Foreign Physicians: Preliminary Findings on the Use of J-1 Visa Waivers to Practice in Underserved Areas
Published: 2006-05-18T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Many U.S. communities face difficulties attracting physicians to meet their health care needs. To address this problem, states and federal agencies have turned to foreign physicians who have just completed their graduate medical education in the United States under J-1 visas. Ordinarily, these physicians are required to return home after completing their education, but this requirement can be waived at the request of a state or federal agency if the physician agrees to practice in, or work at a facility that treats residents of, an underserved area. In 1996, GAO reported that J-1 visa waivers had become a major means of providing physicians for underserved areas, with over 1,300 requested in 1995. Since 2002, each state has been allotted 30 J-1 visa waivers per year, but some states have expressed interest in more. GAO was asked to report on its preliminary findings from ongoing work on (1) the number of J-1 visa waivers requested by states and federal agencies and (2) states' views on the 30-waiver limit and on their willingness to have unused waiver allotments redistributed. Such redistribution would require legislative action. GAO surveyed the 50 states, the District of Columbia, 3 U.S. insular areas--the 54 entities that are considered states for purposes of requesting J-1 visa waivers--and federal agencies about waivers they requested in fiscal years 2003-05.
section_title: What GAO Found
paragraphs: The use of J-1 visa waivers remains a major means of placing physicians in underserved areas of the United States. States and federal agencies reported requesting more than 1,000 waivers in each of the past 3 years. In contrast to a decade ago, states are now the primary source of waiver requests for physicians to practice in underserved areas, accounting for more than 90 percent of such waiver requests in fiscal year 2005. The number of waivers individual states requested that year, however, varied considerably. For example, about one-quarter of the states requested the maximum of 30 waivers, while slightly more than a quarter requested 10 or fewer. Regarding the annual limit on waivers, about 80 percent of the states--including many of those that requested the annual limit or close to it--reported the 30-waiver limit to be adequate for their needs. About 13 percent reported that this limit was less than adequate. Of the 44 states that did not always request the limit, 25 reported that they would be willing to have their unused waiver allotments redistributed, at least under certain circumstances. In contrast, another 14 states reported that they would not be willing to have their unused waiver allotments redistributed. These states cited concerns such as the possibility that physicians seeking waivers would wait until a redistribution period opened and apply to practice in preferred locations in other states.

section_title: Letter
paragraphs: I am pleased to be here today as you consider the states’ authority to  request J-1 visa waivers for foreign physicians to practice in underserved  areas of the United States. As you know, many communities throughout  the country—including rural and low-income urban areas—experience  difficulties in attracting physicians to meet their health care needs. To  address this problem, states and federal agencies have turned to foreign  physicians who have just completed their graduate medical education in  the United States. Many of these foreign physicians entered the United  States on temporary visas, called J-1 visas, and are ordinarily required to  return to their home country or country of last legal residence for 2 years  when they complete their graduate medical education. This foreign  residence requirement, however, can be waived by the Department of  Homeland Security in certain circumstances, including at the request of a  state or federal agency if the physician agrees to practice in an  underserved area for at least 3 years. By law, up to 30 J-1 visa waivers per  year can be granted in response to each state’s requests—regardless of the  state’s size or need for physicians. There is no limit in the number of J-1  visa waivers that may be granted in response to federal agencies’ requests.
In 1996, we reported that the number of J-1 visa waivers requested by  states and federal agencies for physicians to work in underserved areas  had risen dramatically—from 70 in 1990 to more than 1,300 in 1995—and  that requesting waivers had become a major means of providing  physicians for underserved areas. We estimated that, in 1995, the number  of waiver physicians practicing in underserved areas exceeded the number  of physicians practicing there through the National Health Service Corps  (NHSC) programs—the Department of Health and Human Services’ (HHS)  primary mechanism for addressing shortages of physicians and other  primary care health professionals. We reported that slightly over half of  these waiver physicians practiced internal medicine, and many also had  medical subspecialties. Further, more than one-third of the waiver  physicians practiced in nonprofit community and migrant health centers,  while nearly one-fourth were in private practices. We also noted that  controls for ensuring that these physicians met the terms of their waiver  agreements were somewhat weak. In the 10 years since our earlier report,  the Department of Agriculture and the Department of Housing and Urban  Development—which together requested more than 80 percent of the J-1  visa waivers for physicians in 1995—decided to stop doing so.
You and others have expressed an interest in determining how J-1 visa  waivers are being used to place physicians in underserved areas. We were  also asked to report on one option that has been raised as a possible  means to accommodate those states that have expressed an interest in  having more than 30 waivers granted at their request each year—the  possibility of redistributing some states’ unused waiver allotments. My  remarks today are based on preliminary findings from our ongoing work  and will focus on (1) the number of waivers requested by states in relation  to the number requested by federal agencies; (2) practice specialties and  settings of physicians whose waivers were requested by states; (3) states’  activities to monitor compliance with waiver agreements; and (4) states’  views on both the adequacy of the annual limit of 30 J-1 visa waivers per  state and on having unused waiver allotments redistributed, which would  require legislation.
To address these issues, we administered a Web-based survey to the  entities eligible to request J-1 visa waivers for physicians under the  authority granted to the states—the 50 states, the District of Columbia,  Puerto Rico, Guam, and the U.S. Virgin Islands (hereafter referred to as  “states”). We sent the survey to the official in each state authorized to sign  waiver requests or to his or her designee. The survey asked for  information on states’ J-1 visa waiver requests for fiscal years 2003  through 2005 and on their views on the adequacy of the 30-waiver limit and  having their unused waiver allotments redistributed. We received a  100 percent response rate. We reviewed the surveys for internal  consistency and followed up with respondents to resolve discrepancies  and clarify responses; however, we did not verify the accuracy of the  responses. We also reviewed relevant laws, regulations, and documents,  and interviewed officials involved in reviewing and granting waivers at the  Departments of State and Homeland Security. We also interviewed  officials at HHS and the Educational Commission for Foreign Medical  Graduates—the private, nonprofit organization that sponsors foreign  physicians as exchange visitors for graduate medical education. We shared  facts included in this statement with officials at the Department of State,  the Department of Homeland Security, and HHS and made changes as  appropriate. We conducted our work from August 2005 through May 2006  in accordance with generally accepted government auditing standards.
In summary, we found that the use of J-1 visa waivers remains a major  means of placing physicians in underserved areas of the United States,  with more than 1,000 waivers requested in each of the past 3 years for  physicians to practice in nearly every state. In fiscal year 2005, states made  more than 90 percent of these waiver requests. About 44 percent of the  states’ waiver requests were for physicians to practice exclusively primary  care, while about 41 percent were for physicians to practice exclusively  nonprimary care specialties, such as anesthesiology or cardiology.  Regarding practice settings, more than three-fourths of the states’ waiver  requests were for physicians to work in hospitals or private practices.  While states do not have explicit responsibility for monitoring physicians’  compliance with their waiver agreements, most states reported that they  had conducted some monitoring activities, such as requiring periodic  reports on patients treated and conducting site visits to the practice  locations. Six states—which together accounted for about   13 percent of all state waiver requests in fiscal year 2005—reported that  their states had not conducted any monitoring activities that year. Finally,  regarding the states’ authority to request waivers, about 80 percent of the  states—including many of the states that requested the annual limit or  close to it—reported the 30-waiver limit was adequate for their needs.  About 13 percent, however, reported that this limit was less than adequate.  Of the 44 states that did not always request the limit, 25 reported that they  would be willing to have their unused waiver allotments redistributed, at  least under certain circumstances, if authorized by law. In contrast,  another 14 states reported that they would not be willing to have their  unused waiver allotments redistributed. These states cited concerns such  as the possibility that physicians seeking waivers would wait until a  redistribution period opened and apply to practice in preferred locations  in other states.
subsections: section_title: Background
paragraphs: Many foreign physicians who enter U.S. graduate medical education  programs do so as participants in the Department of State’s Exchange  Visitor Program—an educational and cultural exchange program aimed at  increasing mutual understanding between the peoples of the United States  and other countries. Participants in the Exchange Visitor Program enter  the United States with J-1 visas. More than 6,100 foreign physicians with  J-1 visas took part in U.S. graduate medical education programs during  academic year 2004–05. This number was about 40 percent lower than a  decade earlier, when about 10,700 foreign physicians with J-1 visas were in  U.S. graduate medical education programs.
Physicians participating in graduate medical education on J-1 visas are  required to return to their home country or country of last legal residence  for at least 2 years before they may apply for an immigrant visa, permanent  residence, or certain nonimmigrant work visas. They may, however,  obtain a waiver of this requirement from the Department of Homeland  Security at the request of a state or federal agency, if the physician has  agreed to practice in, or work at a facility that treats residents of, an  underserved area for at least 3 years.
States were first authorized to request J-1 visa waivers on behalf of foreign  physicians in October 1994. Initially, states were authorized to request  waivers for up to 20 physicians each fiscal year; in 2002, the annual limit  was increased to 30 waivers per state. Physicians who receive waivers  may work in various practice settings, including federally funded health  centers and private hospitals, and they may practice both primary care and  nonprimary care specialties. States and federal agencies may impose  additional limitations on their programs beyond federal statutory  requirements, such as limiting the number of requests they will make for  physicians to practice nonprimary care specialties.
Obtaining a J-1 visa waiver through a state request involves multiple steps.  A physician must first secure a bona fide offer of employment from a  health care facility that is located in, or that treats residents of, an  underserved area. The physician, the prospective employer, or both then  submit an application to a state to request the waiver. The state submits a  request for the waiver to the Department of State. If the Department of  State recommends the waiver, it forwards its recommendation to the  Department of Homeland Security’s U.S. Citizenship and Immigration  Services (USCIS). USCIS is responsible for making the final determination  and notifying the physician when a waiver is granted. According to  officials involved in recommending and approving waivers at the  Department of State and USCIS, after review for compliance with  statutory requirements and security issues, nearly all states’ waiver  requests are recommended and approved. Once physicians are granted  waivers, they must work at the site specified in their waiver applications  for a minimum of 3 years. During this period, although states do not have  explicit responsibility for monitoring physicians’ compliance with the  terms and conditions of their waivers, states may conduct monitoring  activities at their own initiative.
For purposes of J-1 visa waivers, HHS has specified two types of  underserved areas in which waiver physicians may practice: health  professional shortage areas (HPSAs) and medically underserved areas and  populations (MUA/Ps). In general, HPSAs are areas, population groups  within areas, or facilities that HHS has designated as having a shortage of  primary care health professionals and are identified on the basis of, among  other factors, the ratio of population to primary care physicians. MUA/Ps  are areas or populations that HHS has designated as having shortages of  health care services and are identified using several factors in addition to  the availability of primary care providers. In 2004, Congress gave states  the flexibility to use up to 5 of their 30 waiver allotments each year— which we call “flexible waivers”—for physicians to work in facilities that  serve patients who reside in a HPSA or MUA/P, regardless of the facilities’  location.
No one federal agency is responsible for managing or tracking states’ and  federal agencies’ use of J-1 visa waivers to place physicians in underserved  areas. Further, no comprehensive data are available on the total number of  waivers granted for physicians to practice in underserved areas. HHS’s  Health Resources and Services Administration is the primary federal  agency responsible for improving access to health care services, both in  terms of designating underserved areas and in administering programs— such as the NHSC programs—to place physicians and other providers in  them. However, HHS’s oversight of waiver physicians practicing in  underserved areas has generally been limited to those physicians for  whom HHS has requested J-1 visa waivers.
section_title: Waivers Remain a Major Means for Providing Physicians, and States Request Most Waivers
paragraphs: J-1 visa waivers continue to be a major means of supplying physicians to  underserved areas in the United States, with states and federal agencies  reporting that they requested more than 1,000 waivers in each of fiscal  years 2003 through 2005. We estimated that, at the end of fiscal year 2005,  the number of physicians practicing in underserved areas through the use  of J-1 visa waivers was roughly one and a half times the number practicing  there through NHSC programs.
In contrast to our findings a decade ago, states are now the primary source  of waiver requests for physicians to practice in underserved areas. In fiscal  year 2005, more than 90 percent of the waiver requests for physicians were  initiated by the states, compared with fewer than 10 percent in 1995. (See  fig. 1.) Every state except Puerto Rico and the U.S. Virgin Islands reported  requesting waivers for physicians in fiscal year 2005, for a total of 956  waiver requests. In 1995—the first full year that states had authority to  request waivers—nearly half of the states made a total of 89 waiver  requests.
During the past decade, the two federal agencies that requested the most  waivers for physicians to practice in underserved areas in 1995—the  Department of Agriculture and the Department of Housing and Urban  Development—have discontinued their programs. These federal agencies  together requested more than 1,100 waivers for physicians to practice in 47  states in 1995, providing a significant source of waiver physicians for some  states. For example, these federal agencies requested a total of 149  waivers for physicians to practice in Texas, 134 for New York, and 105 for  Illinois in 1995. In fiscal year 2005, the three federal agencies that  requested waivers for physicians to practice in underserved areas—the  Appalachian Regional Commission, the Delta Regional Authority, and  HHS—requested a total of 56 waivers for physicians to practice in 15  states.
With diminished federal participation, states now obtain waiver physicians  primarily through the 30 waivers they are allotted each year. The number  of waivers states actually requested, however, varied considerably among  the states in fiscal years 2003 through 2005. For example, in fiscal year  2005, about one-quarter of the states requested the maximum of 30  waivers, while slightly more than a quarter requested 10 or fewer (see fig.  2). Collectively, the 54 states requested 956 waivers, or roughly 60 percent  of the maximum of 1,620 waivers that could have been granted at their  request.
section_title: States Requested Waivers for Physicians to Work in a Variety of Practice Specialties and Settings
paragraphs: Of the waivers states requested in fiscal year 2005, about 44 percent were  for physicians to practice exclusively primary care, while about 41 percent  were for physicians to practice exclusively in nonprimary care specialties,  such as anesthesiology or cardiology. An additional 7 percent were for  physicians to practice psychiatry. A small proportion of requests   (5 percent) were for physicians to practice both primary and nonprimary  care—for example, for individual physicians who practice both internal  medicine and cardiology (see fig. 3).
More than 90 percent of the states that requested waivers in fiscal year  2005 reported that, under their policies in place that year, nonprimary care  physicians were eligible to apply for waiver requests. Some of these states  limited these requests. For example, some states restricted the number of  hours a physician could practice in a nonprimary care specialty. Further,  two states reported that they accepted applications from, and requested  waivers for, primary care physicians only.
Regarding practice settings, more than three-fourths of the waivers  requested by states in fiscal year 2005 were for physicians to practice in  hospitals and private practices, including group practices. In addition,   16 percent were for physicians to practice in federally qualified health  centers—facilities that provide primary care services in underserved  areas—or rural health clinics—facilities that provide outpatient primary  care services in rural areas (see fig. 4). More than 80 percent of the states  requesting waivers in fiscal year 2005 reported requiring facilities where  the physicians worked—regardless of practice setting—to accept some  patients who were uninsured or covered by Medicaid.
section_title: Most States Reported Conducting Some Monitoring Activities
paragraphs: Although states do not have explicit responsibility for monitoring  physicians’ compliance with the terms and conditions of their waivers, in  fiscal year 2005, more than 85 percent of the states reported conducting at  least one monitoring activity. The most common activity—reported by 40  states—was to require periodic reports by the physician or the employer  (see table 1). Some states required these reports to specify the number of  hours the physician worked or the types of patients—for example,  whether they were uninsured—whom the physician treated.
Not all states that requested waivers conducted monitoring activities. Six  states, which collectively accounted for about 13 percent of all state  waiver requests in fiscal year 2005, reported that they conducted no  monitoring activities in that year.
section_title: Most States Reported That the Annual Limit Was Adequate but Reported Differing Views on Having Allotments Redistributed
paragraphs: The majority of the states reported that the annual limit of 30 waivers per  state was at least adequate to meet their needs for J-1 visa waiver  physicians. When asked about their needs for additional waiver  physicians, however, 11 states reported needing more. Furthermore, of the  44 states that did not request their 30-waiver limit in each of fiscal years  2003 through 2005, more than half were willing, at least under certain  circumstances, to have their unused waiver allotments redistributed to  other states in a given year. Such redistribution would require legislation.  Fourteen states reported that they would not be willing to have their  states’ unused waiver allotments redistributed.
subsections: section_title: Most States Reported That the Annual Waiver Limit Was Adequate, While Some Reported the Need for More
paragraphs: About 80 percent of the states reported that the annual limit of 30 waivers  per state was adequate or more than adequate to meet their needs for J-1  visa waiver physicians. However, 13 percent of the states reported that the  30-waiver limit was less than adequate (see fig. 5).
Among the 16 states that requested 29 or 30 waivers in fiscal year 2005, 10  states reported that the annual limit was at least adequate for their needs.  The other 6 states that requested all or almost all of their allotted waivers  that year reported that the 30-waiver limit was less than adequate.
As mentioned earlier, states can use up to 5 of their waiver allotments for  physicians to work in facilities located outside of HPSAs and MUA/Ps, as  long these facilities serve patients who live in these underserved areas.  While we inquired about states’ views on the adequacy of the annual limit  on these flexible waivers, fewer than half of the states reported requesting  flexible waivers in fiscal year 2005—the first year they were authorized to  do so. When asked about the annual limit of 5 flexible waivers, half of the  states (27 states) reported that this limit was at least adequate, but nearly  one-third (17 states) did not respond or reported that they were unsure of  their need for flexible waivers. The remaining 10 states reported that the  annual limit of 5 flexible waivers was less than adequate (see fig. 6). Of  these 10 states, 8 had also reported that the annual limit of 30 waivers per  state was at least adequate for their needs, suggesting that some states  may be more interested in increasing the flexibility with which waivers  may be used than in increasing the overall number of waivers each year.
In addition to commenting on the adequacy of the annual waiver limits,  states estimated their need for additional physicians under their J-1 visa  waiver programs. Specifically, 11 states (20 percent) estimated needing  between 5 and 50 more waiver physicians each. Collectively, these   11 states reported needing 200 more waiver physicians (see table 2).
Although 10 states reported requesting the annual limit of 30 waivers in  each of fiscal years 2003 through 2005, the large majority (44 states) did  not. When asked to provide reasons why they did not use all 30, many of  these states reported that they received fewer than 30 applications that  met their requirements for physicians seeking waivers through their state  J-1 visa waiver programs. Some states, however, offered further  explanations, which touched upon difficulties attracting physicians to the  state, low demand for waiver physicians among health care facilities or  communities, and mismatches between the medical specialties  communities needed and those held by the physicians seeking waivers.  For example:    Difficulties attracting waiver physicians: One state commented that the  increase in the annual limit on waivers from 20 to 30 in 2002 opened more  positions in other states, contributing to a decrease in interest among  physicians seeking waivers to locate in that state. Two states suggested  that because they had no graduate medical education programs or a low  number of them, fewer foreign physicians were familiar with their states,  affecting their ability to attract physicians seeking J-1 visa waivers.
Low demand for waiver physicians: Many states noted low demand for  foreign physicians among health care facilities or communities in the  states. Two of these states commented that they had relatively few  problems recruiting U.S. physicians. Another state commented that health  care facilities—particularly small facilities and those located in rural  areas—may be reluctant to enter into the required 3-year contracts with  waiver physicians because of their own budget uncertainties.
Lack of physicians with needed specialties: One state commented that  most communities in the state need physicians trained in family medicine  and that few physicians with J-1 visas have that training. Similarly, another  state noted a lack of demand among the health care facilities in the state  for the types of medical specialties held by physicians seeking waivers.
In response to a question about whether they had observed any significant  changes in the number of physicians seeking J-1 visa waivers, 15 states  reported seeing less interest from physicians, or fewer applications, since  2001. Some states suggested that the decline might be due to an overall  reduction in the number of physicians with J-1 visas who were in graduate  medical education programs. Three states mentioned the possibility that  more physicians may be opting to participate in graduate medical  education on an H-1B visa, which does not have the same foreign  residence requirement as a J-1 visa.
section_title: States’ Views Differed on Having Unused Waiver Allotments Redistributed
paragraphs: Of the 44 states that did not use all of their waiver allotments in each of  fiscal years 2003 through 2005, slightly over half (25 states) reported that  they would be willing, at least under certain circumstances, to have their  unused waiver allotments redistributed to other states. In contrast, about  one-third of the states with unused waiver allotments (14 states) reported  that they would not be willing to have their unused waiver allotments  redistributed. (See table 3 and, for further details on states’ responses, see  app. I.)
The 14 states that reported they would be willing under certain  circumstances to have their unused waiver allotments redistributed listed  a variety of conditions under which they would be willing to do so, if  authorized by law. These conditions centered around the timing for  redistribution, the approach for redistribution, and the possibility for  compensation.
Timing of redistribution: Seven states reported that their willingness to  have their unused waiver allotments redistributed depended in part on  when the redistribution would occur in a given year. Their comments  suggested concerns about states being asked to give up unused waiver  allotments before having fully determined their own needs for them. For  example, three states reported that they would be willing to release at  least a portion of their unused waiver allotments midway through the  fiscal year. One state reported that it would be willing to have its unused  waiver allotments redistributed once the state reached an optimal  physician-to-population ratio. Finally, two states specified that states  benefiting from any redistribution should be required to use the  redistributed waivers within the same fiscal year.
Approach for redistribution: Three states reported that their willingness  to have their unused waiver allotments redistributed depended on how the  redistribution would be accomplished. Two states reported a willingness  to do so if the allotments were redistributed on a regional basis—such as  among midwestern or southwestern states. Another state reported that it  would be willing to have its unused waiver allotments redistributed to  states with high long-term vacancy rates for physicians. This state was also  willing to have its unused waiver allotments redistributed in emergency  relief situations, such as Hurricane Katrina’s aftermath, to help attract  physicians to devastated areas.
Possibility for compensation: Two states stated that they would be  willing to have their unused waiver allotments redistributed if they were  somehow compensated. One state remarked that it would like more  flexible waiver allotments, equal to the number of unused waiver  allotments that were redistributed. The other state did not specify the form  of compensation.
Other issues: One state commented that it would be willing to have its  unused waiver allotments redistributed as long as redistribution did not  affect the number of waivers it could request in future years. Another state  responded that any provision to have unused waiver allotments  redistributed would need to be pilot-tested for 2 years so that its effect  could be evaluated.
The 14 states that reported that they would not be willing to have their  unused waiver allotments redistributed to other states cited varied  concerns. Several states commented that, because of physicians’ location  preferences and differences in states’ J-1 visa waiver program  requirements, a redistribution of unused waiver allotments could possibly  reduce the number of physicians seeking waivers to practice in certain  states.
Physician location preferences: Three states commented that physicians  seeking J-1 visa waivers might wait until a redistribution period opened so  that they could apply for waivers to practice in preferred states. As one  state put it, if additional waivers were provided to certain states, a  physician might turn down the “number 15 slot” in one state to accept the  “number 40 slot” in another. This concern was also raised by four states  that reported they were willing to have their unused waiver allotments  redistributed under certain circumstances; two of these states specifically  mentioned the possible negative impact that redistribution could have on  rural areas.
Differences in state program requirements: One state commented that  until state requirements for waivers were made consistent among states,  having unused waiver allotments redistributed would benefit states with  more lenient requirements or force states with more stringent  requirements to change their policies. While this state did not specify what  it considered to be stringent or lenient requirements, substantial  differences in state programs do exist. For example, some states restrict  their waiver requests solely to primary care physicians, while others place  no limits on the number of allotted waivers they request for nonprimary  care physicians. In another example, four states require 4- or 5-year  contracts for all physicians or for physicians in certain specialties. One  state commented that if it lost an unused waiver allotment to a state with  more lenient requirements, it would have given away to another state a  potential resource that it had denied its own communities.
Mr. Chairman, this concludes my prepared statement. I will be happy to  answer any questions that you or Members of the Subcommittee may have.
section_title: Contact and Acknowledgments
paragraphs: For information regarding this testimony, please contact Leslie G.  Aronovitz at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Kim Yamane, Assistant Director; Ellen W. Chu;  Jill Hodges; Julian Klazkin; Linda Y.A. McIver; and Perry G. Parsons made  key contributions to this statement.
section_title: Appendix I: State Responses to Selected Survey Questions
paragraphs: Much less than adequate  No  States that requested 30 waivers in each of fiscal years 2003 through 2005 were not asked about  their willingness to have unused waiver allotments redistributed to other states.
section_title: Related GAO Products
paragraphs: State Department: Stronger Action Needed to Improve Oversight and  Assess Risks of the Summer Work Travel and Trainee Categories of the  Exchange Visitor Program. GAO-06-106. Washington, D.C.: October 14,  2005.
Health Workforce: Ensuring Adequate Supply and Distribution Remains  Challenging. GAO-01-1042T. Washington, D.C.: August 1, 2001.
Health Care Access: Programs for Underserved Populations Could Be  Improved. GAO/T-HEHS-00-81. Washington, D.C.: March 23, 2000.
Foreign Physicians: Exchange Visitor Program Becoming Major Route  to Practicing in U.S. Underserved Areas. GAO/HEHS-97-26. Washington,  D.C.: December 30, 1996.
Health Care Shortage Areas: Designations Not a Useful Tool for  Directing Resources to the Underserved. GAO/HEHS-95-200. Washington,  D.C.: September 8, 1995.
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