery systems around the world by improving the 

quality of the physicians. However, this transfer of knowledge and skills cannot take 

place if international physicians do not return to their home countries. 

The United States should not be an importer of physicians. Physicians should 

come to the U.S. to train and then return home. The ‘‘brain drain’’ in many countries is well documented. Many countries lose their best and brightest young physicians to the United States and other English-speaking countries. The AOA believes 

that policies should facilitate the opposite result. International physicians should 

come here to train and should not be encouraged to stay upon completion of their 

training. In fact, we should require that they return to their home countries and 

practice medicine for an extended period of time before they are eligible to petition 

for a visa, J-1 or otherwise. 

In 2006, almost 9,000 IMGs participated in the National Residency Matching Program (NRMP). Of these applicants, approximately 6,500 were not U.S. citizens and 

2,500 were U.S. citizens who attended a foreign medical school. Almost fifty percent 

of all IMGs match to first year residency positions. In 2006, the total number of 

IMGs who matched to first year positions increased to 4,382. 

Of the 6,500 IMG participants who were not U.S. citizens, 3,151 (48.9%) obtained 

first year positions. 2006 was the fifth consecutive year that the number of non-U.S. 

citizen IMGs matching to first year positions increased. Of the 2,500 U.S. citizen 

IMG participants, 1,231 (50.6%) were matched to first year positions. 2006 was the 

third consecutive year that the number of U.S. citizen IMGs matching to first year 

positions increased. The total number of IMGs filling first year residency positions 

will be much higher than the approximate 4,400 who secured positions through the 

NRMP. Many IMGs are able to secure residency training positions outside the 

match. All of these IMGs are allopathic physicians (MDs) and none are osteopathic 

physicians (DOs). 

PHYSICIAN WORKFORCE

Many experts now believe that the United States will face a shortfall in its physician supply over the next twenty years. While academic and policy experts debate 

the needs and expectations of the future physician workforce, the AOA recognizes 

that we must begin to educate and train a larger cadre of physicians, now. The time 

it takes to educate and train a physician is, at minimum, seven years. This means 

that a student accepted in the matriculating class of 2006 will not enter the physician workforce until at least 2013. Due to the time required to educate and train 

future physicians, we believe a concentrated effort must be focused on increasing capacity over the next five years. If handled appropriately, the country could increase 

the physician workforce dramatically by 2020. 

51

Reliance upon the J-1 Visa program is neither the most effective nor the most desirable way to increase physician supply in rural communities, although we recognize that the program can provide short-term relief. The J-1 program is not capable 

of meeting the physician workforce needs of our nation and should not be promoted 

for this purpose. Yes, a few states and communities have physician services as a 

result of the J-1 program. However, thousands of rural communities remain without 

physician services. The AOA supports increasing our capacity by adopting policies 

that encourage larger numbers of U.S. educated and trained physicians to practice 

in rural and underserved areas. An increase in U.S. educated and trained physicians, if properly selected and trained, will lead to a more predictable and reliable 

physician workforce and is more likely to produce larger numbers of physicians who 

will practice in rural communities. 

Currently, there are 23 colleges of osteopathic medicine. Twenty of those are operating on 23 campuses. Three of those are in formation having recently received preaccreditation. In 2006, these colleges will graduate approximately 2,925 new osteopathic physicians. In 2008, the number of graduates will increase to 3,463. By 2013 

the number of osteopathic physicians graduating from colleges of osteopathic medicine is projected to reach 4,706. 

The AOA, like the Association of American Medical Colleges, requires maintaining 

of quality educational standards while class sizes are increasing. Additionally, we 

anticipate the establishment of at least three additional colleges of osteopathic medicine over the next four years. These new colleges, once established and accredited 

will begin educating approximately 500 to 600 new students each. Once fully enrolled, our current colleges, along with the new colleges of osteopathic medicine, 

should produce an additional 1,000 physicians per year. Assuming a predictable 

growth pattern, the osteopathic profession should produce approximately 5,000 new 

physicians per year beginning in 2015. 

RECRUITMENT AND PLACEMENT

Medical schools and colleges of osteopathic medicine traditionally place significant 

emphasis on an applicant’s academic achievement-grade point average, undergraduate degree program, and scores on the Medical College Admission Test 

(MCAT). While I would never suggest that the academic standards required for admittance be lowered, I do recommend that the nation’s medical education institutions begin evaluating ‘‘other’’ factors. An evaluation of the student’s life, including 

an evaluation of where the student was raised, attended high school, and location 

of family members, provides an indication of where a future physician may practice. 

For example, an applicant from Princeton, New Jersey is less likely to practice in 

a rural community than an applicant from Princeton, Indiana. If the two applicants 

are equally qualified, we should encourage our schools to matriculate the student 

from Princeton, Indiana, an individual more likely to return to rural southwest Indiana once education and training is completed. 

Our medical education system must increase its efforts to promote both primary 

care specialties and experience in rural practice locations. Over the years, the role 

of the rural family physician became less glamorous than that of the urban subspecialist. Far too many medical school students want to be an ‘‘ologist’’ instead of 

a general surgeon, family physician, general internist, or pediatrician. Our nation’s 

health care system needs specialists and subspecialists, but we need far more primary care physicians. Our medical education system must place greater emphasis 

on educating and training primary care physicians and general surgeons. These 

physicians are more likely to practice in a rural or small community hospital and 

are far more likely to practice in rural America. 

INCREASE TRAINING CAPACITY

Currently, there are approximately 96,000 funded residency positions in the 

United States. Of these positions, international medical graduates fill approximately 

ten percent. The number of international medical graduates training in the United 

States has grown steadily over the past decade. The number of funded residency positions has been static since the late 1990’s when Congress, as part of the Balanced 

Budget Act of 1997, placed a limit or ‘‘cap’’ on the number of residency slots any 

existing teaching program may have. With the exception of a provision allowing for 

the establishment of a rural training tract, these caps have been unaltered since 

their establishment. 

The residency cap was established at a time when the general consensus was that 

the country had an adequate supply of physicians. We now recognize this is not correct. The residency caps established by the BBA limit the ability of teaching hospitals to increase training programs, thus preventing responsible growth capable of 

52

meeting our future physician workforce needs. The AOA encourages Congress to either remove or increase the cap on the number of funded graduate medical education training ‘‘slots’’ as established by the Balanced Budget Act of 1997. 

IMPROVE RURAL TRAINING PROGRAMS

There is an old saying in medical education circles that physicians will practice 

within 100 miles of where they train. While the validity of this saying either in a 

world that is flat or alternatively in an era of globalization is unproven, its message 

rings true. Physicians are more likely to practice in settings where they have the 

most experience. While a majority of physician training takes place in the hospital 

setting, it should not be limited to this setting. We need to do more to expose medical students and resident physicians to different practice settings during their 

training years. 

A valuable component of graduate medical education is the experience of training 

at non-hospital ambulatory sites. These sites include physician offices, nursing 

homes, and community health centers. Ambulatory training sites provide an important educational experience because of the broad range of patients and conditions 

treated and by ensuring that residents are exposed to practice settings similar to 

those in which they ultimately may practice. This type of training is particularly 

important for primary care residency programs since a majority of these physicians 

will practice in non-hospital ambulatory clinics upon completion of their training. 

This training also is essential to improving access to care in rural communities. 

Congress has long recognized that a greater focus should be placed on training 

physicians in rural and other underserved communities. In the 1990s, Congress 

began to fear that the current graduate medical education payment formula discouraged the training of resident physicians in ambulatory settings. This opinion was 

based upon the fact that the payment formula only accounted for the resident training time in a hospital setting. Through the Balanced Budget Act of 1997, Congress 

altered the payment formula, removing the disincentives that existed for training 

in non-hospital settings. We accomplished this goal by allowing hospitals to count 

the training time of residents in non-hospital settings for the purpose of including 

such time in their Medicare cost reports for both indirect medical education (IME) 

and direct graduate medical education (DGME) payments. 

This change in the payment formula was designed to increase the amount of 

training a resident physician received in non-hospital settings, enhance access to 

care for patients in rural and other underserved communities, provide an additional 

education experience for residents who are considering practicing in rural communities, and provide a recruitment mechanism for rural and underserved communities in need of physicians. 

The program appeared to be working as intended. However, in 2002 the Centers 

for Medicare and Medicaid Services (CMS) began administratively altering the rules 

and regulations in respect to this issue. As a result, CMS intermediaries began denying the time residents spent in non-hospital settings. In many cases, hospitals 

were forced to repay thousands of dollars as a result of this administrative change 

in regulations. Many Members of Congress urged CMS to work with interested parties to resolve this issue by developing new regulations that clarify the appropriate 

use of non-hospital settings. Unfortunately, these conversations have not produced 

policies that meet the original intent of Congress as established in 1997. As a result, 

hospitals are being forced to train all residents in the hospital setting, eliminating 

the valuable educational experiences offered in non-hospital training sites. Additionally, some teaching hospitals may be forced to eliminate residency programs entirely 

as a result of current CMS policies. 

Allowing hospitals to receive payments for the time resident physicians train in 

a non-hospital setting is sound educational policy and a worthwhile public policy 

goal that Congress clearly mandated in 1997. Additionally, it is good for rural communities. For this reason, the AOA encourages Congress to enact the provisions included in the ‘‘Community and Rural Medical Residency Preservation Act of 2005’’ 

(H.R. 4403). 

H.R. 4403 would establish, in statute, clear and concise guidance on the use of 

ambulatory sites in teaching programs. If enacted, it will preserve the quality education of resident physicians originally envisioned by Congress in 1997. The Medicare program should promote quality graduate medical education, rather than impose unnecessary barriers. 

The AOA also encourages Congress to establish a new grant program, operated 

by the Health Resource Service Administration (HRSA) that would provide ‘‘startup’’ funding for rural hospitals that seek to establish new primary care residency 

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dency program are prohibitive. Due to CMS requirements, hospitals starting new 

residency programs are not eligible for funding for at least 12 months. This lag between the actual start-up date and the date of eligibility for funding is cited as one 

of the main reasons more hospitals, especially smaller hospitals, do not start teaching programs. The AOA believes that numerous primary care residency programs 

at rural hospitals could be established if financial assistance was available to offset 

the associated costs. 

EXPAND PROGRAMS THAT PROVIDE INCENTIVES FOR RURAL PRACTICE

There are numerous existing programs that provide scholarships and loan repayment for physicians who choose to practice in rural communities. These programs 

include the National Health Service Corps, Public Health Service, Indian Health 

Service, and many programs operated by state governments. The AOA supports 

these programs and encourages Congress to continue funding them at levels that 

facilitate greater numbers of physicians practicing in rural and other underserved 

communities. 

Additionally, we believe that some consideration should be given to allow physicians to participate in the programs on a part-time basis. There are numerous communities that need physician services, but they may not need them full time. We 

believe that modifications should be made to federal loan repayment and scholarship programs that allow participants to repay on a part-time basis in exchange for 

a longer term of service. For example, if a physician participates in the National 

Health Service Corps and agrees to a three-year commitment in a rural community—why not allow the physician the option of committing to 4 or 5 year’s service 

on a part-time basis. We believe this would encourage more physicians to participate in these valuable programs without jeopardizing the underlying mission. 

The AOA also proposes a change in the tax code that would provide physicians 

practicing in designated rural communities with a tax credit equal to the amount 

of interest paid on their student loans for any given year that they practice in such 

a community, or until their loans are paid in full. Under current law, individuals 

may deduct up to $2,500 in interest paid on student loans from their federal income 

taxes. However, the income thresholds associated with this provision often prevent 

physicians from qualifying. Our proposal would provide a direct link between practice location and the tax credit. A physician practicing in a rural Indiana who pays 

$8,000 in interest on her student loans in year one would get an $8,000 tax credit 

for that year. The program would continue until the physicians had retired her student loan debt or when she departed the rural community. We believe that this proposal provides a direct incentive to young physicians and would assist in the recruitment and retention of physicians in rural communities. 

IMPROVE ECONOMICS OF MEDICINE

The current practice environment physicians face is challenging. Over the past 

decade escalating professional liability insurance premiums, decreasing reimbursements, and expanded regulations have made the practice of medicine more frustrating for all physicians. These issues are compounded in rural communities where 

physicians are often in solo practice or small group practices, unable to benefit from 

economies of scale that larger group practices in urban areas enjoy. 

According to a 2004 Health Affairs study, more than half of all practicing physicians are in practices of three or fewer physicians. Three-quarters are in practices 

of eight or fewer. They face the same economic barriers as every other small business in America. Costs associated with staff salaries; health and other benefits, 

basic medical supplies, and technology, all essential components of any business, 

continue to rise at a rate that far outpaces reimbursements. When facing deep reductions in reimbursements at the same time that their operational costs are increasing, it is safe to project that most businesses will not be able to continue operation. While most businesses increase, or have the ability to increase, their prices 

to make up the differential between costs and reimbursements, physicians participating in Medicare cannot.

T3Physician Payment—Unless Congress acts, Medicare physician payment 

rates will be cut by 4.6 percent on January 1, 2007. If this cut is imposed, Medicare rates will fall 20 percent below the governments measure of inflation in 

medical practice costs from 2001–2007. If the projected cuts are implemented, 

the average physician payment rate will be less in 2007 than it was in 2001. 

Additionally, two provisions included in the Medicare Modernization Act 

(MMA), which provide increased reimbursements for physicians in rural communities, will expire over the next two years. 

54

In 2002, physician payments were cut by 5.4 percent. Congress acted to avert 

payment cuts in 2003, 2004, 2005, and 2006 replacing projected cuts of approximately 5 percent per year with increases of 1.6 percent in 2003, 1.5 percent in 

2004 and 2005, and 0 percent in 2006. Even with these increases, physician 

payments fell further behind medical practice costs. Practice costs from 2002 

through 2005 were about two times the amount of payment increases. Since 

many health care programs, such as TRICARE, Medicaid, and private insurers 

link their payments to Medicare rates, cuts in other systems will compound the 

impact of the projected Medicare cuts. Medicare cuts actually trigger cuts in 

other programs. 

Additional cuts in Medicare physician payments decrease Medicare beneficiaries’ ability to access to physician services. A MedPAC survey conducted 

earlier this year found that 25 percent of Medicare beneficiaries reported having 

difficulties obtaining an appointment with a primary care physician. These 

problems will only increase if additional cuts are implemented. Additionally, reduced payments may prevent the implementation and adoption of new health 

information technologies. 

Furthermore, reduced payments hamper the ability of physicians to purchase 

and implement new technologies in their practices. According to a 2005 study 

published in Health Affairs, the average costs of implementing electronic health 

records was $44,000 per full-time equivalent provider, with ongoing costs of 

$8,500 per provider per year for maintenance of the system. This is not an insignificant investment. When facing deep reductions in reimbursements, it is 

safe to project that physicians will be prohibited financially from adopting and 

implementing new technologies. 

Physician payments should reflect increases in practice costs. In its 2006 

March Report to Congress, the Medicare Payment Advisory Commission 

(MedPAC) stated that payments for physicians in 2007 should be increased 2.8 

percent. Since 2001, MedPAC has recommended that the flawed SGR formula 

be replaced by a formula based upon increases in physician practice costs minus 

a productivity adjustment, which would produce annual updates equal to the 

Medicare Medical Economic Index (MEI). 

Since its inception in 1965, a central tenet of the Medicare program is the 

physician-patient relationship. Medicare beneficiaries rely upon physicians for 

access to all other aspects of the Medicare program. This relationship has become compromised by dramatic reductions in reimbursements, increased regulatory burdens, and escalating practice costs. Given that the number of Medicare beneficiaries is expected to double to 72 million by 2030, now is the time 

to establish a stable, predictable, and accurate physician payment formula that 

reflects the cost of providing care. 

Congress must act to reform the Medicare physician payment formula. Continued use of the flawed SGR formula will have a negative impact upon patient 

access to care. Additionally, the AOA urges Congress to approve the ‘‘Medicare 

Rural Health Providers Payment Extension Act’’ (H.R. 5118). This legislation 

includes provisions that extend two important rural physician payment provisions originally enacted through the MMA. H.R. 5118 extends, through 2011, 

a provision that provides equity in how the Medicare program views and evaluates the work of physicians regardless of geographic location. By establishing 

a 1.0 floor for the work geographic practice cost indices (GPCI) under the Medicare physician fee schedule, the MMA reversed years of inequities in payments 

between rural physicians and those in larger urban communities. The AOA was 

equally pleased that the MMA included a 5 percent add-on payment for physicians practicing in recognized Medicare physician scarcity areas. We believe 

that these are essential and positive Medicare payment policies that should be 

extended, if not made permanent. Both provisions will enhance beneficiary access and improve the quality of care available. 

Medical Liability Reform—As you know, the nation’s medical liability system 

is broken. In recent years physicians across the nation have faced escalating 

professional liability insurance premiums. According to the National Association 

of Insurance Commissioners (NAIC), between 1975 and 2002 medical liability 

premiums for physicians increased, on average, 750 percent. These premium increases are related directly to an explosion in medical liability lawsuits filed 

against physicians and hospitals and the rapid increase in awards. The Government Accountability Office (GAO) confirms this. In a 2003 report, the GAO stated that losses on medical liability claims are the primary driver of increases in 

medical liability insurance premiums. 

As a result of a broken medical liability system patients face reduced access 

to health care, the overall costs of health care increases, and the future supply 

55

of physicians is threatened. Many physicians no longer provide services that are 

deemed high-risk, such as delivering babies, covering emergency departments, 

or performing certain surgical procedures. This crisis also impacts primary care 

physicians, especially those in rural areas who are often the only physician 

practicing in a community. As a result, patients have seen a decrease in the 

availability of physician services. Additionally, the medical liability crisis has a 

significant impact upon the career choices of future physicians. In a recent poll 

conducted by the AOA, eighty-two percent of osteopathic medical students stated that the cost and availability of medical liability insurance would influence 

their future specialty choices, while 86 percent stated that it would influence 

their decision on where to establish a practice once their training was complete. 

This trend in career choices is disturbing and will have a long-term impact upon 

the health care delivery system in the years ahead. 

We applaud the leadership of this Committee and the House of Representatives in approving the ‘‘Help, Efficient, Accessible, Low-Cost, Timely, Health 

Care Act’’ (HEALTH Act) (H.R. 5). The AOA believes that provisions included 

in H.R. 5 will prove beneficial in stabilizing the nation’s broken medical liability 

system, thus improving access to physician services. 

SUMMARY

Again, the AOA appreciates the opportunity share our views on this important 

issue. We remain committed to working with Congress to enact legislation that will 

ensure access to quality physician services for all Americans, regardless of where 

they reside. In closing we would like to highlight five recommendations made in our 

testimony that we believe will lead to improved global health, increase the availability of U.S. trained physicians, improve the quality of training for future physicians, and improve the recruitment and retention of physicians in rural communities.

1. International Medical Graduates should be encouraged to return to their 

home countries to establish practices and, ultimately, improve the quality of 

care in those health care systems. The United States should not be an importer of physicians, thus contributing to the ‘‘brain drain’’ of other countries. 

By maintaining existing policy that requires IMGs to return home for two 

years before petitioning for a visa, we are fulfilling a noble mission of improving the health care needs of many countries.

2. Congress should consider eliminating the cap on available and funded residency positions in the U.S. This cap hinders the ability of osteopathic and 

allopathic medical schools to educate and train larger numbers of physicians. 

To meet the health care needs of our growing population we must have the 

capacity and financing to train a larger number of physicians.

3. Congress should enact the ‘‘Community and Rural Medical Residency Preservation Act of 2005’’ (H.R. 4403). This legislation would establish, in statute, 

clear and concise guidance on the use of ambulatory sites in graduate medical education programs. If enacted, it will preserve the quality education of 

resident physicians originally envisioned by Congress in 1997.

4. Congress should amend the tax code to allow physicians practicing in rural 

communities an annual tax credit equal to the amount of interest paid on 

their student loans. We believe that this proposal provides a direct incentive 

to young physicians and would assist in the recruitment and retention of 

physicians in rural communities. Additionally, Congress should revise current scholarship and loan repayment programs to allow physicians to fulfill 

their commitment on a part-time basis.

5. Congress should reform the Medicare physician payment formula by eliminating the sustainable growth rate and replacing it with a more equitable 

and predictable payment structure. Additionally, Congress should enact the 

‘‘Medicare Rural Health Providers Payment Extension Act’’ (H.R. 5118), extending much need payment incentives for physicians practicing in rural 

communities.

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Mr. HOSTETTLER. Thank you, Mr. Crosby. 

Ms. Aronovitz? 

TESTIMONY OF LESLIE G. ARONOVITZ, DIRECTOR, HEALTH 

CARE, UNITED STATES GOVERNMENT ACCOUNTABILITY OFFICE 

Ms. ARONOVITZ. Good afternoon, Mr. Chairman and Mr. Lungren. 

I am pleased to be here today as you discuss the States’ authority to request J-1 visa waivers for foreign physicians to practice in 

the Nation’s underserved areas. 

My remarks today are based on preliminary findings from our 

ongoing work, which reviews the number of J-1 visa waivers requested by States and physicians practice locations and specialties, 

States’ activities to monitor compliance with waiver agreements, 

and the States’ views on the adequacy of the 30 waiver per State 

limit. 

As Ms. Lee mentioned, our work is based on a survey of 50 

States, the District of Columbia, Puerto Rico, Guam, and the Virgin 

Islands. I should mention that we also surveyed the three Federal 

agencies that requested J-1 visa waivers on behalf of States in the 

last few years. 

In summary, we found that J-1 visa waivers remain a major 

means of placing physicians in underserved areas, with more than 

1,000 waivers requested in each of the past 3 years for physicians 

to practice in nearly every State. We also found that in fiscal year 

2005, States made more than 90 percent of the J-1 visa waiver requests, with the 3 Federal agencies making up the rest. 

Every State, except Puerto Rico and the Virgin Islands, made requests last year, though the number varied considerably among the 

States. For example, about a quarter of the States requested the 

maximum of 30 waivers, while another quarter or a little bit over—

about 29 percent of them—requested 10 or fewer waivers. 

Collectively, the States requested 956 waivers, or about 60 percent of the total that were available to all the States collectively. 

In terms of demographics, about 44 percent of the States’ waiver 

requests were for physicians to practice only primary care, and 

about 41 percent were for physicians to practice only specialties, 

such as cardiology. More than three quarters of the requests were 

for physicians to work in hospitals or private practices. 

Regarding monitoring, while States do not have an explicit responsibility for monitoring and overseeing the physicians compliance with waiver agreements, most reported conducting at least 

some monitoring activities. For instance, requiring periodic reports 

on whether the intended population in these facilities were actually 

being served or conducting site visits. 

Regarding States’ views on the 30 waiver limit, about 80 percent 

of the States, including many that requested close or all of the 

waivers—the 30 waiver limit—felt that the 30 waiver limit was 

adequate for their needs. However, 7 States reported that this limit 

was less or very much lower than what they needed. 

When asked—when we asked the States if they needed more 

waivers, interestingly, 7—excuse me, 11 States said that they needed a total of 200 more waiver physicians. And this included 4 

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States that said the limit was adequate, but they still reported 

needing more physicians. 

Regarding distribution of unused waivers, of the 44 States that 

did not request their 30 waiver limit—10 States did, 44 did not—

25 of those 44 States said that they would be willing to have their 

unused waiver allotments redistributed at least either willing or 

willing under certain circumstances. 

And for example, some of these circumstances involve their willingness if they were—if it were—it depended on the timing of the 

distribution. They would not want it done in the first half of the 

year, when there was a chance that they still might be able to attract some physicians toward the end of the year. 

Others said they wanted to be sure that their needs were met before they would give up their waivers. Others advocated for a regional distribution approach, while still others mentioned possible 

compensation, perhaps an exchange of unused waiver allotments 

for more flexibility for the waivers that they did use. 

Finally, several States mentioned that they would not want redistribution in 1 year to affect the number of waivers that they received to be able to ask for in another year. 

In contrast to these 25 States, 14 States reported that they 

would not be willing to have their unused waiver allotments redistributed, and they were very concerned about the reduction in the 

number of physicians seeking to practice in their States. They felt 

that if, in fact, physicians knew that there was a redistribution 

program, they might wait until a more preferred location in another State cropped up before they applied for the position in a less 

desirable State. 

What remains unclear and what we could not determine is 

whether any redistribution approach would simply move waiver 

physicians from one State to another or instead increase the overall 

pool of physicians seeking waivers to work in underserved areas. 

I’m happy to elaborate on my findings or answer any other questions that you may have. 

[The prepared statement of Ms. Aronovitz follows:]

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PREPARED STATEMENT OF LESLIE G. ARONOVITZ


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Mr. HOSTETTLER. Thank you very much, Ms. Aronovitz. 

At this time, we will turn to questions from the panel. First of 

all, Ms. Aronovitz, you state that there has been a 40 percent decline in the past 10 years of physicians using the J-1 visa to come 

to the U.S. for medical training. Can this be attributed to increased 

usage of the H-1B visa? 

Ms. ARONOVITZ. We don’t really know. There are no data that 

really break out the physicians using H-1Bs and J-1s specifically 

for that comparison. 

But a lot of the States who have answered our survey and other 

work we’ve done have contemplated different reasons. And one of 

the reasons that some States believe there is a reduction is the fact 

that H-1B visas are being used. So that is a valid thought on the 

part of very many people. 

Mr. HOSTETTLER. Thank you. 

Congressman Moran, as you testified, the J-1 visa has been instrumental in providing physicians to underserved areas all across 

your district. The National Health Services Corps, as you know, 

through HHS provides loan repayment for U.S. citizen health care 

providers who agree to work in rural areas as well as scholarships 

to individuals who will dedicate time of service in rural areas. 

Is your experience with that program such that you believe that 

that could be expanded ‘‘in lieu of’’ the J-1 visa program? Do they 

complement one another? How would you——

Mr. MORAN. Mr. Chairman, I was about to answer your question 

‘‘yes’’ until you said ‘‘in lieu of.’’ I do think that both programs are 

very important. They attract, they focus on additional resources to 

provide health care providers, but they’re two different populations. 

They serve the same population, but you’re dealing with different 

applicants, different types of physicians, folks who come to the 

health care profession in different ways. 

And so, both are very important to us. I would not at all diminish the role that the National Health Service plays in helping provide physicians, encouraging physicians to locate in underserved 

areas. But I don’t envision, based upon even the testimony we’ve 

heard today, the number of physicians that are available from U.S. 

medical schools remains so tight that I think it takes both programs and even more to meet the needs of underserved areas. 

So clearly not in lieu of and any way that we can expand and 

create a greater incentive. One of the things—we have our own 

State program as far as loan repayment for physicians through a 

State law. And many physicians have discovered that they can 

have their loans paid off through recruitment process if they’ll locate to a more urban or suburban setting. 

And so, with the loan program opportunities that are there, I 

think that just because more money can be made elsewhere, we’re 

inducing a number of our physicians to—even though they have the 

loan program—to have their loan paid off by a community that’s 

recruiting them to a different setting. 

Mr. HOSTETTLER. Thank you. 

Mr. Crosby, as you note in your testimony, one of the goals of the 

osteopathic profession is training primary care physicians for rural 

areas. How do you recruit and attract students to your colleges and 

specifically to serve rural areas? 

91

And a second question would be do you believe that the J-1 visa 

waiver program for physicians should be expanded, as some have 

suggested, if not here, then elsewhere? 

Mr. CROSBY. I really couldn’t comment on the second question in 

terms of expansion of the J-1 program itself. But again, if there’s 

a more specific question in terms of supporting that, I’d be happy 

to address it. 

With respect to your first question, I’ll just give you the example, 

Mr. Chairman, one of our newest schools is in Pikeville, Kentucky, 

the heart of Appalachia. And what they do is through the application process, try to recruit entering osteopathic medical students 

from the region who want to go into primary care and pledge to 

stay in that part of the country to practice medicine. 

And about 80 percent of the students coming in want to go into 

primary care, and they’ve graduated two classes now, and 80 percent are staying in Kentucky, northern Tennessee, West Virginia, 

to do just that. So if you tie the application process and you screen 

the applicants with the right mind set, I think you can achieve 

those goals. 

Mr. HOSTETTLER. Thank you. 

Mr. Salsberg, is it fair to say that a number of qualified potential 

medical students are turned down each year because there is a 

shortage of medical school slots? 

Mr. SALSBERG. Yes, we think there are many Americans who 

would be qualified to go to allopathic medical schools if we expand 

our capacity. That’s one of the reasons we’ve recommended the expansion among our members. 

Mr. HOSTETTLER. Thank you. 

The Chair recognizes the gentlelady from Texas, Ms. Jackson 

Lee, for 5 minutes. 

Ms. JACKSON LEE. I thank the Chair very much. 

I think I want to be clear on the record that I do not believe the 

J-1 visa is a replacement for the growing need of physicians here 

in the United States. And I do think it’s important that even beyond the jurisdiction of this Committee, that we focus the Congress 

on what is obviously a rising need that will reach, I think, a crisis 

level sometime over the next decade. And that is, of course, the 

need for doctors across America. 

At the same time, I think that we have solutions that we can address and utilize as we speak, and so I think it’s important to look 

at the immediacy of the problem and address it accordingly. 

Congressman Moran, you’ve heard me make several points which 

I am interested in, and I will have a document to submit from 

the—and I ask unanimous consent to submit the statement of the 

National Health Care Access Coalition into the record, Mr. Chairman. 

Mr. HOSTETTLER. Without objection. 

Ms. JACKSON LEE. And I’ll also take some quotes from this. But 

would you support a redistribution of the unused visa waiver 

shots—slots, rather? 

Mr. MORAN. Well, I was interested in the testimony of the GAO. 

I do think, and I wouldn’t want to admit that my State is one of 

those that would consider itself a less desirable location. But I do 

know that there is a fear among some States that if redistribution 

92

is allowed, that physicians are less likely to locate in what at least 

a physician considers to be a less desirable location for practice. 

I think this is—on the other hand, I think that it’s important 

that those States who desperately need additional physicians and—

have access to those physicians. So I think there is a way——

Ms. JACKSON LEE. We have to fix it, so that we don’t—we 

don’t——

Mr. MORAN. We don’t want to discourage the least—‘‘the least desirable’’ locations from being——

Ms. JACKSON LEE. Allegedly. Allegedly. 

Mr. MORAN. Allegedly. But we also need to recognize there is a 

demand in States. Texas has to be an example. It’s just such a 

large State, that 30 in Kansas is much more beneficial than 30 in 

Texas. 

Ms. JACKSON LEE. Absolutely. And I will cite some evidence of 

that. But let me also get your thoughts because this is what this 

Committee will have to address. The Chairman mentioned it. The 

movement away from J-1 visas to the H-1B visas, and do you have 

some thoughts on how we can legislatively address that question 

because it is a real concern? 

Mr. MORAN. Well, I’ve not given a lot of thought to the H-1B visa 

issue. It is a competitor to this program, and the distinction is that 

it doesn’t meet the needs of underserved areas. And so, from my 

perspective, we—for reasons of access to health care and reasons 

of health care costs—we need more physicians serving patients in 

the United States. 

And so, I wouldn’t want to take away from the physicians that 

come here under the H-1B. But clearly, we’ve got to focus the efforts at those areas of the country, urban cities and rural America, 

that desperately need physicians. 

I think that, generally, we’re going to find that the more prosperous areas of the country will be able to obtain physicians, and 

so the competition between the two programs I think has to be—

the balance of that has to be in favor of those places that are underserved. It’s a life and death issue. 

Ms. JACKSON LEE. Having the Texas Medical Center near and 

around my congressional district and parts of it in my congressional district, the distinction is important. The J-1 visa is temporary, and I think whatever reform we do—whether it’s an extension and other aspects that we need to reform, we should focus on 

that—that they go to underserved areas and they are immediate. 

H-1B visas are individuals in on research, post docs, specialties 

that allow them to go to the choice areas. In fact, the medical centers and prime hospitals and others use H-1B visas to get the talented of the talented. 

Not in any way to deflect on the J-1, but they are in a different 

category, and I think we should note that. So that we don’t undermine the value that J-1 visas have, and there is that distinction 

that should be made. 

Mr. MORAN. We can’t blur that distinction because we will lose 

the effectiveness of the J-1 visa program. 

Ms. JACKSON LEE. I agree with you. Let me ask Ms. Aronovitz. 

You didn’t get a sense, and you’re in the midst of a study, or have 

you——

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Ms. ARONOVITZ. Yes. We have—we do have our results. We 

haven’t analyzed them fully yet. But we do have some preliminary 

results. 

Ms. JACKSON LEE. Then the basic—you get a sense that those 

who are participating or States that are participating view the J1 visa as a positive asset to improving or assisting them in health 

care in their States, respective States? 

Ms. ARONOVITZ. Most definitely. And as I said, most every State 

last year used at least one of their visa waiver slots. 

Ms. JACKSON LEE. So you did not come away, though you’re still 

analyzing, with a massive call for elimination? 

Ms. ARONOVITZ. That’s correct. 

Ms. JACKSON LEE. Mr. Chairman, may I ask unanimous consent 

to put the statement—I asked that. But also—and I will quote from 

them, the Texas Department of State Health Services. I ask unanimous consent to put that letter in the record as well. 

Mr. HOSTETTLER. Without objection. 

The Chair recognizes the gentleman from California for 5 minutes. Mr. Lungren? 

Mr. Daniel LUNGREN OF CALIFORNIA. Thank you very much, Mr. 

Chairman. 

Mr. Moran, I was not in Congress when this program was first 

established, but it obviously was established on a temporary basis. 

Was that because it was to be a pilot project? 

Was that because there was a thought that this need for underserved areas would be a stopgap in that somehow we were going 

to, through other mechanisms, provide for these underserved 

areas? What was the nature of the short term or sunset of it? 

Mr. MORAN. Mr. Lungren, I have the same excuse that you do. 

I was not in Congress when the program was started, and there 

may be others that have the expertise at the table to answer your 

question. 

The Conrad 20 program in 1994, I think, was an effort to give 

States an opportunity that they did not have, and the Federal Government’s process was so slow and cumbersome for the J-1 visa 

program administered by Federal agencies that my guess is that 

Congress said let’s try this. Let’s see how it works. And I think the 

results today, 10 years later, is it is important and vital. 

I also know that in the timeframe which I was here, part of the 

issue was related to the extension followed post 9/11, followed 9/11. 

And there was interest in making the program temporary so that 

we could determine that the necessary security risks were being 

evaluated by now our Department of Homeland Security to make 

certain that those visas that were being approved in no way were 

causing any threat to the national security. 

So I think we’ve been through a series of times in which Congress wants to see how the program is working. And then, most recently, it’s been let’s make certain that there are no security risks 

involved in the program. 

Mr. Daniel LUNGREN OF CALIFORNIA. In my first tenure as a 

Member of Congress, I recall we were dealing with the question of 

underserved areas at that time. And there was some question as 

to why these were underserved areas. I mean, we don’t want to use 

the word ‘‘choice’’ areas versus ‘‘nonchoice’’ areas. 

94

And one of the things that I recall being discussed at that time 

was that physicians like to be kept up to date in their profession. 

That they are assisted in doing that by being surrounded by other 

physicians, by quality medical staffs, by having some access to 

teaching hospitals, if at all possible. 

And so, in some ways, people were suggesting at that time or a 

number of voices suggested at that time we needed stopgap measures to have doctors go for short periods of time to underserved 

areas, knowing they wouldn’t stay there for a long time. 

But there was the hope expressed that with technology in the future, that physicians might look at some of these areas as the 

choice areas for living purposes and that technology would allow 

them to fill that gap of information and reflection and exposure to 

colleagues and to outstanding teaching hospitals and teaching centers. 

I guess my question would be to all of you on the panel, if you 

would give me some idea as to whether that last thought has proven to be unsuccessful or that it has, in fact, proved that we can attract more physicians to these areas that were previously underserved. And I’m talking about rural areas, as opposed to inner city 

right now. 

And that would help me in looking at the legislation as to whether or not when we make it permanent, we’re making it permanent 

because we think this is going to continue to be a problem forever. 

Or is this—have we not seen any change in terms of attracting doctors to the more rural areas in spite of the fact that they now have 

these technological fixes in a sense to be able to keep up with the 

practice, be exposed to new possibilities in medicine and so forth? 

Mr. MORAN. Mr. Lungren, I can only speak from my experience, 

and I’ve worked with communities to recruit physicians. It does not 

seem to me that circumstances are getting any better, that the 

challenge is just as great as it has been in the past, and it’s related 

to not only the issue that you suggest about the desire of collaboration with other physicians. 

It’s issues related to lifestyle and the sense of physicians today 

do not want to be on-call 7 days a week, 24 hours a day. And that’s 

often the necessary practice in a small community. It’s much easier——

Mr. Daniel LUNGREN OF CALIFORNIA. They’re not going to Tuesday to Thursday schedules, are they? 

Mr. MORAN. We have not gone to Tuesday to Thursday schedules. But with the arrival of advanced nurse practitioners, physician assistants, I think that’s the one bright spot that I see as far 

as attracting and retaining physicians in rural America. We have 

additional assistant help. 

We do have telemedicine that’s available in my State. It’s more 

now used for some consultation with experts, specialists at the University of Kansas School of Medicine. But more likely than not and 

perhaps unfortunately, it’s used for continuing medical education 

for not only physicians, but nurses. It has not become a replacement for hands-on physician practice. 

Mr. HOSTETTLER. The gentleman’s time has expired. Without objection, the gentleman will be yielded an additional 2 minutes for 

the rest of the panel to respond. 

95

Mr. CROSBY. Congressman, I think you raise a very good point. 

Technology offers a lot of promise in rural areas. Our own organization now provides 9 hours of credit for continuing medical education programs that doctors can get over the Internet. And their 

access to the latest information from the New England Journal of 

Medicine to a news-breaking development with pharmaceuticals or 

whatever is immediate access. 

However, there are also I think a changing environment in terms 

of just lifestyle. I met—I was in Des Moines last week. I met a 

young doctor who had started out in Phoenix, got fed up with managed care, and has relocated to rural Iowa just because he wanted 

a different style of practice, which was very attractive to him. 

The one thing that I don’t think you can answer in terms of rural 

areas with technology or not is the whole sense of camaraderie, 

which you mentioned in your opening remarks. 

Another young physician that the National Health Service Corps 

sent out to an island off of Alaska would see 90 patients a day, but 

he couldn’t last more than 2 weeks without having to fly to the 

mainland just to see other physicians, talk to them about things 

that had come up in his practice, and basically cope with that emotional stress of being out there alone without anybody else to fall 

back on if you need it. 

But technology will answer a lot of questions over time. It already is. 

Ms. ARONOVITZ. One thing I can add is in our survey, we actually 

asked States whether they’ve seen an increase or a decline in interest in J-1 visa waiver physicians applying to the different States, 

and it was an open-ended question, and only 21 States chose to answer the question. 

But of the 21, 15 States said that they’ve seen a definite decline 

in interest or in the number of applications by J-1 visa physicians 

or visa holders. Six States, on the other hand, said they’ve actually 

seen an increase specifically in nonprimary care areas, like specialists. 

But two-thirds of the ones that answered really did see a decline, 

and some actually attribute it to the possibility that physicians 

were coming for graduate medical education on H-1Bs. 

Mr. SALSBERG. You know, the problems of physician distribution 

have been with us for a long time and are likely to be with us for 

a long time. And as I mentioned earlier, I think looking at the comprehensive situation, looking at the National Health Service Corps 

is really the best strategy. 

Relying on J-1 visa physicians, who are making an important 

contribution but are a shrinking number, has to be of concern as 

the number of underserved areas, about 20 percent of Americans 

live in federally designated underserved areas. So the J-1 stream 

is clearly not going to be a sufficient stream in looking at the whole 

question of how can we help address maldistribution is really what 

we would recommend. 

Mr. HOSTETTLER. I thank the gentlemen. 

The Chair will now entertain a second round of questions, and 

I will ask just one question in that second round. And that is of 

you, Ms. Aronovitz. 

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You note in your testimony that, in 1995, the number of waivers 

for foreign physicians exceeded the number of physicians participating in the National Health Service Corps that I mentioned earlier, the primary means for providing physicians to underserved 

areas. 

Was there a decline in the usage of the NHSC, the National 

Health Services Corps, as a result of the increased usage of the 

waiver program, or does your data—can your data tell you that? 

Ms. ARONOVITZ. We have—we don’t have enough detailed data to 

really understand some of the implications. But clearly, we haven’t 

seen that strong a relationship or that correlation. And in fact, now 

we see that J-1 visa waiver physicians represent about one and a 

half times the number of National Health Service Corps doctors 

that are in the field. 

Mr. HOSTETTLER. Thank you. That’s helpful. 

The Chair recognizes the gentlelady from Texas for purposes of 

second round of questions. 

Ms. JACKSON LEE. Thank you, Mr. Chairman, and I should be 

narrow in my comments. 

I think the answer to your last question really has to do with 

what has been noted by the National Health Care Access Coalition, 

which is the numbers suggest that we need to expand to 200,000 

doctors, and that there are currently only fewer than 800,000 doctors and that there will be a growing shortage over the next, as I 

indicated, couple of decades. So we’re facing a shortage, and I think 

there have been many suggestions here that we could utilize. 

Mr. Crosby, I just—what is the training of your physicians in 

your specialty? 

Mr. CROSBY. Osteopathic physicians have the exact same training as allopathic physicians. Go to 4 years of medical school. Perhaps an internship, and then 3 or 4 or 5 years of residency training. 

We deliver babies. We do neurosurgery. We provide osteopathic 

manipulative treatment. The whole scope of care is available 

through osteopathic physicians, and we’re proud to have one of our 

medical schools in the Forth Worth/Dallas area. Sorry it’s not in 

Houston. 

Ms. JACKSON LEE. And the name of it? 

Mr. CROSBY. The Texas College of Osteopathic Medicine, affiliated with the University of North Texas. 

Ms. JACKSON LEE. And I think, as I listen to you, I think you 

even with the expanded ideas that you’ve offered, and I happen to 

support a lot of them——

Mr. CROSBY. Thank you. 

Ms. JACKSON LEE [continuing]. That you still fall in a category 

that what you’re wanting, we’ve got to produce more? 

Mr. CROSBY. Yes. 

Ms. JACKSON LEE. And you have my wholehearted support on 

that issue, and I’m going to be studying your testimony quite extensively because I think there can be some cross-pollenization between, though one might not think, Judiciary and the Energy and 

Commerce. 

I think that does not speak to or speak against the immediacy 

of the J-1 visa, which I want to keep in a temporary framework. 

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And I will offer then simply, Mr. Chairman, the suggestions 

made by the coalition for health care access coalition—the National 

Health Care Access Coalition, which is recommending permanently 

authorize the Conrad program, increase the size of the Conrad program to 40 slots per State, and allow unused slots to be used by 

States that need them. And again, I think we can do so by making 

sure that we have the right kind of structure that it is not abused. 

I then want to make note that there are six pages here of States 

and actual facilities that are asking for J-1 visas, and they do include the great State of Indiana and the great State of Texas. 

I also want to make note of a comment from—that was written 

in the Denver Post, reported on a Dr. Amanpour, and the quote is 

that the doctor’s importance is described. ‘‘He’s keeping us alive. 

The doctor’s fantastic. Without a physician, our nursing home is in 

jeopardy.’’

And one of the victims of small numbers of doctors are nursing 

homes. Very few and I would say competent, qualified, or either 

people right on the edge might not want to go in that direction, and 

our senior citizens need health care. And so, my question is to Dr. 

Salsberg. 

Do you see the need of the parallel of these temporary visas for 

use as well as the growth that we need to do in our medical profession here in the States? 

Mr. SALSBERG. Definitely. I mean, we definitely need to encourage expansion of U.S. medical schools to meet current and future 

medical needs. The concern on the J-1 program, as you know, was 

that that was a program designed to assist, as the Chairman said, 

less educated—assist physicians obtain education in America, 

training in America that could be of use to less developed parts of 

the world. 

And so, I think we need an awareness of those concerns. And 

AAMC is looking at what can we do to assist other parts of the 

world in terms of improving their medical education and training. 

So it really should be a two-way street of what can we do to help 

them. 

Ms. JACKSON LEE. Absolutely. And we hope that it is a two-way 

street as they come and utilize and that they take their training 

back to the nations, particularly developing nations. 

My last point is to cite from the Texas Department of State 

Health Services, and just to show you the starkness of the need. 

Looking at specialties in 2004, there are approximately 228 physicians per 100,000 population for the United States. While in Texas, 

the ratio was 155 physicians per 100,000, or 30 percent below the 

national average. 

Although we, as I said, want to reinforce the value of our hometrained physicians, we also know that the immediate need is to try 

to solve some of these problems and, of course, Texas has asked for 

50 even above the 40 that’s been recommended. 

But I close by simply saying to Congressman Moran, do you feel 

comfortable that we can so structure the J-1 program that we answer a lot of the concerns that have been expressed here today? 

Mr. MORAN. I have little doubt that if we work together as Members of Congress and with the profession, our States, that we can 

find a satisfactory solution. That doesn’t solve the demands for 

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physicians, but moves us in the right direction so that more people 

can receive adequate health care. 

Ms. JACKSON LEE. I thank you, and I thank the Chairman. I 

think this was an important hearing. I thank the GAO for the work 

that they’re still doing and the witnesses that were here today. 

I yield back, Mr. Chairman. 

Mr. HOSTETTLER. I thank the gentlelady. 

I want to thank the panel of witnesses for your input and contribution to the record. It’s been most helpful, and to advise Members that they have 5 legislative days to make additions to the 

record. 

The business before the Subcommittee being completed, we are, 

without objection, adjourned. 

[Whereupon, at 3:10 p.m., the Subcommittee was adjourned.] 

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A P P E N D I X 

MATERIAL SUBMITTED FOR THE HEARING RECORD

PREPARED STATEMENT OF THE HONORABLE SHEILA JACKSON LEE, A REPRESENTATIVE

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

ON IMMIGRATION, BORDER SECURITY, AND CLAIMS

This is a legislative hearing on the Physicians for Underserved Areas Act, H.R. 

4997, which was introduced by Congressman Jerry Moran on March 16, 2006. It 

would make the J-1 Visa Waiver Program permanent. 

The J visa is used for one of the educational and cultural exchange programs. It 

has become a gateway for foreign medical graduates to gain admission to the United 

States as nonimmigrants for the purpose of graduate medical education and training. The visa most of these physicians enter under is the J-1 nonimmigrant visa. 

The physicians who participate in the J-1 visa program are required to return to 

their home country for a period of at least two years before they can apply for another nonimmigrant visa or legal permanent resident status, unless they are granted a waiver of this requirement. 

In 1994, Senator Kent Conrad established a new basis for a waiver of this requirement with an amendment to the Immigration and Nationality Act. It was 

known then as, ‘‘The Conrad State 20 Program.’’ It permitted each state to obtain 

waivers for 20 physicians by establishing that they were needed in health professional shortage areas, known as ‘‘HPSAs.’’

On November 2, 2002, the Conrad 20 program was extended to 2004, and the 

number of waivers available to the states was increased to 30. This program, which 

is now referred to as the ‘‘Conrad 30’’or ‘‘State 30’’ program, expired on June 1, 

2004. On December 3, 2004, it was reinstated and extended to June 1, 2006, which 

is only a few weeks from now. Congressman Moran’s Physicians for Underserved 

Areas Act would eliminate the need for future extensions by making the program 

permanent. 

When the Conrad 30 program was established in 1994, most of those studying the 

supply of physicians in the United States were concerned about the distribution of 

physicians, as opposed to the total number of doctors being trained. It is now generally recognized that we are facing a severe physician shortage. The Health Policy 

Institute estimates that the shortage could grow to as much as 200,000 by 2020, 

an astounding possibility in view of the fact that the physician population in the 

United States currently is only about 800,000. 

The failure to forecast this severe physician shortage may explain why from 1980 

until last year no new medical schools opened in the United States. According to 

the Health Policy Institute, the United States needs to produce an extra 10,000 physicians per year over the next decade and a half in order to meet the demands of 

the country. This number assumes that the number of foreign educated physicians 

will remain constant. 

Senator Conrad and I asked the General Accountability Office (GAO) to do a survey of state views on the Conrad 30 program. All 50 states filled out a GAO questionnaire and promptly returned it to GAO. One of the GAO investigators will testify about the results of the survey, so I will just point out a few key findings. 

Approximately 80% of the states reported that the annual limit of 30 waivers per 

state is adequate. Only 13% reported that it is inadequate. Eleven states estimated 

that they need between 5 and 50 more waiver physicians, which would total 200 

more waiver physicians. In FY2005, 44 states did not use all of their allotted waivers. The total of the unused waivers for that year was 664. Of these 44 states, 25 

reported they were willing, or willing under certain circumstances, to have their unused waiver allotments redistributed. These states had a total of 398 unused waiver 

allotments in FY2005. 

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The J-1 visa waiver program has been in effect now for more than a decade. In 

addition to being a good source of additional physicians, it ensures that the additional physicians will go where they are most needed, health professional shortage 

areas in both rural and urban settings. I urge you therefore to support Congressman 

Moran’s Physicians for Underserved Areas Act to make the program permanent. 

Thank you. 

PREPARED STATEMENT OF THE HONORABLE KENT CONRAD, A U.S. SENATOR FROM

THE STATE OF NORTH DAKOTA

Mr. Chairman, thank you for this opportunity to testify on the ‘‘Conrad State 30’’ 

program as you discuss its reauthorization. I appreciate your interest in addressing 

the physician shortage in the United States with programs such as this. 

When the Conrad 20 program was enacted, approximately 85 percent of North 

Dakota’s counties were designated, either in part or in total, as health professional 

shortage areas (HPSAs). The purpose of this program was to increase the supply 

of physicians to rural America. This very successful program has since been expanded to the Conrad State 30. It is heavily relied upon by a majority of the states, 

especially rural states like North Dakota. 

Before the Conrad 20 program was created, North Dakota’s hospitals and clinics 

had to use the federal J-1 visa waiver, which required a federal agency to certify 

the need for a physician. On one occasion, a facility in North Dakota was forced to 

use the Coast Guard as the interested federal agency. I was grateful that the Coast 

Guard, which has a small station in LaMoure, was willing to assist the local community in obtaining a needed medical professional. But relying on the Coast Guard 

to decide if a town in North Dakota needed a physician made no sense. 

That is why I authored the Conrad State 20 program. It allows an interested 

State agency to make the determination that previously could only be made by a 

Federal agency. Not only are States more qualified to confirm health shortage areas, 

the program also uses HHS designated shortage areas as a baseline requirement, 

with the exception of five waivers that can go to physicians who will be placed in 

a facility that largely treats patients from HPSAs. Since 1994, this program has cut 

in half the number of family practice physician vacancies in North Dakota. It is 

critically important to rural hospitals and clinics in my state and across the country 

that this program be reauthorized. 

However, a serious drop in Conrad State 30 applications has North Dakota hospitals deeply concerned. For instance, St. Luke’s Hospital in Crosby, ND, reports 

that it used to have as many as 150 J-1 physician applications for an opening. Now, 

it has had a five-month vacancy, and only a handful of candidates have applied. 

Many users of the program believe the shrinking pool of J-1 visa waiver doctors is 

due to foreign physicians turning to H-1B visas in lieu of J-1 visas for their graduate medical education. 

Like Chairman Hostettler, my constituents have noticed the disparity in how J1 physicians in residency are treated compared to those on H-1B visas. Residents 

on J-1 visas must go home and contribute to their country’s underserved for two 

years, or stay here and contribute to ours for three. But those on H-1B visas are 

excepted from either requirement; they are free to practice anywhere in the United 

States when they complete their residency programs. I believe we need to explore 

options to level the playing field, such as requiring residents on H1-B visas to serve 

three years in underserved areas. 

I would also like to take this opportunity to express my strong concerns about proposals to re-distribute unused waivers from states like North Dakota to states that 

use all 30 of their Conrad 30 slots. With a shrinking overall pool of J-1 visa waiver 

doctors, any proposal to redistribute unused slots risks further reducing the number 

of these doctors who will apply to serve in North Dakota. In the words of Tioga 

Medical’s President, ‘‘By allowing physicians to wait for the redistribution of slots 

to occur, a physician can opt to wait for states that may be more lucrative in weather conditions, culture, or other amenities.’’ He is right. According to the Government 

Accountability Office, redistribution would likely benefit a handful of more populous 

states to the detriment of very rural states with facilities that have the most difficulty with recruitment. 

The Conrad 30 program has made a very real contribution to augmenting the physician supply in rural areas that need qualified primary care physicians and specialists in critical areas of medicine such as diabetes, cardiology and orthopedic medicine, just to name a few. However, eighty-one percent of North Dakota’s counties 

remain HPSA-designated some twelve years later. With the physician shortage in 

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this country projected to reach 200,000 by 2020, the Conrad 30 program is needed 

now more than ever. 

Since its inception, we have had to reauthorize this program many times—every 

two years since 2000. Such uncertainty is unnecessary. Our rural areas need to 

know they can count on this program for years to come. I urge the Committee to 

support the Physicians for Underserved Areas Act to permanently authorize this 

critical program for rural America and ask that the articles that I’ve included with 

my testimony be submitted for the record.

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ATTACHMENT


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PREPARED STATEMENT OF GREGORY SISKIND, CHAIRMAN, NATIONAL HEALTH CARE

ACCESS COALITION


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LETTER TO THE HONORABLE SHEILA JACKSON LEE FROM CONNIE BERRY, MANAGER, 

TEXAS PRIMARY CARE OFFICE


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