International medical graduates (IMGs) are foreign nationals or U.S. citizens who graduate froma medical school outside of the United States. In 2002, the most recent year for which data areavailable, there were 853,187 practicing physicians in the United States. IMGs accounted for 24.7%(210,355) of these, and 27.4% (26,588) of physicians in residency and fellowship programs. (1) Theuse of foreign IMGs in many rural communities of the United States areas has allowed states toensure the availability of medical care to their residents. This report focuses on those IMGs who are foreign nationals, hereafter referred to as foreign medical graduates (FMGs). Many FMGs first entered the United States to receive graduate medicaleducation and training as cultural exchange visitors through the J-1 cultural exchange program. Other ways for FMGs to enter the United States include other temporary visa programs as well aspermanent immigration avenues such as family- or employment-based immigration, the diversitylottery, and humanitarian relief provisions. (2) Thisreport focuses on FMGs entering through the J-1program. Many FMGs enter the United States under the current Educational and Cultural ExchangeVisitor Program on a J-1 nonimmigrant visa. (3) Nonimmigrants are admitted for a specific purposeand a temporary period of time. Most nonimmigrant visa categories are defined in ï¿½101(a)(15) ofthe Immigration and Nationality Act (INA). These visa categories are commonly referred to by theletter and numeral that denotes their subsection in ï¿½101(a)(15), e.g., B-2 tourists, E-2 treatyinvestors, F-1 foreign students, H-1B temporary professional workers, or J-1 cultural exchangeparticipants. (4) The J-1 visa includes nonimmigrantssuch as professors, students, au pairs, researchscholars, camp counselors, and foreign medical graduates. Table 1 provides data on the number of physicians in residency programs as of August 2003. As the table indicates, J visa holders make up 15.8% of IMGs in residency programs. Table 1. Citizenship/Visa Status of Physicians and International Medical Graduates in Residency Programs, August 1, 2003 Source: CRS presentation of data presented in S. Brotherton, P. Rockey, and S. Etzel, "U.S. Graduate Medical Education, 2003-2004," JAMA , vol. 292, no. 9, Sept. 1, 2004. a. A J-2 nonimmigrant is the spouse or child of a J-1 nonimmigrant. As exchange visitors, FMGs can remain in the United States on a J visa until the completion of their training, typically for a maximum of seven years. After that time, they are required to returnhome for at least two years before they can apply to change to another nonimmigrant status or legalpermanent resident (LPR) status. Under current law, a J-1 physician can receive a waiver of thetwo-year home residency requirement in several ways: the waiver is requested by an interested government agency (IGA); the FMG's return would cause extreme hardship to a U.S. citizen or LPRspouse or child; or the FMG fears persecution in the home country based on race, religion, orpolitical opinion. Most J-1 waiver requests are submitted by an IGA and forwarded to the Department of State for a recommendation. If the Department of State recommends the waiver, it is forwarded to U.S.Citizenship and Immigration Service (USCIS) in the Department of Homeland Security (DHS)forfinal approval. (5) Upon final approval by USCIS, thephysician's status is converted to that of anH-1B professional specialty worker, and the individual is counted against the annual H-1B cap of65,000. In instances where the H-1B cap has been met, the physician's J visa status may beextended, and the physician would be granted H-1B status in the following year. An IGA may request a waiver of the two-year foreign residency requirement for an FMG by showing that his or her departure would be detrimental to a program or activity of official interestto the agency. In return for sponsorship, the FMG must submit a statement of "no objection" fromhis or her home country, have an offer of full-time employment, and agree to work in a healthprofessional shortage area or medically underserved area for at least three years. According toUSCIS regulations, the FMG must be in H-1B status while completing the three-year term and mustagree to begin work within 90 days of receipt of the waiver. If an FMG fails to fulfill the three-yearcommitment, he or she becomes subject to the two-year home residency requirement and may notapply for a change to another nonimmigrant, or LPR status until meeting that requirement. Althoughany federal government agency can act as an IGA, the main federal agencies that have been involvedin sponsoring FMGs are the Department of Veterans Affairs (VA), the Department of Health andHuman Services (HHS), the Appalachian Regional Commission (ARC), and the United StatesDepartment of Agriculture (USDA). (6) State healthdepartments may also act as IGAs. Department of Veterans Affairs (VA). The Department of Veterans Affairs allows facility directors to request J-1 waivers in instances whereit is in the interest of the Department and its programs, and efforts to recruit a qualified U.S. citizenor LPR have failed. The facility director must supply documentation of recruitment efforts anddetailed information on applicants who did not qualify for the position. In order for the VA toconsider a waiver application, the applicant must submit copies of his or her medical license, visa,test results, proposed and current clinical privileges, references, curriculum vitae, and current addressand phone numbers. Once a waiver has been approved, the physician must serve for at least threeyears in a VA facility. The facility does not have to be in a designated shortage area. Department of Health and Human Services (HHS). Historically, the Department of Health and Human Services had been veryrestrictive in its sponsorship of J-1 waiver requests. HHS emphasized that the exchange visitorprogram was a way to pass advanced medical knowledge to foreign countries, and that it should notbe used to address medical underservice in the United States. (7) HHS' position was that medicalunderservice should be addressed by programs such as the National Health Service Corps. Prior toDecember 2002, HHS only sponsored waivers for physicians or scientists involved in biomedicalresearch of national or international significance. In December 2002, HHS announced that it wouldbegin sponsoring J-1 waiver requests for primary care physicians and psychiatrists in order toincrease access to healthcare services for those in underserved areas. (8) HHS began accepting waiverapplications on June 12, 2003, but suspended its program shortly after for reevaluation. OnDecember 10, 2003, HHS released new program guidelines, which many maintain are morerestrictive and have limited the states' access to physicians. Appalachian Regional Commission (ARC). Established by Congress in 1965, ARC is a joint federal and state entity charged with, among otherthings, ensuring that all residents of Appalachia have access to quality, affordable health care. Theregion covered by ARC consists of all of West Virginia and parts of Alabama, Georgia, Kentucky,Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee,and Virginia. ARC submits a request for a waiver at the request of a state in its jurisdiction. The waiver must be recommended by the governor of the sponsoring state. In return, the FMG must agree to provideprimary care for at least 40 hours a week for three years at a health professional shortage area facility. The facility must be a Medicare or Medicaid-certified hospital or clinic that also accepts medicallyindigent patients. The facility must prove that it has made a good faith effort to recruit a U.S.physician in the six months preceding the waiver application, and the J-1 physician may not havebeen out of status for more than six months after receiving the J-1 visa. In addition, the physicianmust be licensed by the state in which he or she will be practicing, and must have completed aresidency in family medicine, general pediatrics, obstetrics, general internal medicine, generalsurgery, or psychiatry. The physician must sign an agreement stating that he or she will comply withthe terms and conditions of the waiver, and will pay the employer $250,000 if he or she does notpractice in the designated facility for three years. United States Department of Agriculture (USDA). To help medically underserved rural areas, USDA became a participant in the J-1 waiver programin 1994. It ceased its participation in 2002. While participating in the J-1 waiver program, USDAsponsored over 3,000 waivers for J-1 physicians. As a participant it required that all applicationssubmitted be initiated by a health care facility or state department of health. To qualify for aUSDA-sponsored waiver, the physician was required to have an employment offer of no less thanthree years from a health care facility in a designated medically underserved rural area, and wasrequired to work at least 40 hours a week as a primary care physician. Following the September 11, 2001 terrorist attacks, the USDA Office of the Inspector General recommended that USDA review its participation in the J-1 waiver program. On September 26,2001, the processing of waiver applications was suspended pending the outcome of the review.