(PDF provides a complete and accurate display of this text.)
109th Congress Report
HOUSE OF REPRESENTATIVES
2d Session 109-715
PHYSICIANS FOR UNDERSERVED AREAS ACT
December 5, 2006.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
Mr. Sensenbrenner, from the Committee on the Judiciary, submitted the
R E P O R T
[To accompany H.R. 4997]
[Including cost estimate of the Congressional Budget Office]
The Committee on the Judiciary, to whom was referred the bill
(H.R. 4997) to permanently authorize amendments made by the
Immigration and Nationality Technical Corrections Act of 1994
for the purpose of permitting waivers of the foreign country
residence requirement with respect to certain international
medical graduates, having considered the same, report favorably
thereon with amendments and recommend that the bill as amended
The amendments are as follows:
Strike all after the enacting clause and insert the
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Physicians for Underserved Areas
SEC. 2. WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT WITH RESPECT TO
INTERNATIONAL MEDICAL GRADUATES.
Section 220(c) of the Immigration and Nationality Technical
Corrections Act of 1994 (8 U.S.C. 1182 note; Public Law 103-416) (as
amended by section 1(a)(1) of Public Law 108-441) is amended by
striking ``June 1, 2006.'' and inserting ``June 1, 2008.''.
SEC. 3. EFFECTIVE DATE.
The amendment made by section 2 shall take effect as if enacted on
May 31, 2006.
Amend the title so as to read:
A bill to extend for 2 years the authority to grant
waivers of the foreign country residence requirement with
respect to certain international medical graduates.
Purpose and Summary
H.R. 4997 reauthorizes for two years the program whereby
aliens who participate in medical residencies in the United
States on exchange program visas (known as ``J'' visas) do not
have to leave the U.S. at the conclusion of their residencies
to reside abroad for two years if they agree to practice
medicine for three years in an area designated by the Secretary
of Health and Human Services (``HHS'') as having a shortage of
health care professionals.\1\
\1\ This program is sometimes referred to as the ``Conrad 30''
program, after Senator Conrad, the original author of the program.
Background and Need for the Legislation
Aliens who participate in medical residencies in the United
States on ``J'' exchange program visas must generally leave the
U.S. at the conclusion of their residencies to reside abroad
for two years before they can be eligible for permanent
residence or status as ``H-1B'' or ``L'' visa nonimmigrants.\2\
The intent behind this policy is to encourage American-trained
foreign doctors to return home to improve health conditions and
advance the medical profession in their native countries.
\2\ Immigration and Nationality Act Sec. 212(e)(iii).
In 1994, Congress created a waiver (until June 1, 1996) of
the two-year foreign residency requirement when a state
department of public health requested it for foreign doctors
who committed to practice medicine for no less than three years
in a geographic area or areas designated by the Secretary of
HHS as having a shortage of health care professionals.\3\ The
number of foreign doctors who could receive the waiver was
limited to 20 per state. In 1996, Congress extended the waiver
to June 1, 2002.\4\ In 2002, Congress extended the waiver until
June 1, 2004.\5\ At the same time, the numerical limitation on
waivers was increased to 30 per state.
\3\ See the Immigration and Nationality Technical Corrections Act,
Pub. L. No. 103-416, Sec. 220 (1994).
\4\ See the Illegal Immigration Reform and Immigrant Responsibility
Act, Pub. L. No. 104-208, Sec. 622 (1996).
\5\ See the 21st Century Department of Justice Appropriations
Authorization Act, Pub. L. No. 107-273, Sec. 11018 (2002). Section
11018 incorporated the language of H.R. 4858, which was reported by the
House Judiciary Committee on June 24, 2002, and passed the House on
June 25, 2002.
In late 2004, Congress extended the waiver until June 1,
2006.\6\ The extension allows five of each state's 30 waivers
to go to doctors not practicing medicine in areas designated by
the Secretary of HHS as having a shortage of health care
professionals, as long as the doctors receiving the waivers
agree to serve patients living in such areas. Also, if a
physician seeking a waiver will practice specialty medicine,
there must be a shortage of health care professionals able to
provide services in that specialty to the patients who will be
served by the physician. Finally, the extension exempts
physicians from the H-1B numerical cap.
\6\ See Pub. L. No. 108-441.
The waiver requirements are as follows: the Secretary of
Homeland Security may authorize a waiver upon the request of an
interested U.S. government agency or a director of a state
department of public health (or its equivalent) as in the
public interest \7\ if:
\7\ See INA Sec. 212(e).
(1) In the case of an alien who is otherwise contractually
obligated to return to a foreign country, the government of
such country furnishes the U.S. government with a statement in
writing that it has no objection to a waiver;
(2) The alien demonstrates a bona fide offer of full-time
employment at a health facility or health care organization and
that employment has been determined by the Secretary of Health
and Human Services to be in the public interest;
(3) The alien agrees to begin employment within 90 days of
receiving the waiver, and agrees to continue to work for not
less than three years (unless the Secretary determines that
extenuating circumstances exist, such as closure of the
facility or hardship to the alien, which would justify a lesser
period of employment at such facility or organization, in which
case the alien must demonstrate another bona fide offer of
employment at a health care facility or health care
organization for the remainder of the three-year period); and
(4) The alien agrees to practice medicine for the three-
year period only in the geographic area or areas which are
designated by the Secretary of HHS as having a shortage of
health care professionals (except in the case of a request by
the Department of Veterans Affairs or in the case of a request
by an interested Federal agency to employ the alien full-time
in medical research or training) or in a medical facility that
serves patients who live in medically underserved areas (up to
5 waivers per state).
H.R. 4997 reauthorizes in its present form the waiver
program for physicians who receive training in the United
States on a J-visa and agree to practice in underserved areas
until June 1, 2008.
The Subcommittee on Immigration, Border Security, and
Claims held one day of hearings on H.R. 4997 on May 18, 2006.
Testimony was received from: Congressman Jerry Moran; Edward
Slasber, the Center for Workforce Studies; John B. Crosby, the
American Osteopathic Association; and Leslie G. Aronovitz, the
United States Government Accountability Office.
On September 27, 2006, the Committee met in open session
and ordered favorably reported the bill H.R. 4997 with an
amendment by voice vote, a quorum being present.
Vote of the Committee
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, the Committee notes that there
were no recorded votes during the committee consideration of
New Budget Authority and Tax Expenditures
Clause 3(c)(2) of rule XIII of the Rules of the House of
Representatives is inapplicable because this legislation does
not provide new budgetary authority or increased tax
Congressional Budget Office Cost Estimate
In compliance with clause 3(c)(3) of rule XIII of the Rules
of the House of Representatives, the Committee sets forth, with
respect to the bill, H.R. 4997, the following estimate and
comparison prepared by the Director of the Congressional Budget
Office under section 402 of the Congressional Budget Act of
September 28, 2006.
Hon. F. James Sensenbrenner, Jr.,
Chairman, Committee on the Judiciary,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 4997, the
Physicians for Underserved Areas Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Mark
Donald B. Marron,
H.R. 4997--Physicians for Underserved Areas Act
CBO estimates that implementing H.R. 4997 would result in
no significant net cost to the federal government. The bill
would affect direct spending, but we estimate that any effects
would be insignificant. H.R. 4997 contains no intergovernmental
or private-sector mandates as defined in the Unfunded Mandates
Reform Act and would not affect the budgets of state, local, or
Until June 1, 2006, foreign students attending medical
school in the United States were permitted to remain after
graduation if they agreed to work for at least three years in
certain regions of the country considered to be underserved by
physicians or if they accepted employment with certain federal
agencies. That program was limited to 30 individuals a year for
each state that participated in the program. Under current law,
such individuals must return to their native countries. H.R.
4997 would reestablish this program through June 1, 2008.
Based on the participation of foreign medical students in
those employment programs in recent years, CBO expects that the
bill's provisions would affect fewer than 2,000 persons
annually. The Bureau of Citizenship and Immigration Services
(CIS) would collect fees to provide work permits for those
individuals. CIS fees are classified as offsetting receipts (a
credit against direct spending). The agency is authorized to
spend such fees without further appropriation, so the net
impact on CIS spending would be insignificant.
The CBO staff contact for this estimate is Mark Grabowicz.
This estimate was approved by Robert A. Sunshine, Assistant
Director for Budget Analysis.
Performance Goals and Objectives
The Committee states that pursuant to clause 3(c)(4) of
rule XIII of the Rules of the House of Representatives, H.R.
4997 would extend for two years the program whereby aliens who
participate in medical residencies in the United States on
``J'' exchange program visas do not have to leave the U.S. at
the conclusion of their residencies to reside abroad for two
years if they agree to practice medicine for three years in an
area designated by the Secretary of Health and Human Services
as having a shortage of health care professionals.
Constitutional Authority Statement
Pursuant to rule XI, clause 2(1)(4) of the Rules of the
House of Representatives, the Committee finds the authority for
this legislation in Article I, section 8 of the Constitution.
Section-by-Section Analysis and Discussion
The following discussion describes the bill as reported by
Sec. 1. Short title
This bill may be cited as the ``Physicians for Underserved
Sec. 2. Waiver of foreign country residency requirement with respect to
international medical graduates
This section extends for two years the program whereby
aliens who participate in medical residencies in the United
States on ``J'' exchange program visas do not have to leave the
U.S. at the conclusion of their residencies to reside abroad
for two years if they agree to practice medicine for three
years in an area designated by the Secretary of Health and
Human Services as having a shortage of health care
Sec. 3. Effective date
This section makes the amendments in Section 2 effective as
if they had been enacted on May 31, 2006.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
SECTION 220 OF THE IMMIGRATION AND NATIONALITY TECHNICAL CORRECTIONS
ACT OF 1994
SEC. 220. WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT WITH RESPECT
TO INTERNATIONAL MEDICAL GRADUATES.
(a) * * *
* * * * * * *
(c) Effective Date.--The amendments made by this section
shall apply to aliens admitted of the United States under
section 101(a)(15)(J) of the Immigration and Nationality Act,
or acquiring such status after admission to the United States,
before, on, or after the date of enactment of this Act and
before [June 1, 2006.] June 1, 2008.
WEDNESDAY, SEPTEMBER 27, 2006
House of Representatives,
Committee on the Judiciary,
The Committee met, pursuant to notice, at 10:09 a.m., in
Room 2141, Rayburn House Office Building, the Honorable F.
James Sensenbrenner, Jr. (Chairman of the Committee) presiding.
Chairman Sensenbrenner. The Committee will be in order. A
working quorum is present.
I would like to note that this will likely be the final
Committee markup during the 109th Congress, and my last as
Additionally, this will be the last markup for several
esteemed members of the Committee who are planning to move on
from the halls of Congress. I would like to recognize each of
these individuals and to thank them for their service to the
nation and to this Committee.
Chairman Henry Hyde will be retiring at the end of this
year after 31 years of service representing the 6th District of
Illinois. He has been a member of the Judiciary Committee
throughout his entire congressional tenure, and, as we all
know, he served very capably as Chairman from 1995 to 2001, and
as Chairman of the International Relations Committee for the
past 6 years. He leaves an impressive legacy, particularly as a
forceful advocate for the rights of the unborn, and will be
greatly missed. We all wish him well as he moves on to the good
life, to find his life after Congress.
Congressman William Jenkins will also be retiring at the
end of this Congress. He has served on the Committee since 1997
when he began his congressional career. Thank you for your
excellent service, and we wish you well.
Congressman Mark Green is currently running to be governor
of the great state of Wisconsin. He has been a valuable member
of the Committee, and I trust that he will ably serve my fellow
Wisconsinites and me as governor. And good luck to you.
In addition, three Committee staff are set to retire at the
end of the year: our majority chief clerk Tish Schwartz,
publishing clerk Joseph McDonald, and our office manager
Michele Utt. Together, they have over 81 years of combined Hill
experience. And thank you all for your years of dedication and
Now, we ain't done yet, so it is time to start on in.
Chairman Sensenbrenner. The next item on the agenda is H.R.
4997, the ``Physicians for Underserved Areas Act,'' for
purposes of markup. And I move its favorable recommendation to
Without objection, the bill will be considered as read and
open for amendment at any point.
[The bill, H.R. 4997, follows:]
Chairman Sensenbrenner. The chair recognizes the gentleman
from Indiana, Mr. Hostettler, the Chairman of the Immigration
Subcommittee, for 5 minutes to explain the bill.
Mr. Hostettler. Thank you, Mr. Chairman.
Today, we are considering H.R. 4997, the ``Physicians for
Underserved Areas Act.'' This legislation authored by our
colleague, Jerry Moran of Kansas, reauthorizes the J-1 Visa
Waiver Program for physicians who agree to work in underserved
areas, which expired on June 1 of this year.
Under current law, foreign doctors may come to the United
States to complete their residency training. Many do so using
the J-1 visa, which is for cultural exchange and training
One of the requirements for physicians who use the J visa
is that the participant return to his or her home country for 2
years upon completion of the training program in the United
States. The purpose of this foreign residency requirement is to
encourage American-trained physicians to return to their
country and improve medical conditions there.
Since 1994, Congress has waived the 2-year foreign
residency requirement for physicians who agree to work in an
underserved area of the United States, as designated by the
Department of Health and Human Services. Each state receives 30
such waivers per year.
The waiver program allows states to recruit foreign-born
physicians to areas that are unable to recruit sufficient
numbers of American physicians. Many communities that might
otherwise have no access to medical services now have
physicians nearby as a result of this program.
It also responds to an overall shortage of physicians in
the United States, a shortage that seems to be growing. Several
months ago, the Subcommittee on Immigration, Border Security,
and Claims examined this legislation, and it was apparent to me
that there is in fact a growing physician shortage in the
However, the J visa waiver program is only a temporary fix
to a much larger problem. Congress must also focus on other
ways to address the shortage. Medical training programs in the
United States should be sufficiently expanded so that we are
training more American physicians here in the United States.
I plan to offer an amendment on behalf of myself and
Ranking Member Sheila Jackson-Lee that would reauthorize the
program for 2 years, rather than permanently.
The physician shortage in the United States is a
multifaceted problem, and I believe we should revisit the issue
from time to time so that we don't lose sight of the real
problems that need to be addressed.
A 2-year reauthorization will also give us the opportunity
to address problems faced by larger states like Texas, where
the need for waivers each year exceeds 30, without
disadvantaging small states.
By reauthorizing the waiver program through this
legislation, we will provide states with some relief to the
physicians shortage they are currently facing, but it is a
temporary fix to a much larger problem.
I am hopeful that this Committee and other Committees of
jurisdiction will work to find ways to educate and train
greater numbers of American physicians, and reduce our reliance
on foreign physicians.
I yield back the balance of my time.
Chairman Sensenbrenner. The gentleman from Michigan, Mr.
Conyers, is recognized for 5 minutes.
Mr. Conyers. Mr. Chairman, I rise in support of H.R. 4997.
I am pleased that we are considering the bill to extend the J-1
Visa Waiver Program for another 2-year period. This visa waiver
program is critically important to bringing essential medical
services to residents of underserved rural and urban areas,
including parts of my own district in Detroit.
The J-1 program allows some foreign doctors who have
completed their medical training in the United States to remain
here to practice medicine for 2 years, if they will serve
patients in the regions of the country that the Federal
Government defines as medically underserved.
These tend to be less-affluent urban areas with high
population densities and insufficient medical services from
general practitioners and specialists, as well as rural areas
that are far from medical centers and may have trouble
attracting enough doctors to meet the community's needs.
These communities are particularly desperate for physician
services because of the growing national shortage of doctors
our own country is facing. A recent Los Angeles Times article
detailed the looming crisis quite well, in medical care in the
United States as demand for medical services explodes. The
article noted industry fears that shortages may become even
more severe over the next decade due to the flat medical school
enrollments, aging baby boomers, and the high number of doctors
headed for retirement.
While some communities enjoy a glut of physicians, one in
five Americans live in rural or urban areas with so few doctors
that the Federal Government has classified these regions as
medically underserved. It is these Americans that foreign
doctors assist when they get a J-1 visa to practice medicine in
communities that don't have enough American doctors.
I do believe we need to make improvements in this program
so that it better meets the needs of the underserved. Right
now, some states who receive J-1 doctors through the Conrad 30
Program don't use their allotment of 30 waivers each year,
while other states find that 30 waivers are insufficient to
meet the medical needs of their communities.
In addition, some states may not need 30 waivers, but other
states have trouble recruiting all of the doctors they need.
The result is that some citizens are still unable to get
essential medical care.
We need a plan that ensures that states having trouble
recruiting enough doctors will be able to fill their allotment
for J-1 doctors, and secondly, ensures that states which fill
their annual allotment of J-1 doctors can get more of them to
meet their needs, without impinging on any other state.
In this way, the needs of all states, and most importantly
all of the citizens in underserved areas, can be met until our
medical schools in this country are able to increase the number
of graduates to meet our domestic needs.
I am pleased that the Subcommittee Chairman Hostettler and
Ranking Member Jackson-Lee are mutually pledged to work on a
solution to these additional problems in the coming Congress. I
look forward with them and other colleagues in the House and
Senate to improve, extend and sustain this vital visa program
in the near future.
I return the balance of my time.
Chairman Sensenbrenner. Without objection, all members'
opening statements will appear in the record to this point.
[The prepared statement of Ms. Jackson-Lee follows:]
Prepared Statement of the Honorable Sheila Jackson-Lee, a
Representative in Congress from the State of Texas, and Member,
Committee on the Judiciary
Foreign doctors who want to receive medical training in the United
States on J visas are required to leave the country afterwards. They
must return to their countries for two years before they can receive a
visa to work in the United States as physicians. In 1994, Congress
established a waiver of this requirement. The waiver applies to doctors
who will commit to practicing medicine for no less than three years in
a geographic area designated by the Secretary of Health and Human
Services as having a shortage of health care professionals.
The waiver program has been successful for more than a decade. It
permits each state to obtain waivers permitting up to 30 of these
physicians to work in medically underserved areas. It is not a
permanent program. It sunsetted June 1, 2006. The Physicians for
Underserved Areas Act, H.R. 4997, would reinstate the program and make
The amendment that Rep. Hostettler and I are offering would provide
for a two-year extension instead of making the program permanent. Rep.
Hostettler has agreed to work with me next year on devising a way to
redistribute unused visa waivers.
A distribution problem was revealed by a study that Rep. Hostettler
and I asked the General Accountability Office (GAO) to conduct.
According to the GAO study, the system of providing up to 30 waivers
per state is not working well. A substantial percentage of the states
do not need 30 waivers a year. There were 664 unused waivers in FY2005.
Other states need more than 30 waivers a year for their medically
The states that reported needing more than 30 waivers only want
between 5 and 50 more physicians. Their needs can be met by
redistributing some of the unused waivers, but this must be done
carefully. Some states expressed concern to GAO about redistributing
unused waivers. They are afraid that physicians would wait and apply to
the more popular states that would be receiving the redistributed
waivers. This problem has to be resolved before we can move forward
with the development of a redistribution plan.
I urge you to vote for the amendment to H.R. 4997 that would
provide for a two-year extension and give us time for consideration of
modifications in the program. Thank you.
Chairman Sensenbrenner. Are there any amendments?
The gentleman from Indiana, for what purpose do you seek
Mr. Hostettler. I have an amendment at the desk.
Chairman Sensenbrenner. The clerk will report the
The Clerk. ``Amendment to H.R. 4997, Offered by Mr.
Hostettler of Indiana and Ms. Jackson-Lee of Texas. Page 2,
strike lines 7 and 8 and insert the following''----
[The amendment by Mr. Hostettler and Ms. Jackson-Lee
Mr. Hostettler. Mr. Chairman, I ask unanimous consent that
the amendment be considered as read.
Chairman Sensenbrenner. Without objection, so ordered. The
gentleman is recognized for 5 minutes.
Mr. Hostettler. I thank the Chairman.
Mr. Chairman, this amendment reflects an agreement between
myself and Congresswoman Jackson-Lee, the Ranking Member of the
As you have pointed out, her opening statement will be made
a part of the record. Our colleague, Ms. Jackson-Lee, is in
Houston, attending the funeral of fallen Houston Police Officer
Rodney Joseph Johnson, who was slain in the line of duty.
This amendment reauthorizes the J Visa Waiver Program for
an additional 2 years, as opposed to a permanent
reauthorization. By authorizing the program for 2 years,
Congress will have time to further examine needed changes to
the program and address those changes only after careful
I hope you will join me in supporting this bipartisan
And I yield back the balance of my time.
Chairman Sensenbrenner. The gentleman from Michigan?
Mr. Conyers. Mr. Chairman, I rise in support of the
Chairman Sensenbrenner. The gentleman is recognized for 5
Mr. Conyers. I notice that both our Ranking Member and the
Subcommittee member are in agreement. I agree with the
amendment. I also ask unanimous consent to add into the record
the Los Angeles Times article about the looming crisis.
Chairman Sensenbrenner. Without objection.
[The article follows:]
Mr. Conyers. I turn back the rest of my time.
Chairman Sensenbrenner. The question is on agreeing to the
amendment offered by the gentleman from Indiana, Mr.
Those in favor will say ``aye.''
The ayes appear to have it. The ayes have it. The amendment
is agreed to.
Are there further amendments?
If there are no further amendments, a reporting quorum is
present. The question occurs on the motion to report the bill,
H.R. 4997, favorably, as amended.
All in favor will say ``aye.
The ayes appear to have it. The ayes have it. The motion to
report favorably is agreed to.
Without objection, the bill will be reported favorably to
the House in the form of a single amendment in the nature of a
substitute, incorporating the amendment adopted here today.
Without objection, the staff is directed to make any
technical and conforming changes. And all members will be given
2 days, as provided by the House rules, in which to submit
additional, dissenting, supplemental or minority views.
Chairman Sensenbrenner. For what purpose does the gentleman
from Texas seek recognition?
Mr. Smith. Mr. Chairman, I would like unanimous consent to
speak out of turn for 1 minute.
Chairman Sensenbrenner. Without objection.
Mr. Smith. Mr. Chairman, you are not expecting this, but it
occurs to me that you were nice enough a few minutes ago to pay
tribute to three members of this Committee who are leaving. I
thought this might also be an appropriate time to, frankly, pay
tribute to you and your leadership of the full Committee.
You have, frankly, many legacies. We all know and feel how
much of a workhorse this Committee has been. I checked not too
long ago and determined that the Judiciary Committee is second
only to one other Committee in the number of bills it has sent
to the House floor not under suspension. That is, again, a
tribute to your leadership.
Furthermore, you have fought for all of your jurisdiction
in ways that give a new standard to your cause. You and Mr.
Conyers have done a great job in protecting that jurisdiction.
Finally, Mr. Chairman, as I think everyone knows, you are
an acknowledged top negotiator, one of the best that has ever
served in the House, and we appreciate your efforts in that
Also, your emphasis on oversight should not be overlooked.
There are many times where we have passed legislation and we
really don't follow up to make sure that it is being
implemented in the way we intended. You have done a superb job
in making sure that that oversight has been done, and done in
And finally, Mr. Chairman, I don't know if Phil Kiko is
here, your chief of staff, but he has certainly been an able
support to you and an excellent chief of staff and has helped
all of us achieve our goals.
So just know that your many years of service have been
appreciated, and we hope to have your skills available to us in
the next Congress. [Applause.]
Chairman Sensenbrenner. I thank the gentleman from Texas.
And let me remind him and the other members and those in the
audience that the Constitution says that the statements of the
gentleman from Texas cannot be questioned in any other place.
The purpose for which this markup has been called having
been completed, without objection, the Committee stands
[Whereupon, at 10:50 a.m., the Committee was adjourned.]