United States General Accounting Office

GAO Report to Congressional Committees

December 1996 FOREIGN

PHYSICIANS

Exchange Visitor

Program Becoming

Major Route to

Practicing in U.S.

Underserved Areas

G O A

years

1921 - 1996

GAO/HEHS-97-26

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-271030 

December 30, 1996

Congressional Addressees

Placing enough physicians in underserved areas remains a longstanding

problem in the United States, despite many attempts to resolve the

situation. To address this problem, a growing number of locations are

turning to non-U.S. citizens who have just completed their graduate

medical education in the United States. These physicians generally enter

the United States under an exchange visitor program administered by the

United States Information Agency (USIA). Their visas, called J-1 visas,

require them to leave the country when their medical training is done, but

this requirement can be waived at the request of a federal agency or a

state. This waiver is usually accompanied by a requirement that the

physician practice for a specified period in an underserved area.

The growing use of these waivers is not without controversy. The

Department of Health and Human Services (HHS) is the main federal

agency responsible for addressing physician shortages and medical

underservice. HHS has taken the position that the J-1 visa is a way to pass

advanced medical knowledge to other countries and that waivers of the J-1

visa requirement should not be used as a means to address medical

underservice in the United States.1

 Instead of using waivers to address

underservice, HHS administers its own federal programs specifically for

this purpose, particularly the National Health Service Corps (NHSC). Some

other groups, including the Pew Health Professions Commission and the

Institute of Medicine’s Committee on the U.S. Physician Supply, believe

that allowing foreign physicians to remain in the United States after

completing their graduate medical education could contribute to a general

oversupply of physicians, which could drive up medical costs.2

 Many

communities that need physicians, however, are using these waivers to

address physician shortages, stating that they could not recruit qualified

physicians without doing so.

1

See 45 C.F.R. 50.3(a)(1995). This position was reiterated in an August 1995 letter from the Secretary of

HHS to the heads of other federal agencies. However, HHS does request waivers for physicians and

scientists engaged in critical biomedical research.

2

See Pew Health Professions Commission, Critical Challenges: Revitalizing the Health Professions for

the Twenty-First Century (San Francisco: University of California San Francisco Center for the Health

Professions, 1995) and Institute of Medicine, The Nation’s Physician Workforce: Options for Balancing

Supply and Requirements (Washington, D.C.: National Academy Press, 1996).

Page 1 GAO/HEHS-97-26 Waivers for Foreign Physicians
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To provide information that would be useful to the Congress in addressing

this issue, we conducted a self-initiated study focused primarily on the

following questions:

• How many foreign physicians with J-1 visas receive waivers, where do

they practice, and what are their medical specialties?

• Do federal agencies and states effectively coordinate policies and

procedures for granting these waivers?

• To what extent are foreign physicians who receive waivers complying with

waiver requirements to practice in underserved areas?

To conduct this work, we developed two surveys addressing the extent to

which states and federal agencies used waivers to meet physician

shortages. One polled all states to determine the size of their programs for

requesting waivers. The other surveyed health care facilities for a random

sample of physicians who received waivers. These surveys provided more

complete information than was available from participating agencies,

including USIA, the Immigration and Naturalization Service (INS), and the

federal agencies requesting waivers for physicians. We supplemented this

work with reviews of existing data, interviews with agency officials and

others involved with the waivers, and field work in three states.3

 Appendix

I explains our methodology in more detail.

Results in Brief The number of waivers for physicians with J-1 visas to work in

underserved areas has risen dramatically in the past few years, from 70 in

1990 to over 1,300 in 1995. Requesting waivers for physicians with J-1 visas

has become a major means of providing physicians for underserved areas;

in 1994 and 1995, the number of waivers processed for these physicians

equaled about one-third of the total identified need for physicians in the

country. In the process, a program to transfer knowledge to other

countries has partially given way to a domestic placement effort that now

includes professional recruiters and immigration attorneys. Almost all

these waiver physicians have primary care medical specialties and they are

practicing in 49 states and the District of Columbia. Their practice

locations range from health centers in public housing projects to private

practices affiliated with for-profit hospitals.

This growing domestic placement effort is rudderless. While only one

agency was requesting waivers to address physician shortages in 1990,

3

We included waivers granted to physicians for practicing in underserved areas only. As such, we did

not include in our analysis physicians whose waivers were requested by the Department of Veterans

Affairs (VA) or physicians whose waivers were requested by other agencies for research purposes .

Page 2 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

nearly 30 federal and state agencies were processing waiver requests for

physicians from hospitals, health centers, and other health care facilities

by 1995. Among them, no agency has clear responsibility for ensuring that

placement efforts are coordinated. The agencies have generally operated

independent of one another, resulting in overlap and oversupply, which

has led to the accumulation of more physicians than needed to remove

shortage designations in some states. Although the federal agencies are

now working together informally, they still have differing policies,

overlapping jurisdictions, and varying communication with the states. The

coordination problem is compounded by the policy differences between

HHS and the agencies requesting waivers for physicians. HHS believes that

the physicians should return home after completing their training to meet

the intent of the exchange visitor program, and the other agencies view the

waiver provision as a means to secure physicians to meet the health care

needs of their constituents.

While more than 9 of every 10 physicians whose waivers were processed

between 1994 and 1995 were practicing at their locations in January 1996,

controls are somewhat weak for ensuring that physicians continue to meet

the terms of their agreements. Analysis by us and the Appalachian

Regional Commission’s (ARC) Inspector General found instances in which

physicians were not practicing at the facility where agencies believed them

to be or were not practicing full-time in the underserved areas for which

their waivers were granted. In addition, even when the physicians and

facilities follow the agencies’ rules, the rules do not restrict physicians

from working with those segments of the population that already are

adequately served—for example, working in a location that has been

identified as having an underserved migrant group, but treating other

segments of the population instead.

Proposed regulations published by USIA and developed in working with the

informal interagency group, coupled with recent amendments to the

Immigration and Nationality Act would address many of the coordination

and compliance problems, but not all of them. This report contains

matters for congressional consideration that would resolve some of these

problems, including clarification of federal policies, management of the

program, and improvement of monitoring and enforcement penalties.

Background J-1 visas allow foreign nationals to participate as exchange visitors in

cultural and educational programs in the United States. USIA is responsible

for managing the J-1 visa program and designates organizations as

Page 3 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

program sponsors. In 1995, over 9,000 foreign physicians with J-1 visas

were in the United States for graduate medical education or training.

These exchange visitors constituted about one-tenth of all individuals

receiving graduate medical education (see app. II). Because many

exchange visitors are in the United States for several years for graduate

medical education and training, each year a few thousand new physicians

receive J-1 visas and enter the United States to begin graduate medical

education and training while a few thousand complete their training.

To ensure that the J-1 visa program works as intended in passing learning

and experience to other countries, the Congress has imposed restrictions

on J-1 visa holders, including physicians in graduate medical education.

These physicians are required to return to their home country (or to their

country of last legal residence) for at least 2 years after completion of

training. However, they may obtain a waiver of this requirement and

remain in the United States. For most physicians, the waivers are

requested on their behalf by a federal agency or by a state agency or

department that is responsible for public health issues.4

 These federal

agencies and states generally request waivers of the 2-year foreign

residence requirement so that the physicians can practice for several years

in underserved areas (see table 1).5

 The federal agencies and states submit

these requests to USIA.

4

For simplicity, we will refer to these state agencies or departments as states.

5

Physicians with J-1 visas may also obtain a waiver if INS determines that the return to their home

countries would create an exceptional hardship to their spouse or child (who must be a U.S. citizen or

lawful resident alien) or if the return would subject them to persecution because of race, religion, or

political beliefs. However, these individuals are not required to practice medicine in an underserved

area, so we did not include physicians who received waivers under these provisions in our review. See

app. III for additional information on the 2-year foreign residence requirement and the waiver

provisions that have evolved since the exchange visitor program was authorized in 1948.

Page 4 GAO/HEHS-97-26 Waivers for Foreign Physicians
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Table 1: Conditions for Waivers for

Physicians With J-1 Visas

Interested U.S. government agenciesa

State agencies or departments

responsible for public health issues

For whom can they request waivers?

J-1 visa exchange visitors, including those

in graduate medical education or training,

who are participating in a program or

activity sponsored by or of interest to the

agency

J-1 visa exchange visitors in graduate

medical education or training

What are the conditions for approving the request?

(1) The waiver is in the public interest and

(2) compliance with the foreign residence

requirement would be detrimental to a

program or activity of interest to the agency

(1) The waiver is in the public interest, 

(2) the physician agrees to practice

medicine for at least 3 years in an area

designated by the Secretary of HHS as

having a shortage of health care

professionals,b and 

(3) the physician has a bona fide offer of

full-time employment and agrees to begin

work within 90 days of receiving the waiver

How many waivers can be granted each fiscal year?

No limit Each state, regardless of size or identified

physician need, is limited to 20 new

waivers for physicians each year

aAmendments in the Omnibus Consolidated Appropriations Act, 1997, impose additional

requirements not in effect at the time of our review on physicians sponsored by interested U.S.

government agencies so that their responsibilities are now more consistent with those of

physicians sponsored by states. However, the amendments did not impose any annual limits on

the number of waivers (see app. III).

bThese include (1) geographic areas, population groups, and health care facilities that HHS has

designated as Health Professional Shortage Areas and (2) Medically Underserved Areas or

Populations, those designated by HHS as having shortages of health care services based on

factors such as physician-to-population ratios, infant mortality, and poverty rates.

USIA reviews the program, policy, and foreign relations aspects of the case

and forwards its recommendations to the INS Commissioner. For waiver

requests made by interested U.S. government agencies or states, INS may

only grant the waiver if USIA submits a favorable recommendation. Figure 1

illustrates the waiver process.

Page 5 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

Figure 1: J-1 Waiver Process

May Reenter the 

United States Under 

Another Visa 

(Immigrant or 

Nonimmigrant)

Contact With

Health Center or

Other Employer 

Return to Home

Country 

Waiver Process

J-1 Visa Physician 

in Graduate 

Medical Education 

in the 

United States

Returns Home for 

at Least 2 Years

Can Apply For 

Permanent Residency 

 or Nonimmigrant Status

Free to Practice 

Anywhere in the 

United States

Interested Government Agency Request

· Must Be in the Public Interest 

· Leaving the U.S. Must Be Detrimental to

 Agency Programs or Activities 

· Other Requirements Vary

· No Numerical Limit on Requests

a

Clinical Practice During Required Employment Term

(For State Requests, Must Maintain Nonimmigrant Status)

Physician Changes Immigration Status

Department of Labor Reviews Employment Conditions

INS Reviews the Waiver Request and Grants Waiver of the 

2-Year Return Home Requirement

USIA Reviews and Recommends the Waiver Request

State Request 

· Must Be in the Public Interest

· Must Be in a Health Professional

 Shortage Area or a Medically

 Underserved Area

· Must Be for at Least 3 Years

· Limit of 20 Waivers per Year

b

aAmendments in the Omnibus Consolidated Appropriations Act, 1997, impose additional

requirements on interested U.S. government agency requests (see app. III).

Page 6 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

bThe physician must also have a bona fide offer of full-time employment, agree to begin work

within 90 days of receiving the waiver, and fulfill the required 3-year employment contract with the

sponsoring health care facility named in the waiver application.

While HHS is the federal agency responsible for addressing physician

shortages it does not use waivers to do so. HHS endorses the philosophy

that exchange visitors return home after completing their training to make

their new knowledge and skills available to their home countries. As a

result, HHS does not support waivers for physicians to remain in the United

States to practice in underserved areas.

Instead, HHS administers other federal programs, such as NHSC, to address

physician shortages in the United States. NHSC supplies physicians and

other health professionals to underserved areas primarily by (1) awarding

scholarships to students who agree to serve in a shortage area after their

health professions training is complete and (2) repaying a set amount of

educational loan debt for each year of service in a shortage area.6

 On

December 31, 1995, 848 NHSC physicians and 685 other NHSC professionals

who received scholarships or federal loan repayment were practicing in

underserved areas of the country.7

In addition to NHSC, HHS has other programs to address medical

underservice. For example, HHS provides federal grant funding to

community health centers that are required to accept all patients

regardless of their ability to pay.

Use of Waivers Has

Grown in Size and

Scope

Begun as an exceptions policy, the number of physicians receiving waivers

of the 2-year foreign residence requirement for J-1 exchange visitors has

grown more than tenfold in the past 5 years. Several factors have

contributed to the increase: more hospitals and other facilities have found

the waiver to be a means to fill their empty positions; more agencies and

states are making requests; and physicians are actively seeking waivers, in

some cases allegedly paying recruiters and immigration attorneys to find

6

Our previous report, National Health Service Corps: Opportunities to Stretch Scarce Dollars and

Improve Provider Placement (GAO/HEHS-96-28, Nov. 24, 1995), discusses the NHSC scholarship and

loan repayment programs. We found that overall, when compared to the scholarship program, the

NHSC loan repayment program offers a better long-term investment of scarce federal resources to

address shortages of primary care providers.

7

ln addition to the scholarship and federal loan repayment programs, NHSC also supports physicians

and other health professionals through a state loan repayment program and other efforts. Including

these NHSC providers, 2,226 NHSC physicians, dentists, and other health care providers were

practicing in underserved areas as of September 30, 1996, of which 1,267 were physicians.

Page 7 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

them a position. Waiver physicians are practicing in virtually every state;

most are primary care physicians.

The Number of Waivers

Has Increased Significantly

The number of waivers being processed for physicians to practice in

underserved areas each year has grown from 70 in 1990, to 1,374 in 1995

(see fig. 2).8

 In 1995, the number of waivers being processed for physicians

was greater than the number of NHSC physicians (1,267) practicing in

underserved areas, and it was enough to offset about 27 percent of the

total physician shortage identified by HHS. Indications are that in 1995,

about half of the foreign physicians that were supposed to return home

were granted waivers of this requirement to practice in an underserved

area in the United States.9

8

Numbers were determined from data from requesting federal agencies and states on waiver requests

submitted to USIA. While USIA data showed similar trends, we relied on data from requesting agencies

because USIA did not maintain data specifically on waivers for physicians to practice in underserved

areas. We excluded from our analysis those physicians whose waivers were requested by VA and

physicians whose waivers were requested by other agencies for research purposes.

9

To estimate the number of physicians who would be required to return home, we counted the number

of physicians sponsored as exchange visitors in graduate medical education and training in the 1994-95

academic year who were not sponsored in the 1995-96 academic year. We compared this to the number

of physicians whose waivers were processed in 1995, to obtain a rough estimate of the percentage of

physicians who were supposed to return home but who received waivers to practice in underserved

areas in the United States. See app. I for additional information on our methodology.

Page 8 GAO/HEHS-97-26 Waivers for Foreign Physicians
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Figure 2: Number of Waivers

Processed for Physicians With J-1

Visas, 1990-95

Waivers Processed

0

250

500

750

1000

1250

1500

1990 1991 1992 1993 1994 1995

Year

Note: Numbers determined from federal agency and state data on waiver requests sent to USIA

for physicians to practice in underserved areas, excluding requests for physicians to conduct

research and requests from VA.

Why do facilities want to employ foreign physicians through the use of the

waivers? In responding to our survey and during our visits to health

centers, physician offices, clinics, and other health care facilities where

these physicians were practicing, many officials said that their facilities

had turned to these physicians because they were unable to recruit U.S.

physicians. For example, the administrator of a county public health unit

in Florida commented that most U.S. physicians are not willing to work in

rural areas, but she has found many physicians with J-1 visas who had

excellent references and credentials and who were willing to practice

there. She said it would be a “travesty” to health care in rural areas if these

waiver physicians were not available. Other reasons cited for hiring these

physicians are their superior foreign language skills and cultural

familiarity with a facility’s patient population. For example, several

physicians received waivers to practice at a migrant health center in

Eastern Washington. These physicians were recruited, in part, because

they are native Spanish speakers, which enables them to effectively treat

the center’s Spanish-speaking patients.

Page 9 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

The sudden increase in the number of waivers being processed in 1994 and

1995 probably reflects the fact that facilities had additional places to turn

to for requesting the waivers. By 1995, four U.S. government agencies and

23 states were requesting waivers of J-1 visa requirements for physicians.

Before 1993, the only agency requesting waivers for a number of

physicians to practice in underserved areas was ARC. ARC began requesting

waivers in the 1980s for physicians to practice in Appalachia.10 However,

ARC requested around 200 or fewer waivers per year, peaking at 266

waivers in 1993. In addition to ARC, since 1993 the Department of

Transportation (DOT) has requested waivers for a handful of physicians to

practice in one rural area where the U.S. Coast Guard operates.11

The rapid growth in waivers began in late 1993 and 1994, when the U.S.

Departments of Agriculture (USDA) and Housing and Urban Development

(HUD) began requesting them for physicians to serve their rural and urban

constituents. Senior officials at both agencies said that they initially

responded to a constituent request to support a specific physician;

however, their offices were subsequently flooded with requests for

waivers for other physicians. Agency officials said that they would like to

limit the number of waivers processed by their agencies, but have not

found a way of effectively restricting them.

The number of waivers also increased because the authority for states to

request waivers was passed in 1994, and 23 states requested waivers in

calendar year 1995.12 As a result of the entry of these federal agencies and

states, physicians seeking waivers were no longer limited to practice

locations in Appalachia and areas serving DOT personnel; instead, they

could practice in rural and urban areas across the country. However, HUD

officials have recently decided to reassess the department’s waiver policy

and stopped accepting requests after August 30, 1996, to conduct a review.

Table 2 shows the number of waiver requests submitted to USIA by each

agency in 1995 and the reason for the requests. For information on the

number of waivers requested by each agency since 1990, see appendix V.

10The Appalachian region includes specific counties in 13 states. See 40 U.S.C. App. 403(1994).

11VA has also requested waivers for physicians. However, because these physicians practice in VA

facilities and not in underserved areas, they were not included in our review.

12On a fiscal year basis, our survey of states regarding J-1 waivers for physicians found that 20 states

had requested waivers in fiscal year 1995 and 34 states had requested or planned to request waivers in

fiscal year 1996. See app. IV for our survey results.

Page 10 GAO/HEHS-97-26 Waivers for Foreign Physicians
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Table 2: Requests for Waivers for

Physicians, by States and Federal

Agency, 1995 Requesting agency

Waivers

requested Reason for requesting waivers

ARC

157

To assist residents of Appalachia in

having access to quality, affordable

health care

DOT

1

To enable physicians to practice in a

rural area where the U.S. Coast Guard

operates

HUDa

375

To assist indigent, medically

underserved urban residents with

access to quality, affordable health

care as part of HUD’s mission to

create communities of opportunity

USDA

752

To address the needs of underserved

rural areas with shortages of

physicians as part of USDA’s

responsibility for coordinating and

providing federal services to rural

communities

Statesb

89

To enable physicians to practice in

areas designated by the Secretary of

HHS as having a shortage of health

care professionals—other reasons

vary by state

Total 1,374

aHUD stopped accepting new requests in August 1996 in order to review its waiver policy.

bStates were first authorized to request waivers in October 1994.

Another factor in the increase in waivers may be the interest among

physicians with J-1 visas themselves. Health care facility officials, as well

as state and federal health officials, said that they have been inundated

with inquiries from physicians who would like to obtain a waiver by

working in a shortage area. In addition, officials at several facilities said

that they were contacted by professional recruiters or immigration

attorneys regarding the availability of a physician to meet their facility’s

needs if the physician could obtain a waiver. Some facility officials and

physicians reported paying up to $25,000 in immigration attorney or

recruiter fees for assistance in matching a physician with a facility and

processing the waiver. During our site visits to facilities where physicians

who had received waivers were practicing, physicians cited several

reasons why they wanted waivers, including that (1) they would not be

able to apply the medical skills they had learned in the United States in

their home countries, (2) they were concerned about violence in their

Page 11 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

home countries, (3) they wanted to serve in an underserved area, (4) their

families and relatives were in the United States, and (5) they had a general

desire to stay in the United States.

Waiver Physicians Practice

Throughout the Country in

a Variety of Settings

In 1996, waiver physicians were practicing in 49 states and the District of

Columbia—every state except Alaska.13 However, the degree to which

they are relied on to relieve physician shortages varies greatly from state

to state. To measure the extent of this reliance, we compared the number

of waivers granted or in process in 1994 and 1995 with the number of

physicians identified by HHS as needed to remove the shortage area

designations in a state.14 In five states (Alabama, Kansas, Kentucky, North

Dakota, and West Virginia), the number of physicians for whom waivers

were processed equaled more than 75 percent of the number of physicians

needed to remove these designations in the state. In other states, such as

California, such physicians equal less than 10 percent of the identified

need.

Physicians with waivers are practicing in a variety of settings. Our survey

results show that more than one-third of physicians who received their

waivers through federal agencies are practicing in nonprofit community or

migrant health centers and about one-fourth are in a private or group

practice. The rest are practicing in hospitals, for-profit health centers, or

other settings (see fig. 3). See appendix VI for more detailed information

on the results of our survey of facilities.

13Although Guam, Puerto Rico, and the U.S. Virgin Islands are also authorized to request waivers for

physicians to practice in underserved areas, they had not done so at the time of our review.

14See app. I for more detailed information on our methodology.

Page 12 GAO/HEHS-97-26 Waivers for Foreign Physicians
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Figure 3: Practice Settings of Waiver

Physicians Practicing on January 1,

1996

39% • Nonprofit Community or Migrant

Health Center

19% • Hospital (Nonprofit and For-Profit)

24%•

Private or Group Practice

•18%

Other

Note: Other includes for-profit health centers, rural health clinics, and other facilities.

Note: Determined from survey results for physicians whose waivers were processed by federal

agencies in 1994 and 1995.

Most Waiver Physicians

Have Primary Care

Specialties

Using our survey results, we estimate that almost all physicians practicing

on January 1, 1996, whose waivers were processed through federal

agencies were practicing in primary care specialties. Overall, more than

half of them were practicing in internal medicine (see fig. 4). The other

major primary care specialties were pediatrics and family practice.

Page 13 GAO/HEHS-97-26 Waivers for Foreign Physicians
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Figure 4: Practice Specialties of

Waiver Physicians Practicing on

January 1, 1996

55% • Internal Medicine

24%•

Pediatrics

•11%

Family Practice

1%

Obstetrics/Gynecology

•

10%

Other

Note: Determined from our survey results for physicians whose waivers were processed by

federal agencies in 1994 and 1995.

We estimate that one-third of the waiver physicians who had primary care

specialties also had subspecialties. The most prevalent subspecialty was

nephrology (medicine concerned with kidney disease), which was

reported for about 7 percent of the primary care physicians. Other

subspecialties included infectious diseases, cardiology, and

gastroenterology. Requesting facilities and state officials had mixed views

on the usefulness of subspecialties for meeting their needs. Officials from

some states said that physicians with subspecialties are not as desirable

because they may not remain in the area to practice primary care. In fact,

several states have policies to not request waivers for physicians who have

subspecialties. On the other hand, officials at some facilities said that they

recruited specific physicians, such as a nephrologist, because their

subspecialties enabled them to meet the needs of their patient

populations.

Page 14 GAO/HEHS-97-26 Waivers for Foreign Physicians
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Waivers Are Not

Coordinated

Effectively Across

Participating Agencies

and States

Requests for waivers for physicians with J-1 visas are not coordinated

effectively among the agencies and states or with other medical

underservice programs, such as NHSC. No single entity is responsible for

coordinating practice locations of waiver physicians and HHS, perhaps the

most logical candidate for doing so, opposes the way in which the waivers

are being used. Because no single entity is responsible for coordinating

physicians’ practice locations, the requesting agencies set up varying

policies for requesting the waivers. Because of the lack of coordination,

the number of waivers processed for physicians to practice in some states

has been more than the amount needed to alleviate the identified

physician shortage in that state.

No Agency Is Responsible

for Managing Waivers to

Address Physician

Shortages

No single agency has management responsibility for use of the waivers to

address physician shortages. While USIA and INS must recommend and

approve all waivers of the 2-year foreign residence requirement for

physicians requested by interested government agencies and states, USIA

and INS officials said that they recommend and approve virtually all waiver

requests. USIA officials said that while they check for required

documentation, they almost always rely on the interested government

agencies’ assertions that the waivers are in the public interest. INS officials

said that refusal of the waiver is extremely rare if USIA has given a

favorable recommendation. INS officials said that they are not in a position

to second-guess USIA or the interested government agency as to whether

the public interest would be served if the waiver was granted.

Although HHS is the federal agency responsible for addressing physician

shortages, it is not responsible for managing the use of waivers for

physicians and does not support waivers for physicians to practice in

underserved areas. Specifically, an HHS regulation states that it will not

request a waiver

“when the application demonstrates that the exchange visitor is needed merely to provide

services for a limited geographical area and/or to alleviate a local community or

institutional manpower shortage, however serious.”15

The current Secretary of HHS has reiterated the department’s position on

waivers for physicians with J-1 visas. In an August 1995 letter to the heads

of USDA, HUD, and ARC, the Secretary stated

15See 45 C.F.R. 50.3(a)(1995).

Page 15 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

“In summary, this Department has viewed the J-1 visa to be a means of sharing advanced

medical knowledge and allowing the benefits of training to accrue to the home country.

The Department does not view waivers as a mechanism to help resolve the problems of

shortage areas.”

Federal Agency and State

Policies Are Not

Consistent

Without any overall management of the use of waivers, waiver policies

vary considerably between agencies, leading in some cases to “shopping”

by the physicians seeking a waiver to obtain the most advantageous terms.

Policies vary with regard to such matters as eligible practice locations and

state involvement and the consequences of the physician’s failure to

complete the agreed-upon length of service. For example, ARC restricts

physicians to practice locations in federally designated Health

Professional Shortage Areas, while the physicians who received waivers

through USDA and HUD have been allowed to practice in other areas,

including designated Medically Underserved Areas. ARC officials said that

they excluded the Medically Underserved Area designations because

(1) this designation is not an accurate measure of physician shortage;

(2) the designations have not been updated; and (3) including them would

allow physicians to practice in virtually any location in Appalachia.16

Federal agency and state officials also said that and our review found

cases where physicians or their immigration attorneys were shopping

between agencies; that is, requesting waivers through multiple agencies at

the same time.

State health officials commented that they would like consistency in

waiver policies across federal agencies. One state health official

commented that participation of multiple federal agencies has resulted in

confusing and sometimes contradictory program guidelines and has

placed a burden on states to coordinate programs.

Largely Autonomous

Efforts Lead to

Coordination Problems

Thus far, the various efforts to use waiver physicians to address medical

underservice have operated largely independent of each other and of other

programs to address medical underservice. By 1995, there were nearly 30

federal agencies and states processing requests for waivers for physicians

with J-1 visas. Most of them were operating independent of one another.

16Our prior report, Health Care Shortage Areas: Designations Not a Useful Tool for Directing

Resources to the Underserved (GAO/HEHS-95-200, Sept. 8, 1995), identified a number of weaknesses

in HHS’ Health Professional Shortage Area and Medically Underserved Area designation systems.

Among them was the lack of periodic review and update of Medically Underserved Area designations.

In addition, one state we visited for this assignment reported that (1) 90 percent of the state’s federally

designated Medically Underserved Areas had not been reevaluated for more than 10 years and (2) HHS

has not acted upon proposed deletions of these designations.

Page 16 GAO/HEHS-97-26 Waivers for Foreign Physicians
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The four federal agencies have no formal process for coordinating their

waiver requests and they have overlapping jurisdictions. For example,

while USDA’s policy has been to request waivers for rural areas and HUD’s

policy has been to request waivers for urban areas, the two agencies have

not agreed on which areas are rural and which are urban. As a result, we

found some locations, such as Buffalo, New York, and Decatur, Illinois,

where USDA requested waivers for one or more physicians and HUD

requested waivers for additional physicians to practice in the same city

and in some cases the same facility. There is no mechanism for each

federal agency to know how many waivers the other has requested to

address the physician shortage in an area.

Coordination is also lacking between state and federal efforts. State health

officials do not always know where physicians receiving waivers through

federal agencies are practicing and, therefore, they cannot coordinate

these placements with state programs to address medical underservice.

While ARC requires that facilities’ requests for waivers come through the

states, other agencies do not. This leads to situations where the states are

unaware of the level of placements that are occurring. For example, health

department officials in Texas, which does not request waivers for

physicians under the state authority, did not know how many physicians

received waivers through federal agencies to practice in the state. As a

result, when we scheduled our visits to practice sites in Texas, state

officials were surprised to find out that federal agency records showed

over 20 waiver physicians practicing in El Paso.

Waivers for physicians also are not well-coordinated with other programs

addressing underservice, such as those operated by HHS. One such

program is NHSC. When combined with NHSC physicians, federal agencies

and states have requested waivers for more physicians than are needed to

remove the shortage designations in some states. We found that for eight

states, the number of physicians who received waivers in 1994 and 1995

(or had waivers in process), combined with the number of NHSC physicians

in service at the end of 1995, exceeded the number of physicians needed to

remove the shortage area designations in the state. (See app. VII for more

information on the identified need, number of waivers being processed,

and the number of NHSC physicians practicing in each state.) Without

information on the number of physicians needed in the area and the

number of NHSC and waiver physicians already addressing that need,

federal agencies and states will not know if the needs of an area are

already being met when considering whether or not to request a waiver for

a physician.

Page 17 GAO/HEHS-97-26 Waivers for Foreign Physicians
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Another HHS program with which physician waivers are not

well-coordinated is the Community Health Center program.17 This means

that federal agencies and states may not know of problems identified by

HHS when considering requests from community health centers. For

example, waivers were requested through HUD for several physicians to

practice at a health center that had its HHS funding discontinued due to

financial management problems. When requesting the waivers for these

physicians, HUD officials did not know that HHS had identified problems

with the health center. As a result, they could not take those problems into

consideration when deciding whether the waivers were in HUD’s and the

public’s interest.

Coordination between the agencies involved in the requests and other

programs to address medical underservice is important, because not all

the agencies processing the waiver requests have expertise in addressing

health care issues. For example, USDA and HUD officials involved in the

waiver requests said that their offices lacked expertise in health issues. In

USDA, waivers for physicians are processed in the department’s

Agricultural Research Service by an office that has experience processing

waiver requests for a small number of research scientists who were in the

United States as exchange visitors. At HUD, the waivers were processed in

the Office of the Deputy Assistant Secretary for Intergovernmental

Relations.

Most Physicians

Comply With

Agreements but

Controls Are Weak

Although most physicians who obtain waivers of their J-1 visa foreign

residence requirement are apparently complying with the terms of their

service agreements, weak controls mean there is little to deter physicians

or their employers from failing to comply if they choose to break these

terms. For example, we found instances in which a physician never

practiced at the intended facility, unbeknownst to the agency processing

the request.

Most Physicians Are

Complying With

Agreements, but Some Are

Not

Including all current waiver physicians when assessing compliance with

requesting agency policies can present somewhat of a misleading picture,

because so many of these physicians have been at their jobs for a

relatively short time, in many cases for less than 1 year.

17HHS funds community and migrant health centers to provide primary care services to medically

underserved populations, including the poor, uninsured, minorities, women, children, and the elderly.

Page 18 GAO/HEHS-97-26 Waivers for Foreign Physicians
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To provide a more accurate picture of whether physicians stay for the full

term of their agreement, we analyzed those physicians whose waivers had

been requested through ARC from 1990 to 1992. We estimate that

90 percent completed the minimum employment period required by ARC,

which was 2-years,18 for the facility that requested the waiver.19 On

January 1, 1996, over one-fourth (28 percent) were still practicing at the

same facility that requested the waiver and nearly half of these

(13 percent) had been there for more than 4 years.

We also examined the shorter-term compliance record of all physicians

practicing on January 1, 1996, after receiving waivers through federal

agencies between 1994 and 1995. We estimate that 96 percent of them

were working at the facility for which the waiver was requested. The

remaining 4 percent had left or did not plan to work at that facility.

Although this percentage is similar to the percentage of ARC physicians

who did not complete their 2-year agreements, the percentage may grow

because many of the physicians had completed only a fraction of their

employment contract by the start of 1996.20 For example, none of the

physicians with waivers through HUD had been practicing for more than 1

year by that date.

Reasons for Failure to

Comply With Agency

Policies Rested Partly With

Facilities, Partly With

Physicians

For the physicians in our sample and in the states we visited, several

reasons they were not practicing at the location for which the waiver was

requested had to do with changes made by the facility that initiated the

request. We found cases in which a facility made the request and then

determined that the physician was no longer needed. In at least one case,

it appears that the employer made this determination before the waiver

was even granted, but the physician still received the waiver. Here are

examples in which the facility changed its mind:

• In letters asking USDA to request waivers for three physicians, a clinic in

Illinois said that the physicians were needed to help meet an urgent

18ARC increased the minimum employment period from 2 to 3 years in 1995 to be consistent with the

3-year minimum employment period required for waivers requested through the states.

19Of the physicians that did not work for 2 years at the facilities for which ARC requested a waiver, we

found at least a portion had worked in other shortage areas in Appalachia. Although these physicians

may have helped to address physician shortages in these areas, they did not address the particular

situation that ARC deemed to be in the public interest. In addition, because ARC did not know where

they were practicing, ARC could not effectively coordinate physician practice locations with other

waiver requests and with other agencies’ and states’ programs.

20As an example, we found that at least 4 of the physicians in our 1994 to 1995 survey sample had left

the facility after January 1, 1996, before practicing there for the required 2 to 3 years. One was

practicing in another shortage area; the others are discussed in our examples.

Page 19 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

primary care delivery crises in the rural community where the practice site

was located. Six months after one of the physicians began working there,

she was terminated because the clinic had determined that it was

overstaffed. She is now practicing in another city in Illinois that has an

identified shortage of physicians who serve Medicaid patients. The second

physician was transferred from the location on the waiver request to

another location that is not in a federally designated shortage area.21 The

third physician was practicing only part-time at the practice site for which

the waiver was requested. He said that because there were not enough

patients in that location, he spends about half his time working at the main

clinic in Champaign, Illinois.

• A medical group asked HUD to request waivers for three physicians to work

at a practice purchased from a retiring physician outside of Atlanta. When

we called the practice site, we were told that only one of the three was

practicing there. An official from the medical group said that the practice

no longer had enough patients to support these physicians. As a result, one

physician never worked at the site, one physician worked a brief period

and then went to practice at a prison in Michigan, and one physician

remained to work for the new employer after the practice was sold. INS

officials said that waivers had been approved for all three physicians,

including the one who was never employed there. Before we notified

them, HUD officials were unaware that the facility had been sold and that

two of the physicians were not practicing there.

We also found instances in which the reason for not meeting the

requirements of an agreement resulted from the physician’s actions. For

example, in two separate cases, physicians were fired when they refused

to complete the requirement for working 40 hours a week at the requesting

facility. In one instance, the fired physician notified USDA that he was going

to practice at another hospital and when USDA officials told him he could

not because the hospital was not in a shortage area, the physician broke

off contact with them. The facility official said that he had heard that the

physician was pursuing additional graduate medical education in the

United States. In the second instance, the facility reported the physician’s

firing directly to INS, which revoked his nonimmigrant work status.

Reviews conducted by ARC’s Inspector General have disclosed similar

instances in which conditions of agreements were not met. Six of eight

reviews conducted by the Inspector General from 1994 to 1995 found that

contrary to ARC policy, some physicians were not practicing primary care

21This location is in a state-designated shortage area, which has a lower physician-to-population ratio

than a federally designated area.

Page 20 GAO/HEHS-97-26 Waivers for Foreign Physicians
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at least 40 hours per week in a Health Professional Shortage Area. Instead,

employers were using the physicians in subspecialty practices or in

locations not designated as shortage areas.

Monitoring Varies Among

Federal Agencies and

States

Agency controls to help ensure that physicians comply with waiver

agreements vary among the federal agencies and states. These controls

range from periodic reports and site visits, to reliance on employers to

enforce the employment contracts. For example, ARC requires the facilities

to verify and the waiver physicians to certify that they are complying with

ARC policies. In addition, the ARC Inspector General conducts site visits to

the physicians’ practice locations. In contrast, while HUD and USDA officials

said that they had started or planned to start requiring periodic reports,

officials at both agencies said that they do not have the staff resources to

monitor physician compliance. These officials said that because the use of

waivers to address physician shortages is not authorized or funded as a

program, their agencies do not have the resources available to effectively

manage it as a program.

In its site visits to monitor compliance, ARC’s Inspector General attributed

most of the problems identified to the employers. However, for waivers

requested through both federal agencies and states, the applicable federal

laws and regulations do not specify penalties against employers that fail to

comply with agency policies. ARC tries to address this shortcoming by

requiring employers to sign a statement certifying that they will comply

with the waiver policy, and applications from employers found to be in

violation of the policy receive additional scrutiny to ensure that the

problems have been corrected.

Proposed Regulations

and Recent

Legislation Could

Improve Coordination

and Enforcement

The growth in the number of waiver physicians has not gone unnoticed by

federal agency officials and legislators. They have recently taken actions

that could address some of the coordination and compliance problems

identified. A group of federal agency officials has met informally to discuss

waiver requests and USIA has proposed regulations to make the waiver

requests more consistent. In addition, recent amendments to the

Immigration and Nationality Act impose additional requirements for

waivers obtained through federal agencies. The new regulations, if

finalized, and the 1996 amendments could address many of the

coordination and compliance problems, but not all of them.

Page 21 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

Agency Efforts Are Under

Way to Improve

Coordination

Recognizing the need for better coordination, officials from USIA, INS, HHS,

and the requesting federal agencies have been meeting since late 1995 to

discuss the use of waivers to address physician shortages. The officials

formed an informal interagency group that has discussed revising

regulations addressing waiver requests.22 USIA, in working with the other

agencies, published a proposed regulation in the Federal Register on

September 5, 1996.23 In the preamble to the proposed regulation, USIA

noted that with the entry of USDA and HUD into the waiver process,

inconsistency in the administration of waiver requests among the different

agencies has created some confusion. For a request by a U.S. government

agency, the regulation would condition approval on the physician’s

commitment to practice primary care for at least 3 years in a designated

Health Professional Shortage Area or a Medically Underserved Area or to

practice psychiatric care in a mental health Health Professional Shortage

Area. To prevent physicians from shopping between agencies, the foreign

medical graduate would have to certify that he or she is only requesting a

waiver through one agency.

Recent Amendments

Require More Consistent

Policies

The Omnibus Consolidated Appropriations Act, 1997,24 included

amendments to the Immigration and Nationality Act that create greater

consistency among waiver efforts by subjecting state and federally

sponsored waiver physicians to the same statutory requirements. The

amendments strengthen penalty provisions for federally sponsored waiver

physicians by prohibiting them from obtaining permanent residence or

U.S. citizenship without completing the required 3-year agreement. If they

fail to complete the 3-year agreement, they must fulfill the 2-year foreign

residence requirement.25 These changes (1) make the waiver conditions

much more consistent, which may help to alleviate the confusion cited by

agency officials, and (2) help to strengthen controls with regard to

penalties for waivers requested through federal agencies.

Some Problems Would

Remain Unaddressed

While the efforts of the interagency group and enactment of the 1996

amendments should improve coordination of the waiver requests for

22DOT, on the other hand was not included in this interagency group. DOT has only requested waivers

for one location and does not have formal agency policies regarding the waivers.

23See 61 Fed. Reg. 46,745 (1996).

24P.L. 104-208 (1996).

25Physicians whose waivers were obtained through states have been subject to these requirements

since 1994.

Page 22 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

physicians with J-1 visas, they will leave several problems unaddressed.

Specifically, they do not address the following issues:

• Fully coordinating with other underservice programs or with waiver

requests by other agencies. The amendments neither designate an agency

as responsible for managing the waivers nor require the waivers to be

coordinated with HHS programs such as NHSC or the Community Health

Center program. Among federal agencies and states requesting the

waivers, the problems of overlapping jurisdictions and the lack of

information on the practice locations of waiver physicians could result in

more physicians practicing in an area than are needed, as identified by

HHS; a continued need for physicians in other areas; and a lack of

coordination with state efforts to address physicians shortages. In

addition, although HHS has started to collect information on the number of

physicians practicing under waivers in an area, there is no directive for

this information to be used or shared in making decisions on waivers for

physicians or other federal assistance.

• Ensuring that the use of waivers for physicians is a last resort. In an effort

to ensure that the employers have a true need for a physician, ARC, USDA,

and HUD policies, as well as the proposed USIA regulations, require the

facilities to provide some documentation of past recruitment efforts. This

procedure, however, does not ensure that the use of waivers for

physicians is the option of last resort for areas with physician shortages. In

some cases it appears that other qualified physicians are available, but the

facility prefers to hire the physicians with J-1 visas. For example, officials

from one multispecialty clinic told us that they interviewed several

applicants for a specialist physician position, including candidates who

were not under J-1 visas, but they chose the physician with a J-1 visa and

obtained a waiver because he was the most qualified. The use of waivers is

now a ready means for acquiring physicians, some of whom are being

actively marketed by the physicians themselves or placement specialists

such as recruiters. The current statute and regulations do not require

waivers to be used only as a last resort.

• Monitoring compliance. It is unclear whether agencies would devote

sufficient resources to effectively monitor compliance. USDA, for example,

relies on employers to enforce the employment contracts, citing a lack of

staff resources to conduct its own monitoring. However, as we and ARC’s

Inspector General found, many of the examples of physicians who failed

to comply with agency policies resulted from actions taken by the

employers. As a result, a reliance on employers to do the policing does not

appear adequate to prevent the kinds of situations we found. HUD officials

Page 23 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

also said that their monitoring efforts were limited by the availability of

staff resources.

• Addressing the needs of the medically underserved. Under existing

procedures, locating a waiver physician in a medical shortage area is no

guarantee that the needs of the underserved will be addressed. An area’s

underserved may be only a specific part of the population (such as migrant

workers or low-income people), and not all federal agencies’ and states’

policies contain requirements or monitoring to ensure that a physician’s

practice includes such groups. For example, if the underserved part of the

population is low-income, the requesting agencies’ and states’ policies do

not all require that a waiver physician in such an area accept Medicaid,

have a sliding fee scale, or accept anyone for services regardless of his or

her ability to pay. In one area where the identified need was care for

migrant farm workers, a waiver physician was in a group practice a block

away from a federally funded migrant health center. A senior official at the

migrant health center said that the waiver physician did not impact the

center’s patient load because they both served different patient

populations.

• Establishing penalties against a facility for failing to comply with agency

policies. The new regulations and the 1996 amendments do not establish

any penalties for employers who fail to comply. The ARC Inspector General

noted that the most significant programmatic issue that surfaced during

that office’s review was the limited accountability of employers and the

lack of potential actions against employers who did not use physicians

with waivers in accordance with the intended purposes noted in the

program.

Conclusions The use of waivers for physicians with J-1 visa requirements has become

so extensive that this exception policy now resembles a full-fledged

program for addressing medical underservice in the United States. Many

health care facilities and states cite examples of the utility of these waivers

in providing a qualified physician for an underserved area. However, while

the agencies involved in processing the waivers are operating with the best

of intentions, the growing use of waivers is not being managed as a

program, and this is having detrimental results.

• Federal efforts to address physician shortages are not coordinated among

the federal agencies or with the states. Several agencies, including those

not traditionally involved in physician supply issues, have set up de facto

physician supply programs using their existing authority and agency

resources.

Page 24 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

• Despite some improvements, monitoring efforts to ensure that physicians

fulfill the terms of their agreements remain spotty.

• Accountability for reducing the actual conditions of underservice is

limited. Physicians can practice in underserved areas but not actually

target their efforts to that part of the population that is underserved.

The rapid growth in waivers for physicians makes this an opportune time

for the Congress to reassess what it wants the waiver provision to

accomplish. The running disagreement between HHS and other federal

agencies about the role of waivers in addressing physician shortages in

underserved areas needs resolution, and better coordination and

management of the overall effort are needed if it is to be continued.

Matters for

Congressional

Consideration

If the Congress wants to continue to address medical underservice in the

United States through the use of waivers for physicians with J-1 visa

requirements, it should consider requiring that the use of such waivers be

managed as a program. Specifically, the Congress should consider the

following:

• Clarifying how the use of waivers for these physicians fits into the overall

federal strategy to address medical underservice. This should include

determining the size of the waiver program and establishing how it should

be coordinated with other federal programs.

• Designating leadership responsibility for managing the program. This

responsibility could be given to a single federal agency, such as HHS; to

several federal agencies, for example, through a memorandum of

understanding; or it could be delegated to the states.

• Establishing penalties against facilities that fail to comply with

requirements of the waiver.

• Directing the entity(ies) managing the program to implement procedures

and criteria for the selection and placement of physicians and for

monitoring compliance with waiver requirements. These procedures and

criteria could include requiring the state to clearly support the use of the

physician for addressing unmet need and to show that it has sought other

options for fulfilling this need.

Agency Comments

and Our Evaluation

We provided a draft copy of this report to seven agencies that are involved

with waivers for physicians to practice in underserved areas.

Page 25 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

• ARC, USDA, and USIA provided formal written comments (see apps. VIII, IX,

and X). These comments indicate general agreement with our conclusions

and matters for congressional consideration.

• HUD and Justice (the parent department for INS) chose not to provide

formal comments. However, we discussed our findings with HUD and INS

officials, and they raised no objections to our findings or matters for

congressional consideration. DOT has had limited involvement in waivers

for physicians with J-1 visas and did not have comments on the draft

report.

• HHS did not submit formal comments by the end of our 30-day comment

period. However, the Director of the department’s Office of International

Affairs (who also chairs the department’s Exchange Visitor Waiver Review

Board) informed us that his office had fully reviewed the draft report and

was in general agreement with the findings. Regarding our matters for

congressional consideration, he said that HHS favored the option of

delegating responsibility for the waivers to the states.

The three agencies that provided formal written comments also expressed

their support for the need for better coordination between the

participating agencies, states, and other programs to address medical

underservice. One agency, USDA, also expressed concern about the lack of

available funding to operate its program effectively. USDA suggested that an

alternative to funding the program from appropriated research funds

would be to initiate a fee-for-service type application fee to offset

operational costs, which would require legislation to authorize the

collection and utilizations of fees.

We concur that any entity involved in managing waiver requests for

physicians should commit adequate resources for oversight and

operational support to ensure that the physicians address unmet needs for

physician resources. Although we did not examine financing options for

managing the waivers in our review, we did note that a few states, such as

Michigan, have been requiring user fees of up to $500 per application.

We also received comments on technical matters from several of the

agencies, which we considered in preparing our final report.

We are sending copies of this report to the Secretaries of Agriculture,

Health and Human Services, Housing and Urban Development, and

Transportation, as well as the Director of the United States Information

Agency, the Federal Co-Chairman of the Appalachian Regional

Page 26 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

Commission, and the Attorney General. We also will make copies available

to others on request. Please contact me on (202) 512-7119 if you or your

staff have any questions. Major contributors to this report are listed in

appendix XI.

Bernice Steinhardt

Director, Health Services

 Quality and Public Health Issues

Page 27 GAO/HEHS-97-26 Waivers for Foreign Physicians
B-271030 

List of Addressees

The Honorable Nancy L. Kassebaum

Chairman

The Honorable Edward M. Kennedy

Ranking Minority Member

Committee on Labor and Human Resources

United States Senate

The Honorable Alan K. Simpson

Chairman

The Honorable Edward M. Kennedy

Ranking Minority Member

Subcommittee on Immigration

Committee on the Judiciary

United States Senate

The Honorable Michael Bilirakis

Chairman

The Honorable Henry A. Waxman

Ranking Minority Member

Subcommittee on Health and Environment

Committee on Commerce

House of Representatives

The Honorable Lamar S. Smith

Chairman

The Honorable John Bryant

Ranking Minority Member

Subcommittee on Immigration and Claims

Committee on the Judiciary

House of Representatives

Page 28 GAO/HEHS-97-26 Waivers for Foreign Physicians
Page 29 GAO/HEHS-97-26 Waivers for Foreign Physicians
Contents

Letter 1

Appendix I 

Scope and

Methodology

34

Number of Waivers 34

Survey of Health Care Facilities 36

Survey of States Regarding Waivers for Physicians With J-1 Visas 37

Coordination 37

Compliance 38

Appendix II 

Exchange Visitors in

Graduate Medical

Education in the

United States

39

Appendix III 

Waiver of the Foreign

Residence

Requirement for

Exchange Visitors

40

History of the 2-Year Foreign Residence Requirement 40

Participants in Graduate Medical Education or Training Face

More Stringent Conditions

42

State Requests for Waivers 43

1996 Amendments 44

Appendix IV 

Results of GAO

Questionnaire for

States Regarding J-1

Visa Waivers for

Physicians

45

Page 30 GAO/HEHS-97-26 Waivers for Foreign Physicians
Contents

Appendix V 

Waiver Requests for

Physicians With J-1

Visas, by States and

Federal Agency,

1990-95

49

Appendix VI 

Results of GAO Survey

of Health Care

Facilities Regarding

Waivers for

Physicians With J-1

Visas, 1994-95

Requests

50

Appendix VII 

Physician Need and

Number of Waiver and

National Health

Service Corps

Physicians, by State,

1995

52

Appendix VIII 

Comments From the

Appalachian Regional

Commission

55

Page 31 GAO/HEHS-97-26 Waivers for Foreign Physicians
Contents

Appendix IX 

Comments From the

Department of

Agriculture

57

Appendiux X 

Comments From the

United States

Information Agency

60

Appendix XI 

GAO Contacts and

Staff

Acknowledgments

61

Bibliography 62

Tables Table 1: Conditions for Waivers for Physicians With J-1 Visas 5

Table 2: Requests for Waivers for Physicians, by States and

Federal Agency, 1995

11

Table II.1: Immigration Status of Physicians in

ACGME-Accredited and Combined Specialty Programs, August 1,

1995

39

Table VI.1: Waiver Physician Employment Status 50

Table VI.2: Practice Settings of Waiver Physicians Practicing on

January 1, 1996

51

 Table VI.3: Practice Specialties of Waiver Physicians Practicing

on January 1, 1996

51

Table VII.1: Physician Need and Number of Waiver and NHSC

Physicians, by State, 1995

53

Figures Figure 1: J-1 Waiver Process 6

Figure 2: Number of Waivers Processed for Physicians With J-1

Visas, 1990-95

9

Figure 3: Practice Settings of Waiver Physicians Practicing on

January 1, 1996

13

Page 32 GAO/HEHS-97-26 Waivers for Foreign Physicians
Contents

Figure 4: Practice Specialties of Waiver Physicians Practicing on

January 1, 1996

14

Abbreviations

ACGME Accreditation Council for Graduate Medical Education

AMA American Medical Association

ARC Appalachian Regional Commission

COGME Council on Graduate Medical Education

DOT Department of Transportation

ECFMG Educational Commission for Foreign Medical Graduates

HHS Department of Health and Human Services

HUD Department of Housing and Urban Development

INS Immigration and Naturalization Service

NHSC National Health Service Corps

USDA United States Department of Agriculture

USIA United States Information Agency

VA Department of Veterans Affairs

Page 33 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix I 

Scope and Methodology

To accomplish our objectives, we interviewed (1) federal agency officials

responsible for requesting the waivers at ARC, HUD, USDA, and DOT; (2) HHS

officials in the department’s Office of International Affairs and the Health

Resources and Services Administration; (3) officials responsible for

processing the waiver requests at USIA and INS, including INS service

centers; (4) officials from the Department of Labor and the State

Department; and (5) officials from the Educational Commission for

Foreign Medical Graduates (ECFMG), the National Association of

Community Health Centers, the American Medical Association (AMA), the

Council on Graduate Medical Education (COGME), and the U.S. Commission

on Immigration Reform. We also reviewed relevant legislation, studies, and

policy documents and conducted two mail surveys: one of the states

regarding the use of waivers of the J-1 visa foreign residence requirement

for physicians in their states, and another of the facilities that requested

such waivers for physicians. We obtained and analyzed data on requests

for waivers for physicians from USIA and the requesting federal agencies

and reviewed a small sample of case files.

We also visited three states—Washington, Texas, and Georgia. We selected

these three states for a cross-section of states where waiver physicians

were practicing: Washington was quick to establish a state program; Texas

had a large number of physicians with waivers through federal agencies

but the state was not requesting waivers; and Georgia had a state program

as well as physicians whose waivers were requested through ARC, HUD, and

USDA. During our site visits, we met with state and other health officials,

visited 14 sites where waiver physicians were practicing, and interviewed

health care facility officials and 20 physicians who received waivers. We

selected the sites in order to visit physicians in a variety of practice

settings, including federally funded community and migrant health

centers, a health center serving residents in public housing, city and

county health departments, a capitated-rate program for the Medicare- and

Medicaid-eligible elderly, and private and group practices affiliated with

both public and for-profit hospitals.

We conducted our work between November 1995 and September 1996 in

accordance with generally accepted government auditing standards.

Number of Waivers To determine the number of waivers for physicians granted at the request

of ARC, USDA, and HUD, we requested copies of the agencies’ databases.

Each database contained information about when the agency requested

that USIA recommend the waiver. We used the date that the agencies sent

Page 34 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix I 

Scope and Methodology

the request to USIA in our calculations because neither USIA nor INS has a

cost-effective means of identifying waiver requests by occupation and USIA

and INS officials said that they recommended or approved virtually all the

physician waiver requests made by the interested U.S. government

agencies. While we did not review the agencies’ computer-based systems,

we did review the requesting agencies’ data for consistency and accuracy

and selectively compared the agency data with that held by USIA. We

obtained information on the waiver requests made by DOT from its Office

of the General Counsel. We obtained information on state requests for

waivers from our survey of states regarding waivers for physicians and

follow-up telephone calls to state officials. Our scope did not include

waiver requests from VA or requests from other agencies for physicians to

conduct research.

Because the agencies requesting waivers do not consistently track the

practice dates of the physicians, we could not identify the number of

physicians in practice at any given point in time. Instead, we used the

dates that the agencies and states submitted their requests for waivers to

USIA and assumed that those physicians whose waivers were requested in

1994 or 1995 were either already practicing at the facility listed in agency

data on December 31, 1995, or had their waivers in process to begin

practicing shortly thereafter. We compared this number with (1) the

number of physicians needed to remove the primary care Health

Professional Shortage Area designations in the state on December 31,

1995, and (2) the number of NHSC physicians (who received NHSC

scholarships or NHSC federal loan repayment in return for practicing in an

underserved area) who were practicing on December 31, 1995. We

obtained these data from HHS’ Health Resources and Services

Administration. We also compared the number of waivers with the number

of NHSC physicians practicing in underserved areas on September 30, 1995,

including NHSC physicians who did not have NHSC scholarship or federal

loan repayment obligations.

To estimate the number of physicians who completed graduate medical

education and training in 1995 who would be subject to the 2-year foreign

residence requirement, we subtracted the number of exchange visitor

physicians who were continuing applicants in the 1995-96 academic year

from the number of physicians sponsored by ECFMG in the prior academic

year. While this number is not exact because it may include a small

number of physicians who were involved in research and some physicians

who did not complete their training, it does represent a reasonable

estimate of the number of exchange visitor physicians with J-1 visas who

Page 35 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix I 

Scope and Methodology

completed graduate medical education or training who would be required

to return home without a waiver to remain in the United States. The

number of waiver requests for physicians to practice in underserved areas

that the agencies sent to USIA in 1995 (1,374) is about 64 percent of this

figure. Therefore, we estimate that half of the physicians who were

supposed to return home after completing their graduate medical

education or training received waivers to practice in underserved areas in

the United States instead.

Survey of Health Care

Facilities

To identify characteristics of the physicians who received waivers of the

J-1 visa foreign residence requirement and to measure the compliance and

retention of these physicians, we selected a random sample of 40 from 355

physicians for whom ARC requested waivers between 1990 and 1992.

Because most federal agencies only began requesting waivers in the past

several years, we also selected a random sample of 211 of 1,994 physicians

for whom ARC, DOT, HUD, and USDA received waiver requests in 1994 and

1995 (this was a stratified sample, including 40 of 362 ARC requests; 2 of 2

DOT requests; 49 of 477 HUD requests, and 120 of 1,153 USDA requests). We

sent a questionnaire to the contact person at the facility that had requested

the waivers, using the information provided by the federal agencies. For

each physician, we asked the contact person to tell us (1) if the physician

worked or planned to work at the facility; (2) if the physician was working

at the facility as of January 1, 1996; (3) if the physician left and the date he

or she stopped working at the facility; (4) whether or not the physician

obtained permanent residency during his or her employment; and (5) the

physician’s medical specialty, subspecialty, and practice setting. We

received responses for 39 of the 40 physicians in our 1990 to 1992 ARC

sample and for 200 of 211 physicians in our 1994 to 1995 samples (38 of 40

ARC physicians, 2 of 2 DOT physicians, 49 of 49 HUD physicians, and 111 of

120 USDA physicians).

We used the survey results of the 1990 to 1992 ARC sample to estimate the

rate of completion of ARC’s required 2-year contract among all waiver

physicians whose waivers were requested between 1990 and 1992. We

counted those physicians who worked for at least 1.75 years as meeting

the ARC minimum contract period at that time, which was 2 years. We used

1.75 years of practice as our measure of compliance to allow for vacation

and other leave. At a 95-percent confidence level, the rate of compliance

among the 1990 to 1992 requests is at least 80 percent and the percent still

at the requesting facility on January 1, 1996, is at least 19 percent.

Page 36 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix I 

Scope and Methodology

We used the survey results of the 1994 to 1995 samples to estimate the rate

of compliance, to date, of physicians whose waiver requests were received

by ARC, DOT, HUD, and USDA from 1994 to 1995. We counted those physicians

who were working on January 1, 1996, for the facility listed in agency data

as in compliance. At a 95-percent confidence level, the rate of compliance

among the 1994 to 1995 requests (those practicing on January 1) is at least

93 percent.

We also used the survey results of the 1994 to 1995 samples to estimate the

practice specialties and practice settings of physicians who were

practicing on January 1, 1996. For this analysis, we included those 150

physicians who were practicing on January 1, 1996, for the facilities listed

by the agency. The estimates at the 95-percent confidence intervals are

shown in tables VI.2 and VI.3.

We also obtained comments on the use of waivers for physicians from the

survey respondents.

Survey of States

Regarding Waivers for

Physicians With J-1

Visas

To identify the states’ participation in requesting waivers for physicians,

we used a questionnaire for information on (1) whether or not the state

had requested or planned to request waivers for physicians with J-1 visas

in fiscal years 1995 and 1996, and (2) the state’s involvement in waivers for

these physicians. We sent a questionnaire to the contact person provided

by USIA or the official responsible for public health issues in all 54 eligible

jurisdictions, including the 50 states, the District of Columbia, Guam,

Puerto Rico, and the U.S. Virgin Islands. Each state reported on the

number of waivers requested by the state, if any; factors considered in

state requests; monitoring activities; and state involvement in requests for

waivers made by federal agencies. The respondents also commented on

the use of waivers for physicians to address medical underservice and

provided a copy of their state’s written policies, if any, regarding these

waivers.

In addition, to obtain information on the number of waivers for physicians

requested by the states in 1995, we telephoned officials at those states that

indicated they had requested waivers in fiscal years 1995 or 1996.

Coordination To determine the conditions attached to the waivers, we interviewed state

and federal agency officials, reviewed their written waiver policies, and

analyzed the results of our state survey.

Page 37 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix I 

Scope and Methodology

To look at coordination of physician placements, we cross-tabulated the

agency data on waiver requests received by the agencies between 1994 and

1995 by state and selected those physicians whose waiver requests were

sent to USIA between 1994 and 1995. We obtained the number of physicians

who were NHSC scholarship or federal loan repayment recipients who were

practicing in each state as of December 31, 1995, from HHS’ Bureau of

Primary Health Care.26 We added the number of waiver physicians and

NHSC physicians and compared them with the number of

full-time-equivalent physicians needed to remove primary care Health

Professional Shortage Area designations in that state as of December 31,

1995. We used the shortage area dedesignation level because it is the

primary measurement used by HHS and the requesting agencies to establish

the need for physicians.27

We used USIA’s data file to identify those locations for which more than

one agency requested waivers for physicians and checked the requesting

agencies’ data to see if they showed a request for that practice location.

Compliance We identified instances where physicians did not comply with the terms of

the waiver through (1) discussions with the ARC Inspector General and a

review of reports from that office, (2) our survey of facilities where

requesting agencies believed that the physicians were practicing, (3) site

visits to facilities where the physicians were supposed to be practicing,

and (4) discussions with USIA and other agency officials. If a facility

indicated that the physician never worked there, we contacted the facility,

INS, or both to obtain information on the reason the physician never

worked there and to confirm that a waiver had been granted. We also

reviewed case files at the requesting agencies and USIA to check for

documentation, if any, of the physician’s departure from the facility or

noncompliance. For physicians that did not work at or left the facilities,

we tried to locate the physician through AMA data; the unique provider

identification number database, which is maintained by the Medicare

program; telephone listings; state licensing boards; and other sources.

26For this analysis, we did not include physicians practicing under the NHSC state loan repayment

program or the community scholar program, because data on the number of these physicians

practicing in each state on December 31, 1995, were not readily available from HHS. If these physicians

were included, the number of NHSC physicians in practice on December 31, 1995, would increase.

27We used the Health Professional Shortage Area designation as a measure of need for this reason.

However, our prior work found problems with HHS’ shortage area designations. Our report,

GAO/HEHS-95-200, Sept. 8, 1995, discusses these problems in detail.

Page 38 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix II 

Exchange Visitors in Graduate Medical

Education in the United States

Exchange visitors are only a portion of physicians in graduate medical

education programs. As shown in table II.1, about 1 in 10 physicians in

programs accredited by ACGME was an exchange visitor in August 1995. Of

those who were international medical graduates—physicians who did not

graduate from U.S. or Canadian medical schools—about 1 in 3 was an

exchange visitor. Only these exchange visitor physicians are subject to the

J-visa 2-year foreign residence requirement. Hence, while policy changes

regarding waivers for exchange visitors will affect more than one-third of

the international medical graduates in graduate medical education or

training, most international medical graduates will not be affected.

Table II.1: Immigration Status of

Physicians in ACGME-Accredited and

Combined Specialty Programs,

August 1, 1995

All physicians

International medical

graduate physiciansa, b

Immigration status Number Percent Number Percent

Exchange visitor (J-visa) 9,573 9.8 9,183 36.8

Nonimmigrant (H-visa) 2,618 2.7 2,363 9.4

Permanent U.S. resident 8,937 9.1 6,985 28.0

Naturalized U.S. citizen 8,730 8.9 1,973 7.9

Native U.S. citizen 61,886 63.1 2,057 8.2

Refugee 963 1.0 862 3.4

Unknown 4,501 4.6 980 3.9

Miscellaneousc 827 0.8 579 2.3

Total 98,035 24,982

Note: Percent columns may not total 100 because of rounding.

aDoes not include graduates of Canadian medical schools.

bMedical school type was not indicated for 454 residents (0.5 percent of all residents).

cIncludes temporary visitors on B-2 visas and students on F-1 visas.

Source: AMA.

Page 39 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix III 

Waiver of the Foreign Residence

Requirement for Exchange Visitors

Under the Mutual Educational and Cultural Exchange Act of 1961,28 the

Director of USIA establishes programs intended to promote mutual

understanding between the people of the United States and other

countries by means of educational and cultural exchanges. Under these

exchange visitor (J-1 visa) programs, designated organizations sponsor

nonimmigrant aliens’ temporary visits to the United States for the

purposes of teaching, instructing or lecturing, studying, observing,

conducting research, consulting, demonstrating special skills, or receiving

training. ECFMG is the designated sponsor for exchange visitors

participating in graduate medical education.29 After completing this

program, it is expected that participants will return to their home

countries and impart what they have learned and experienced to the

people of their country.

Section 212(e) of the Immigration and Nationality Act30 requires that

certain J-1 visa program participants, including participants in graduate

medical education, reside at least 2 years in the countries of their

nationalities or last residences after leaving the United States. They must

meet this requirement before they are eligible to apply for nonimmigrant

visas (H and L) as temporary workers, for permanent residencies in the

United States, or as immigrants.

History of the 2-Year

Foreign Residence

Requirement

There was no 2-year foreign residence requirement or waiver provision in

the exchange visitor program authorized with the passage of the U.S.

Information and Educational Exchange Act of 1948.31 The act required

participants to depart the United States after completing their programs.

The 2-year foreign residence requirement and its related waiver provision

evolved through a number of legislative changes after the exchange visitor

program was authorized in 1948.

In 1956, the Congress amended the 1948 act to require that participants

reside in and be physically present in their home countries or cooperating

countries for at least 2 years before applying for immigrant visas,

nonimmigrant H visas, or adjustments of status to permanent resident. In

28P.L. 87-256 (1961).

29To be eligible for ECFMG sponsorship, foreign physicians must pass a medical science examination

and meet English-language requirements, fulfill minimum medical education requirements, and have a

contract for a position in a program accredited by ACGME.

308 U.S.C. 1182(e) (1994).

31P.L. 80-402 (1948).

Page 40 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix III 

Waiver of the Foreign Residence

Requirement for Exchange Visitors

recommending this amendment, the Senate Committee on Foreign

Relations stated that it was needed to counteract situations in which some

participants were departing the United States as required, going to Canada

or Mexico, and immediately returning to the United States on immigrant

visas. The Committee stated that this defeated the primary objective of the

exchange program; that is, to impart participants’ experiences in the

United States to the people of their country. It further stated,

“the amendment would make perfectly clear to all concerned...and, above all, the foreign

nationals themselves—that the exchange program is not an immigration program and

should not be used to circumvent the operation of the immigration laws.”32

The 1956 amendment also provided for a waiver of the foreign residence

requirement on the basis of a request from an interested U.S. government

agency showing the waiver to be in the public interest.33

The Mutual Educational and Cultural Exchange Act of 1961, under which

the exchange visitor program now operates, contains a provision

amending the Immigration and Nationality Act, which established the

foreign residence requirement. Under that provision, a participant could

reside for 2 years in a foreign country other than his or her home country.

The act also provided for a waiver of the foreign residence requirement

(1) upon a determination that departure from the United States would

impose exceptional hardship on the participant’s spouse or child (who

must be a U.S. citizen or a lawful resident alien) or (2) at the request of an

interested U.S. government agency (after a favorable recommendation).

The conference report states

“To make available the services of exchangees who possess talents desired by our

universities, foundations and other institutions, the language of the House bill was

modified to permit the waiver of the foreign residence requirement on the request of an

interested U.S. Government agency.”34

An amendment to the foreign residence provision in 1970 removed the

blanket application of the foreign residence requirement for exchange

visitors and imposed it only on participants (1) whose participation was

financed in some way by the United States or their home countries or

32S. Rep. No. 1608, 84th Cong., 2d Sess. 2, 3 (1956).

33P.L. 84-555 (1956).

34H. Conf. Rep. No. 1197, 87th Cong., 1st Sess. 17 (1961).

Page 41 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix III 

Waiver of the Foreign Residence

Requirement for Exchange Visitors

(2) whose home countries clearly needed their services.35 Also,

participants could no longer meet the 2-year foreign residence requirement

by residing in other foreign countries but had to reside in the countries of

their nationalities or their last foreign residences before coming to the

United States. This requirement still applies. The 1970 act also established

two additional bases for waivers: persecution because of race, religion, or

political opinion and statements by the participant’s home countries that

they had no objections to the waivers. These bases still apply except that

the statement of no-objection waiver is no longer available to participants

in graduate medical education or training.

Participants in

Graduate Medical

Education or Training

Face More Stringent

Conditions

After 1970, changes to the foreign residence and waiver provisions

primarily strengthened restrictions on participants coming to the United

States for graduate medical education or training. In 1976, the Congress

imposed restrictions on medical graduates’ participation in the exchange

visitor program. In the 1976 act, the Congress noted

“that there is no longer an insufficient number of physicians and surgeons in the United

States such that there is no further need for affording preference to alien physicians in

admission to the United States under the Immigration and Nationality Act.”36

In light of this finding, the Congress tightened immigration laws for foreign

doctors and strengthened requirements affecting J-1 visa program

participants who were coming to the United States for graduate medical

education or training. The latter were

• made subject to the 2-year foreign residence requirement whether or not

their programs were financed by a government,

• made ineligible to apply for waivers on the basis of no-objection

statements from their home countries,

• limited to 3-year stays in the United States,

• required to make a commitment to return to their home countries after

completing their training, and

• required to provide written assurance by their home countries that after

completing their training and returning home, they would be appointed to

positions in which they would fully use the skills acquired in their

education or training.37

35P.L. 91-225 (1970).

36P.L. 94-484 (1976).

37P.L. 94-484.

Page 42 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix III 

Waiver of the Foreign Residence

Requirement for Exchange Visitors

In 1981, USIA asked the Congress to extend the limit up to 7 years for

medical doctors to encourage them to study in the United States rather

than in a Communist country. The House Committee on the Judiciary

questioned USIA officials regarding the likelihood that physicians would be

willing to return home after 7 years, during which time they may have

raised families in the United States. The Congress increased the usual

permissible duration of stay to 7 years, but it imposed additional

requirements:38

• Graduate medical education or training participants were required, as a

continuing reminder, to furnish annual affidavits to INS attesting that they

would return to their home countries upon completion of the education or

training for which they came to the United States.

• U.S. officials were required to issue an annual report to the Congress on

participants who had submitted affidavits, including their names and

addresses, the programs in which they are participating, and their status in

the programs.

In reporting on this legislation, the House Committee on the Judiciary

“notes the flagrant abuse of the exchange program during the past decade

and seeks to alleviate possible ‘brain drain’ from various countries.” It said

that the affidavits were to ensure that the physicians comply with the

terms of their agreement.39

State Requests for

Waivers

Amendment of the Immigration and Nationality Act in 199440 established

another basis for physicians to obtain waivers of the J-1 visa foreign

residence requirement. Under the amendment, up to 20 waivers for

physicians with J-1 visas may be granted at the request of a state41

department of public health or its equivalent each fiscal year. The law

imposed several conditions for state-requested waivers:

• The alien physician must (1) demonstrate a bona fide offer of full-time

employment at a health facility, (2) agree to begin employment at that

facility within 90 days of receiving the waiver, and (3) agree to work there

38P.L. 97-116 (1981).

39H.R. Rep. No. 264, 97th Cong., 1st Sess. 16 (1981)

40P.L. 103-416 (1994).

41“The term state includes the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. 8

U.S.C. 1101(a)(36)(1994).

Page 43 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix III 

Waiver of the Foreign Residence

Requirement for Exchange Visitors

for at least 3 years while maintaining a nonimmigrant work status (H-1B

visa).42 (The physician’s status as a nonimmigrant may not be changed

until the employment contract is fulfilled.)

• The alien physician must agree to practice medicine for at least 3 years in

a geographic area or areas designated by the Secretary of HHS as having a

shortage of health care professionals.

• If the alien physician is otherwise contractually obligated to return to a

foreign country, that country’s government must furnish a statement to the

Director of USIA that it has no objection to a waiver.

• If the physician fails to fulfill the contract, he or she must reside and be

physically present in the country of his or her nationality or last residence

for at least 2 years after departing the United States before becoming

eligible to apply for an immigrant visa, for permanent residence, or for any

other change of nonimmigrant status

The 1994 amendments apply only to exchange visitors who were admitted

to the United States under a J-visa or acquired J-visa status before June 1,

1996.

1996 Amendments Other amendments to the Immigration and Nationality Act regarding

waivers for physicians with J-1 visas were passed in the 104th Congress.

The amendments were included in the Omnibus Consolidated

Appropriations Act, 1997,43 and (1) impose additional requirements for

waivers requested by interested U.S. government agencies, and (2) extend

authorization for waivers for aliens entering the United States with a J-visa

or acquiring such status through May 31, 2002.

The amendments subject physicians seeking waivers through interested

U.S. government agencies to some of the same requirements as those

sponsored by state agencies. For example, the amendments require such

physicians to (1) agree to work for at least 3 years for the health facility

named in the application, (2) work in an area designated by the Secretary

of HHS as having a shortage of health care professionals, (3) begin work

within 90 days of receipt of the waiver, and (4) maintain a nonimmigrant

status until their 3-year commitment is completed. Physicians who do not

fulfill this commitment become subject to the 2-year foreign residence

requirement.

42The Attorney General may determine that extenuating circumstances, such as the closure of the

facility or hardship to the alien, would justify a period of less than 3 years.

43P.L. 104-208 (1996).

Page 44 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix IV 

Results of GAO Questionnaire for States

Regarding J-1 Visa Waivers for Physicians

United States General Accounting Office

GAO Questionnaire

April 1996 Survey of States

Regarding J-1 Visa

Waivers for

Physicians

Page 45 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix IV 

Results of GAO Questionnaire for States

Regarding J-1 Visa Waivers for Physicians

INTRODUCTION

The U.S. General Accounting Office is

conducting a review of J-1 visa waivers

for physicians to practice in medically

underserved communities. As part of

this study, we are collecting information

on state J-1 visa waiver programs as well

as on states’ roles in requests for J-1 visa

waivers made by U.S. government

agencies. We are sending this

questionnaire to all 50 states, the District

of Columbia, Guam, Puerto Rico, and the

Virgin Islands of the United States.

INSTRUCTIONS

Please complete the questionnaire and

return it, along with a copy of your

state’s policies on J-1 visa waivers for

physicians, if any, within ONE WEEK of

receipt. You can use the enclosed

pre-addressed envelope or send it via

FAX on (206) 287-4872. The

questionnaire should take about 15

minutes to complete.

Please provide the name, title, and

telephone number of the individual who

completed this questionnaire so that we

may consult him or her, if necessary, for

clarification of your responses or

additional information.

name:__________________________

title:___________________________

phone #:( )

STATE J-1 VISA WAIVER PROGRAM

1. Did your state request any state J-1 visa

waivers for physicians in federal fiscal year

1995 (10/1/94 - 9/30/95)?

37% yes--> 82(total)# of waivers requested

63% no

2. Has your state requested or will it be

requesting any state J-1 visa waivers for

physicians in federal fiscal year 1996 (10/1/95

-9/30/96)?

63% yes

28% no -->skip to question 8

9% undecided-->skip to question 8

3. How many state J-1 visa waivers has your

state requested from October 1, 1995

through March 31, 1996? (enter 0 if none

were requested during that time)

102 (total) waivers requested

4. How many applications for state

J-1 visa waivers did your state receive from

employers between October 1, 1995 and

March 31, 1996? (enter 0 if no applications

were received during that time)

112 (total) applications

please continue on next page-->

Page 46 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix IV 

Results of GAO Questionnaire for States

Regarding J-1 Visa Waivers for Physicians

5. Based on your current situation, how

adequate is the annual limit of 20

state J-1 visa waivers to meet your

state’s needs for physicians under

this program? (check one)

18% much more than adequate

29% more than adequate

27% adequate

6% less than adequate

0% much less than adequate

18% too early to tell

3% no response

6. Listed below are some of the factors

you might consider when reviewing

state J-1 visa waiver applications.

Which of the following factors, if any,

does your state consider in deciding

whether to request state J-1 visa

waivers? (check all that apply)

97% Whether the practice location

is in a health professional

shortage area (HPSA)

65% Whether the practice location

is in a medically underserved

area/population (MUA/MUP)

29% Whether other state J-1 visa

waiver physicians are

practicing in the area

24% Whether other J-1 visa waiver

physicians who received

waivers through U.S.

government agencies are

practicing in the area

27% Whether physicians under

National Health Service Corps

(NHSC) obligations are

practicing in the area

85% Whether the facility has tried

recruiting in the past without

success

0% None of the above factors

7. We are also interested in any activities your

state conducts to monitor compliance with

the conditions of the J-1 visa waiver. Which

of the following activities, if any, does your

state conduct or intend to conduct this year

for state J-1 visa waiver physicians? (check

all that apply)

35% We require periodic reports by the

physician

50% We require periodic reports by the

facility

21% We conduct periodic site visits

82% We rely on the employers to enforce

employment contracts

15% We rely on other federal or state

agencies to monitor compliance

38% We act in response to reports from

other federal or state agencies

32% other (please specify)

______________________________

3% No activities

please continue on next page-->

Page 47 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix IV 

Results of GAO Questionnaire for States

Regarding J-1 Visa Waivers for Physicians

J-1 VISA WAIVERS REQUESTED BY

U.S. GOVERNMENT AGENCIES

8. J-1 visa waivers may also be

requested by interested U.S.

government agencies (e.g., Dept. of

Agriculture, Appalachian Regional

Commission, Dept. of Housing and

Urban Development). Which of the

following activities does your state

conduct for interested government

agencies’ requests for J-1 visa

waivers for physicians in your state?

(check all that apply)

72% Prepare a letter from a state

official when supporting the

waiver

78% Verify that the request is for a

needy area

37% Track practice locations of the

agencies’ J-1 visa waiver

physicians

15% Monitor physician compliance

with the conditions of the

waiver

48% Provide assistance to facilities

applying for U.S. government

agencies’ J-1 visa waivers

7% Other (please explain)

_____________________________

_____________________________

9% No involvement

9. If you have any comments on the J-1 visa

waiver program, such as the reasons for

participation or nonparticipation, please

enter them in the space below. (Attach

separately if additional space is needed)

36 states provided comments

10. Please include a copy of your state’s written

policies, if any, regarding J-1 visa waivers

for physicians, with your completed

questionnaire.

33 states provided written policies

Thank you for your assistance. When our

study is complete, we will send you a copy

of our report.

Page 48 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix V 

Waiver Requests for Physicians With J-1

Visas, by States and Federal Agency, 1990-95

Waivers requested by federal agencies

Year

Waivers

requested

by statesa DOT ARC HUD USDA Total

1990 70 70

1991 121 121

1992 164 164

1993 2 266 6 274

1994 1 217 9 268 495

1995 89 1 157 375 752 1,374

Total 89 4 995 384 1,026 2,498

Note: Determined on the basis of the date the agency sent the request to USIA. USIA officials

said that they recommend virtually all waiver requests and INS officials said that they approve

virtually all waiver requests that have a favorable USIA recommendation.

aStates were first authorized to request waivers in October 1994.

Page 49 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix VI 

Results of GAO Survey of Health Care

Facilities Regarding Waivers for Physicians

With J-1 Visas, 1994-95 Requests

This appendix contains the responses to questions we asked facilities that

requested waivers of the J-1 visa foreign residence requirement for

physicians. We sent the questionnaire to the facilities for 211 physicians

who had their waivers requested through ARC, DOT, HUD, and USDA from

1994 to 1995 (determined on the basis of the date the agency received the

waiver request). We analyzed the practice specialties and practice settings

for the 150 physicians who were practicing on January 1, 1996, for the

facilities listed on agency data.

Table VI.1: Waiver Physician Employment Status

DOT ARC HUD USDA Population

estimate

Status Percent

Number of

responses Percent

Number of

responses Percent

Number of

responses Percent

Number of

responses percent

Practicing at

the facility on

January 1,

1996 100 2 100 38 59 29 73 81 75

Left before

January 1,

1996 0 0 0 0 0 0 3 3 2

Never

practiced/not

planning to

practice there 0 0 0 0 2 1 2 2 2

Planning to

start after

January 1,

1996 0 0 0 0 39 19 23 25 22

Total 2 38 49 111

Note: Physicians whose waivers were requested in 1994-95. Percent columns may not total 100

because of rounding.

Page 50 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix VI 

Results of GAO Survey of Health Care

Facilities Regarding Waivers for Physicians

With J-1 Visas, 1994-95 Requests

Table VI.2: Practice Settings of Waiver Physicians Practicing on January 1, 1996

Figures are percent

Practice setting

DOT 

(n=2)

ARC 

(n=38)

HUD 

(n=29)

USDA 

(n=81)

Population

estimate

Sampling

error for all

agenciesa

Nonprofit community or migrant health center that

receives federal funding 0 29 21 24 24 +/- 7

Nonprofit community health center with no federal

funding 0 16 28 10 15 +/- 5

For-profit health center 0 0 3 4 3 +/- 3

Hospital 0 3 24 25 19 +/- 6

Private or group practice 100 32 21 22 24 +/- 7

Otherb 0 21 3 16 15 +/- 5

Note: Physicians whose waivers were requested in 1994-95 who were practicing on January 1,

1996, at the facilitity that requested the waiver. Percent columns may not total 100 because of

rounding; n = number of responses.

aAt a 95-percent confidence level, the sampling error associated with the population estimate.

bIncludes rural health clinics, mental health clinics, health department clinics, and other practice

settings.

Table VI.3: Practice Specialties of Waiver Physicians Practicing on January 1, 1996

Figures are percent

Practice specialty

DOT 

(n=2)

ARC 

(n=38)

HUD 

(n=29)

USDA 

(n=81)

Population

estimate

Sampling

error for all

agenciesa

Internal medicine 100 53 48 59 55 +/- 8

Pediatrics 0 16 41 21 24 +/- 6

Family practice 0 21 3 9 11 +/- 5

Obstetrics/gynecology 0 3 0 0 1 +/- 1

General practice 0 0 0 2 1 +/- 2

General surgery 0 0 0 1 1 +/- 1

Psychiatry 0 8 0 2 3 +/- 3

Other 0 0 7 5 4 +/- 3

Note: Physicians whose waivers were requested in 1994-95 who were practicing on January 1,

1996. Percent columns may not total 100 because of rounding; n = number of responses.

aAt a 95-percent confidence level, the sampling error associated with the population estimate.

Page 51 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix VII 

Physician Need and Number of Waiver and

National Health Service Corps Physicians,

by State, 1995

This appendix contains information for each state showing (1) the

identified physician need in the state (2) the number of physicians with

waivers granted or in process, and (3) the number of physicians who

received NHSC scholarships or federal loan repayment who were practicing

in the state. We used the number of full-time-equivalent physicians

identified by HHS as needed to remove primary care Health Professional

Shortage Area designations in the state on December 31, 1995, because it

is the primary measurement used by HHS and the requesting agencies to

establish the need for physicians.44 Although physicians with waivers may

also practice in designated Medically Underserved Areas, HHS does not

remove this designation and, as a result, there is no dedesignation level to

measure the need for physicians in the Medically Underserved Area. To

measure the number of waiver physicians who would be practicing on

December 31, 1995, or shortly thereafter, we used data from the requesting

agencies and states on the number of waiver applications sent to USIA from

1994 to 1995. For the number of NHSC physicians in a state, we used the

number of NHSC scholarship and loan repayment recipients who were

practicing on December 31, 1995. This is a conservative number of NHSC

physicians; however, because it does not include the number of physicians

who were NHSC state loan repayment recipients practicing in shortage

areas, which was not available by state from NHSC at the time of our

review.

As shown in table VII.1, the degree to which the identified physician

shortage can be offset by the waiver physicians practicing in a state varied

between the states. In addition, when combined with the NHSC physicians

practicing there, the number exceeded the number of physicians needed to

remove some states’ primary care Health Professional Shortage Area

designations, while other states’ identified physician needs were not met

by these two physician sources.

44As noted in our report, GAO/HEHS-95-200, Sept. 8, 1995, HHS’ measure of full-time providers needed

to dedesignate a Health Professional Shortage Area does not take into account the number of waiver

physicians or NHSC providers practicing in the area. As a result, the number of waiver physicians or

NHSC providers practicing in an area would not change the number of physicians that HHS identified

as needed to remove a shortage area designation.

Page 52 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix VII 

Physician Need and Number of Waiver and

National Health Service Corps Physicians,

by State, 1995

Table VII.1: Physician Need and Number of Waiver and NHSC Physicians, by State, 1995

Agency requesting waiver for physiciana

State

Physicians

neededb NHSCc USDA DOT HUD ARC States Total

Waiver

physicians

as a percent

of identified

need

NHSC

physicians

as a percent

of identified

need

Alaska 18.7 1 0 5

Alabama 123.7 29 29 3 75 107 86 23

Arizona 58.5 28 15 4 5 24 41 48

Arkansas 61.4 8 39 1 40 65 13

California 511.3 46 33 11 44 9 9

Colorado 74.2 22 5 3 8 11 30

Connecticut 56.6 8 11 11 19 14

Delaware 4.4 5 1 1 23 114

District of Columbia 30.1 3 1 2 3 10 10

Florida 206.4 32 33 12 3 48 23 16

Georgia 196.5 26 15 2 11 1 29 15 13

Guam 3.1 0 0

Hawaii 6.0 2 0 33

Idaho 36.0 10 1 1 3 28

Illinois 165.0 40 81 37 1 119 72 24

Indiana 85.7 7 18 7 4 29 34 8

Iowa 34.4 25 12 12 35 73

Kansas 35.8 18 26 3 29 81 50

Kentucky 103.1 12 19 8 64 18 109 106 12

Louisiana 217.6 8 112 6 118 54 4

Maine 19.9 8 9 9 45 40

Maryland 36.9 16 2 5 1 8 22 43

Massachusetts 64.0 20 9 6 15 23 31

Michigan 243.6 34 56 44 2 102 42 14

Minnesota 31.8 12 19 1 2 22 69 38

Mississippi 136.0 15 71 17 1 89 65 11

Missouri 95.6 34 51 8 7 66 69 36

Montana 16.1 8 3 3 19 50

Nebraska 18.2 8 6 1 7 38 44

Nevada 41.1 4 0 10

New Mexico 65.0 4 5 5 8 6

New Jersey 53.8 11 4 20 24 45 20

New Hampshire 12.4 3 3 24 0

New York 387.9 78 63 89 21 173 45 20

(continued)

Page 53 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix VII 

Physician Need and Number of Waiver and

National Health Service Corps Physicians,

by State, 1995

Agency requesting waiver for physiciana

State

Physicians

neededb NHSCc USDA DOT HUD ARC States Total

Waiver

physicians

as a percent

of identified

need

NHSC

physicians

as a percent

of identified

need

North Carolina 121.9 26 23 2 10 6 41 34 21

North Dakota 19.1 2 16 2 2 20 105 10

Ohio 160.8 30 8 21 22 3 54 34 19

Oklahoma 63.3 4 23 4 27 43 6

Oregon 80.1 12 1 1 1 15

Pennsylvania 123.2 35 3 6 48 57 46 28

Puerto Rico 334.6 8 0 2

Rhode Island 20.0 5 2 3 5 25 25

South Carolina 127.3 22 19 17 5 41 32 17

South Dakota 31.2 5 6 6 19 16

Tennessee 85.8 12 18 8 25 51 59 14

Texas 386.3 18 130 52 182 47 5

Utah 28.6 21 1 1 3 73

Vermont 7.0 2 1 1 14 29

Virgin Islands 5.7 1 0 18

Virginia 80.2 15 5 18 23 29 19

Washington 102.2 33 6 7 13 13 32

West Virginia 55.2 5 1 45 1 47 85 9

Wisconsin 87.6 7 25 9 4 38 43 8

Wyoming 7.7 3 3 3 39 39

Total 5,178.6 848 1,020 2 384 374 89 1,869 36 16

aNumber of waiver requests for physicians submitted to USIA in 1994 and 1995.

bNumber of full-time-equivalent physicians needed to remove all primary care Health Professional

Shortage Area designations in the state, as of December 31, 1995.

cNumber of physicians who were NHSC scholarship and loan repayment recipients practicing in

the state, as of December 31, 1995.

Page 54 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix VIII 

Comments From the Appalachian Regional

Commission

Page 55 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix VIII 

Comments From the Appalachian Regional

Commission

Page 56 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix IX 

Comments From the Department of

Agriculture

Page 57 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix IX 

Comments From the Department of

Agriculture

Page 58 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix IX 

Comments From the Department of

Agriculture

Page 59 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendiux X 

Comments From the United States

Information Agency

Page 60 GAO/HEHS-97-26 Waivers for Foreign Physicians
Appendix XI 

GAO Contacts and Staff Acknowledgments

GAO Contacts Frank C. Pasquier, Assistant Director, (206) 287-4861

Patricia K. Yamane, Evaluator-in-Charge, (206) 287-4772

Timothy L. Clouse, Evaluator, (206) 287-4771

Acknowledgments In addition to those named above, the following individuals made

important contributions to this report: Sarah F. Jaggar, Issue Area

Director; Susan Lawes, Senior Evaluator; Susie Anschell, Evaluator; Julie

Rachiele, Technical Information Specialist; Evan Stoll, Computer

Specialist; Jerry Aiken, Computer Specialist; Julian Klazkin, Senior

Attorney; Stan Stenersen, Evaluator; Lisa DeCora, Intern; Kathleen Belfi,

Support Services Technician; and William J. Carter-Woodbridge,

Communications Analyst.

Page 61 GAO/HEHS-97-26 Waivers for Foreign Physicians
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