<DOC>
[109th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:27608.wais]
PHYSICIANS FOR UNDERSERVED AREAS ACT
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON IMMIGRATION,
BORDER SECURITY, AND CLAIMS
OF THE
COMMITTEE ON THE JUDICIARY
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
ON
H.R. 4997
__________
MAY 18, 2006
__________
Serial No. 109-111
__________
Printed for the use of the Committee on the Judiciary
Available via the World Wide Web: http://judiciary.house.gov
______
U.S. GOVERNMENT PRINTING OFFICE
27-608 WASHINGTON : 2006
_____________________________________________________________________________
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COMMITTEE ON THE JUDICIARY
F. JAMES SENSENBRENNER, Jr., Wisconsin, Chairman
HENRY J. HYDE, Illinois JOHN CONYERS, Jr., Michigan
HOWARD COBLE, North Carolina HOWARD L. BERMAN, California
LAMAR SMITH, Texas RICK BOUCHER, Virginia
ELTON GALLEGLY, California JERROLD NADLER, New York
BOB GOODLATTE, Virginia ROBERT C. SCOTT, Virginia
STEVE CHABOT, Ohio MELVIN L. WATT, North Carolina
DANIEL E. LUNGREN, California ZOE LOFGREN, California
WILLIAM L. JENKINS, Tennessee SHEILA JACKSON LEE, Texas
CHRIS CANNON, Utah MAXINE WATERS, California
SPENCER BACHUS, Alabama MARTIN T. MEEHAN, Massachusetts
BOB INGLIS, South Carolina WILLIAM D. DELAHUNT, Massachusetts
JOHN N. HOSTETTLER, Indiana ROBERT WEXLER, Florida
MARK GREEN, Wisconsin ANTHONY D. WEINER, New York
RIC KELLER, Florida ADAM B. SCHIFF, California
DARRELL ISSA, California LINDA T. SANCHEZ, California
JEFF FLAKE, Arizona CHRIS VAN HOLLEN, Maryland
MIKE PENCE, Indiana DEBBIE WASSERMAN SCHULTZ, Florida
J. RANDY FORBES, Virginia
STEVE KING, Iowa
TOM FEENEY, Florida
TRENT FRANKS, Arizona
LOUIE GOHMERT, Texas
Philip G. Kiko, General Counsel-Chief of Staff
Perry H. Apelbaum, Minority Chief Counsel
------
Subcommittee on Immigration, Border Security, and Claims
JOHN N. HOSTETTLER, Indiana, Chairman
STEVE KING, Iowa SHEILA JACKSON LEE, Texas
LOUIE GOHMERT, Texas HOWARD L. BERMAN, California
LAMAR SMITH, Texas ZOE LOFGREN, California
ELTON GALLEGLY, California LINDA T. SANCHEZ, California
BOB GOODLATTE, Virginia MAXINE WATERS, California
DANIEL E. LUNGREN, California MARTIN T. MEEHAN, Massachusetts
JEFF FLAKE, Arizona
BOB INGLIS, South Carolina
DARRELL ISSA, California
George Fishman, Chief Counsel
Art Arthur, Counsel
Allison Beach, Counsel
Cindy Blackston, Professional Staff
Nolan Rappaport, Minority Counsel
C O N T E N T S
----------
MAY 18, 2006
OPENING STATEMENT
Page
The Honorable John N. Hostettler, a Representative in Congress
from the State of Indiana, and Chairman, Subcommittee on
Immigration, Border Security, and Claims....................... 1
The Honorable Sheila Jackson Lee, a Representative in Congress
from the State of Texas, and Ranking Member, Subcommittee on
Immigration, Border Security, and Claims....................... 2
WITNESSES
The Honorable Jerry Moran, a Representative in Congress from the
State of Kansas
Oral Testimony................................................. 6
Prepared Statement............................................. 8
Mr. Edward Salsberg, Director, Center for Workforce Studies,
Association of American Medical Colleges
Oral Testimony................................................. 9
Prepared Statement............................................. 12
Mr. John B. Crosby, J.D., Executive Director, The American
Osteopathic Association
Oral Testimony................................................. 48
Prepared Statement............................................. 49
Ms. Leslie G. Aronovitz, Director, Health Care, United States
Government Accountability Office
Oral Testimony................................................. 58
Prepared Statement............................................. 60
APPENDIX
Material Submitted for the Hearing Record
Prepared Statement of the Honorable Sheila Jackson Lee, a
Representative in Congress from the State of Texas, and Ranking
Member, Subcommittee on Immigration, Border Security, and
Claims......................................................... 99
Prepared Statement of the Honorable Kent Conrad, a U.S. Senator
from the State of North Dakota................................. 100
Prepared Statement of Gregory Siskind, Chairman, National Health
Care Access Coalition.......................................... 106
Letter to the Honorable Sheila Jackson Lee from Connie Berry,
Manager, Texas Primary Care Office............................. 119
PHYSICIANS FOR UNDERSERVED AREAS ACT
----------
THURSDAY, MAY 18, 2006
House of Representatives,
Subcommittee on Immigration,
Border Security, and Claims,
Committee on the Judiciary,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:04 p.m., in
Room 2141, Rayburn House Office Building, the Honorable John N.
Hostettler (Chairman of the Subcommittee) presiding.
Mr. Hostettler. The Subcommittee will come to order.
Good afternoon. Today's hearing will examine H.R. 4997, the
``Physicians for Underserved Areas Act.'' This legislation is
sponsored by Congressman Jerry Moran, who has joined us today
as a witness.
H.R. 4997 makes permanent the J-1 visa waiver program for
physicians who agree to work in underserved areas--sometimes
referred to as the ``Conrad program'' after the original author
of the program, Senator Kent Conrad.
Under current law, foreign doctors may come to the United
States to complete their residency training. Many do so using
the J-1 visa, which is for cultural exchange and training
programs.
One of the requirements for physicians who use the J visa
is that the participant return to his or her country for 2
years upon completion of the training program in the United
States. The purpose of this foreign residency requirement is to
encourage American-trained physicians to return to their
country and improve medical conditions there.
Since 1994, Congress has waived the 2-year foreign
residency requirements for physicians who agree to work in an
underserved area of the United States as designated by the
Department of Health and Human Services. Each State receives 30
such waivers per year.
The waiver program allows States to recruit physicians to
areas that may be considered unattractive to American
physicians. Many communities that might otherwise have no
access to medical services now have physicians nearby as a
result of this program. It also responds to an overall shortage
of physicians in the United States, a shortage that seems to be
growing.
While today's hearing will address legislation to
reauthorize a visa program for foreign physicians, I believe
Congress must also focus on other ways to address the physician
shortage. First, I am interested to hear from our witnesses
today what is being done to increase the capacity of medical
training programs here in the United States. Educating more
physicians here at home is one obvious way we can alleviate the
shortage.
I'm also interested in the expansion of programs, such as
the National Health Services Corps, which provides incentives
for U.S. physicians to work in underserved areas.
In looking at the J-1 visa waiver program, we must keep in
mind the intent behind the 2-year foreign residency
requirement. We want to make sure that we aren't facilitating
``brain drain'' from countries that desperately need well-
trained medical personnel.
In its 2006 World Health Report, the World Health
Organization cited the migration of health care workers from
poorer countries to richer countries as a major problem whose
``consequences can be measured in lives lost.''
J visas are designed to allow foreigners to participate in
exchange and training programs here in the U.S. and then take
those skills back to their home country. But right now, a
significant portion of these physicians are staying here in the
United States.
Another factor that is complicating the training goal of
the J-1 visa program is that foreign physicians are now using
the H-1B visa to come to the U.S. for their residencies.
Physicians who come to the U.S. on an H-1B visa for the
residency training are not required to return to their home
country for 2 years.
As a result, foreign physicians prefer to use the H-1B and
fewer are using the J-1 visa. With fewer physicians using the
J-1 program, there are fewer available physicians to
participate in the J-1 waiver program to work in underserved
areas, and there are also fewer physicians returning to needier
countries.
I believe we need to closely examine this disparity in
treatment and consider a uniform policy for foreign physicians
who receive training in the U.S. The J-1 visa waiver program
may be helpful in getting physicians to underserved areas, but
it is, hopefully, a temporary fix to a much larger problem.
I am hopeful that this Committee and other Committees of
jurisdiction will work to find ways to educate and train
greater numbers of American physicians and reduce our reliance
on foreign physicians.
At this time, the Chair recognizes the gentlelady from
Texas, the Ranking Member of the Subcommittee, Ms. Jackson Lee,
for purposes of an opening statement.
Ms. Jackson Lee. Thank you very much, Mr. Chairman.
I appreciate this hearing. I appreciate the witnesses. And
you have certainly crafted or laid the parameters down that it
is complex, but it's a good program.
And the legislation that my friend and colleague Mr. Moran
has, has great merit because we do know that there are certain
concerns that you've expressed that I join you in. We don't
want to have a brain drain of some of our developing nations
all over the world. In fact, we want to be partners in good
health care.
But at the same time, we want to ensure the normal flow of
talented physicians in underserved areas, and I might say, with
a State as big as Texas, we're already asking for an increase
or a need that would cover the vast State--vast areas of our
State.
So we know that we have to find a way to answer your
concerns to discern the purpose of the utilization of other
visas versus the J-1. We have to address the question of
overstays, and I might say we have to address the question of
training more American doctors, helping our Nation's medical
schools, and providing resources for nurses in America, and
training and teachers.
But I do believe that this is a valuable program, and I'm
delighted that the GAO is present, Mr. Chairman, because I do
want to acknowledge, as you well know, that Senator Conrad and
myself asked for a GAO study to assess where we are in this
program and how we can make it effective. And I look forward to
your testimony.
I mentioned, again, the legislation of Congressman Jerry
Moran that was introduced just recently, H.R. 4997. And
specifically, it would make the J-1 visa program permanent.
The J visa is used for one of the educational cultural
exchange programs that has become a gateway for foreign medical
graduates to gain admission to the United States as non-
immigrants for the purpose of graduate medical education
training. The visa that most of these physicians enter under is
the J-1 non-immigrant visa.
And let me just say this. I had the opportunity to speak
before the National Convention of Indo-American Physicians and
Pakistan Physicians. They are what the oath that they take
represents. They're healers. They want to do what is right.
But I tell you, one of the number-one issues was what was
happening to the J-1 visa because they wanted to use it in a
positive sense. And I made a commitment in a legislative
manner, which is to say that this Congress would take the J-1
visa program seriously and know of their interest and passion.
One of the doctors in particular was Dr. Kudir, who has
formerly served--or has served as the leadership of the
Pakistan-American doctors. But they wanted it to be
constructive. And they are participants in making the J-1 visa
work, not to abuse it. And I think we should engage physicians
and those who participate in this program to make it work.
The physicians who participate in the J-1 visa programs are
required to return to their home country for a period of at
least 2 years before they can apply for another non-immigrant
visa or legal permanent resident status, unless they're granted
a waiver of this requirement.
In 1994, Senator Kent Conrad established a new basis for
waiver of this requirement with an amendment to the Immigration
and Nationality Act. It was known as then as the Conrad State
20 program. It permitted each State to obtain waivers for 20
physicians by establishing that they were needed in health
professional shortage areas known as HPSAs.
On November 2, 2002, the Conrad 20 program was extended to
2004, and the number of waivers available to the States were
increased to 30. This program, which is now referred to as the
``Conrad 30'' or ``State 30'' program, expired on June 1, 2004.
On December 3, 2004, it was reinstated and extended to June
1, 2006. That is why we're here today, which is only a few
weeks from now. Congressman Moran's Physicians for Underserved
Areas Act would eliminate the need for future extensions by
making the program permanent.
And I might say because of the recounting of the yearly or
every other year extension, it might make sense that we have
the parameters and the strictures or the structure of the
program such that we can address the permanent aspect of it.
When the Conrad 30 Program was established in 1994, most of
those studying the supply of physicians in the United States
were concerned about the distribution of physicians, as opposed
to the total number of doctors being trained. It is now
generally recognized that we're facing a severe physician
shortage. The Health Policy Institute eliminates--estimates
that the shortage could grow to as much as 200,000 by 2020, an
astounding possibility in view of the fact that the physician
population in the United States currently is only about
800,000.
And might I say that I am not bragging about this
catastrophe, it is one. Obviously, we have to do something
outside the jurisdiction of this Committee with our Nation's
medical schools, the encouragement of physicians or medical
students, and certainly health care in America.
But given where we are today, this is a needed program. The
failure to forecast this severe physician shortage may explain
why from 1980 until last year no new medical schools opened in
the United States. According to the Health Policy Institute,
the United States needs to produce an extra 10,000 physicians
per year over the next decade and a half in order to meet the
demands of the country.
This number assumes that the number of foreign-educated
physicians will remain constant. We might need to have ``hug a
physician'' day in America.
Senator Conrad and I have asked the General Accountability
Office to do a survey of State views on the Conrad 30 program.
All 50 States filled out a GAO questionnaire and promptly
returned it to the GAO. One of the GAO investigators will
testify about the results of that survey, and so I'll look
forward to that.
Approximately 80 percent of the States reported that the
annual limit of 30 waivers per State is inadequate. Only 13
percent reported that it is inadequate. Excuse me. I'm sorry.
Eighty percent of the States reported that the annual limit of
30 waivers per State is adequate, and only 13 percent said it
was inadequate.
Eleven States estimated that they need between 5 and 50
more waiver physicians, which would total 200 more waiver
physicians. Forty-four States did not use all of their
allotted, and the total of the unused waivers for the year was
664, which is one of my views of being able to move some of the
waivers from State to State.
The J-1 visa program has been in effect now for more than a
decade. In addition to being a good source of additional
physicians, it ensures that additional physicians will go where
they are most needed, health professional shortage areas in
both rural and urban settings.
I can assure you, Mr. Chairman and to this Committee, that
it is important for us to have this hearing, but more
importantly, to take it seriously and to address the concerns
of our States, but also Americans who need good health care.
And I look forward to admitting certain letters, but I will
hold them for the witnesses' testimony, and I believe that,
together, we can make this program effective and provide the
good health care for all Americans.
With that, I yield back.
Mr. Hostettler. I thank the gentlelady.
The Chair will now introduce members of our panel of
witnesses.
The Honorable Jerry Moran began his career in public
service in the Kansas State Senate, serving 8 years in that
body, including 2 years as majority leader. As the
representative in Congress of Kansas's 1st District, which has
more hospitals than any congressional district in the country,
Mr. Moran has been a leading advocate for health care reform,
rural health care in particular.
Congressman Moran has been supportive of community health
care centers and has introduced additional measures, such as
the Community Pharmacy Preservation Act, which seeks to keep
small-town pharmacies open and accessible.
His efforts in Congress have earned Mr. Moran the top
legislative award from the National Rural Health Association.
He is the sponsor of the bill H.R. 4997, the legislation that
this panel is discussing today.
Edward S. Salsberg began his career in public health in
1984 at the New York State Department of Public Health, where
he served as a bureau director. In 1996, Mr. Salsberg left the
department to found the Center for Health Workforce Studies at
the School of Public Health of the University at Albany of the
State University of New York, where he served as its executive
director.
Mr. Salsberg has authored and co-authored numerous reports
on the health care workforce and has spoken throughout the
country on the topic. He currently serves as director of the
Center for Workforce Studies at the Association of American
Medical Colleges.
John B. Crosby became the executive director of the
American Osteopathic Association in May 1997. Prior to joining
the AOA, he spent 6 years at the American Medical Association
as senior vice president for health policy, where he was
actively involved with policy development and strategic
planning.
He currently serves on the board of directors of the
Chicago Health Policy Research Council and the Health Care
Quality Alliance in Washington, D.C. Mr. Crosby has worked on
health care issues for both the private and public sectors
since 1977. He has served in positions at think tanks, trade
associations, and on Capitol Hill.
Leslie G. Aronovitz began her service to the U.S.
Government Accountability Office at GAO's Atlanta office in
1974. Before working on health and income security issues, Ms.
Aronovitz was an assistant director in GAO's Accounting and
Financial Management Division. There, she directed much of
GAO's work on the quality of audits performed by public
accountants. This work led to important changes in the way the
accounting profession engaged in self-monitoring.
Ms. Aronovitz has served as director of GAO's health care
team for the past 15 years. Among her numerous responsibilities
as director of the team is research on health professions
shortages.
Gentlemen and lady, we appreciate your presence here today,
and you will notice we have the light system, and we ask--and
without objection, your entire written testimony will be made a
part of the record.
If you can keep within that 5 minutes as much as possible,
we will give an opportunity for the panel to ask questions.
Congressman Moran, you are recognized.
TESTIMONY OF THE HONORABLE JERRY MORAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF KANSAS
Mr. Moran. Mr. Chairman, thank you very much. Thank you for
the privilege of appearing before your Subcommittee today.
I appreciate your comments and am pleased to support your
effort to broaden the inquiry about increasing the availability
of health care professionals across the country. I appreciate
Ms. Jackson Lee and her efforts; we were engaged as allies the
last time this program was reauthorized in 2002.
I've been a Member of Congress now for a decade. Much of my
focus in Washington has been about access to health care. I
represent one of the most rural districts in the country. My
largest community is a population about 45,000.
I represent three quarters of the geography of Kansas, and
you are correct. We have 75 hospitals in the congressional
district, more than any congressional district in the Nation.
My constituents drive long distances to access health care.
They are elderly, generally, and income levels are--would be
below the national average. I have been engaged in the Rural
Health Care Coalition and its efforts since coming to Congress
and have served as its chairman for a number of years.
My colleague in co-sponsoring this bill, Mr. Pomeroy, the
gentleman from North Dakota, is the co-chairman of the Rural
Health Care Coalition today.
This issue is one that I think matters so much. In fact, I
believe that health care is the number-one domestic issue we
face in the country today. And it is about access, but it's
also about affordability.
And I have been involved in the J-1 visa program since
coming to Congress. Many of the physicians who serve, who
provide health care services to my constituents, are J-1 visa
doctors.
And you were right in your recitation of the history. This
has--came about, this program came about in 1994. We've also
had a companion Federal J-1 visa program. And surprising to me
and perhaps to others, Kansas was not a participant in the J-1
visa program on the State level until 2002. Prior to that, we
relied upon the United States Department of Agriculture to
provide J-1 visa access through the Federal program.
And since 2002, when we started the Conrad--now Conrad 30
program, we have provided 66 physicians to the people of our
State. The population of America is 25 percent rural, and yet
physicians, their practice, only 10 percent of practicing
physicians have their practice in rural America. So there's a
tremendous shortage.
Having outlined the rural nature of my district and my
focus in Congress, I also would like to point out that the J-1
visa program is important to urban areas of the country. It is
not just a rural issue. Many of the core centers of our cities
face the same dilemma in trying to attract and retain
physicians.
It's been my experience that if you are a physician who is
primarily interested in making money, you will not locate in
the core of a center of a city. You will not locate in rural
America because the population base, the patient load is
generally older. That means that Medicare has a significant
component of your practice.
In fact, of the 75 hospitals, many of the hospitals in our
congressional district--certainly 60, 70, 80, sometimes even 90
percent of the patients that are admitted to our hospitals are
on Medicare, which means that Medicare is the sole--is nearly
the sole provider of the revenue necessary to generate income
for the hospital or the physician.
And then on top of that, you add Medicaid, which also is a
detriment to a physician's income. Underserved areas exist in
this country, and they exist for a number of reasons, cultural
as well as economic.
This has been a successful program in Kansas since its
arrival in 2002. I know of a number of communities, and I've
talked to constituents who tell me that but ``absent that J-1
physician being in my community, I would not be alive today.''
So it's a matter of economic growth and community
development, but it is a matter of life and death that people
can access a physician, and in many cases, it's a J-1 visa
physician within the confines of their community.
Rush County Memorial Hospital is located about 25 miles
from my hometown. Thirty-seven hundred people live in the
county. They have three J-1 visa physicians. One now, two--a
husband and wife team, who have now retired. That community has
been served by J-1 visa physicians for a number of years--
decades, in fact--since the J-1 visa program was--arrived, and
they now have a physician who has replaced the two who retired.
Greensburg, Kansas, population 1,500. For the last 10
years, the only physicians they've had in the county are J-1
visa physicians. In each of these cases, the community has
attempted, at least initially, to attract a United States, an
American physician without success.
Meade County District Hospital, population of the county is
about 1,600, 1,700, they made that attempt. Finally were
successful in obtaining a J-1 visa physician through the waiver
program. That doctor is now from Romania, has stayed at the
hospital for 6 years. When he retired and left the community,
they attracted a J-1 visa physician from the Maldives Islands.
And finally, the hope--I'm, as you indicated, a supporter
of community health care clinics. I think they're part of
access to health care. They're also a part of a way that we can
reduce health care costs.
And United Methodist Ministries in Garden City, Kansas,
which serves a very diverse population, has now been able to
attract a J-1 visa doctor, originally from Peru, who is
bilingual and is arriving in August of this year to provide
services to those with--really, without any insurance, without
any financial means. And it's only through this J-1 visa
program that this community health clinic has been successful
in attracting a physician.
Mr. Chairman, I am an advocate, a supporter, a--just an
enthusiastic, and I guess it's not just--it's not based upon
emotion. It's based upon the reality that absent this program,
people will not be living, communities will not survive, and
rural America as well as urban America will have one more nail
in its coffin.
So I urge the reauthorization of this program. I'm happy to
discuss potential amendments in a way that we can meet the
needs perhaps of Texas, which has perhaps a greater demand than
the 30 that are allowed, the flexibility to move physicians
around the country, but also the permanent nature.
Again, this is an issue that I've lived from the beginning
of my time in Congress, and it would be nice to have a
permanent program as compared to us rushing in here always at
the last minute, trying to get the J-1 visa program
reauthorized for a short period of time.
I thank the Chairman and the Ranking Member and the
gentleman from California for their attention.
[The prepared statement of Mr. Moran follows:]
Prepared Statement of the Honorable Jerry Moran, a Representative in
Congress from the State of Kansas
I am here today to discuss H.R. 4997, the Physicians for
Underserved Areas Act, which would reauthorize the J-1 Visa Waiver
program. The J-1 Visa Waiver program provides opportunities for
graduates of foreign medical schools, who have trained in U.S. medical
residency programs on the J-1 cultural exchange visa, to stay in the
United States if they serve for three years in an area that has a
health professional shortage. These designated health professional
shortage areas can occur in rural areas as well as urban areas.
State government agencies may sponsor J-1 physician waiver requests
under the State 30 program. The State 30 program is designed to provide
each State up to 30 waivers for physicians each year. Each State has
been given some flexibility to implement its own guidelines, but there
are some basic requirements that are common to all State 30 programs.
The recruitment process takes into consideration the `fit' with the
practice, the community, and the needs of the physician and family.
One of my goals is improving access to health care in rural areas.
It is extremely difficult to recruit health care professionals to
places where doctors are few and access to major metropolitan hospitals
requires hours of travel. According to the U.S. Department of Health
and Human Services, while a quarter of the population lives in rural
areas, only 10 percent of physicians practice there. This definitely
highlights the need for the J-1 Visa Waiver program. Today, I would
like to highlight how this program has benefited my home state of
Kansas and the predominately rural area which I represent.
Kansas has been able to recruit 66 physicians to work in
underserved areas and with underserved populations since 2002. Each
year, the interest has grown and more and more physicians and hospitals
are finding that this match is benefiting not only themselves, but the
communities which they serve.
The Rush County Memorial Hospital located in La Crosse, Kansas is
responsible for providing health care to the 3,700 residents of the
county. With a population that is primarily elderly, having quality
healthcare is a major concern and requirement.
After advertising and spending countless dollars and resources
trying to recruit American born, American trained doctors, Rush County
Memorial turned to the J-1 Visa program to meet their healthcare needs.
They have been able to recruit three J-1 Visa physicians into the area
and would not be able to have top notch healthcare without this
program. In addition, the physicians have been welcomed into the
community and warmly received. One physician has stated that this small
Midwestern town reminds him of his home community in Egypt and has
started to put down roots by buying a home and getting involved in
community events. The J-1 Visa Waiver program has been invaluable to
the Rush County Memorial Hospital.
Greensburg, Kansas is a small, rural community which has had
difficulty recruiting physicians in the past. For the last 10 years,
their physicians have all been J-1 physicians. They have served the
community well and have been providing excellent health care. The
current J-1 physician manages 3 mid-level practitioners, provides
health care to the local assisted living facility and provides care at
the mental health facility which is located 10 miles from his place of
residence. However, he still finds time to work a booth at the local
health fair. For this community, it is imperative that the J-1 Visa
Waiver program be permanently reauthorized.
For 15 years, the Meade District Hospital has tried to get an
American born, American trained physician to move to their rural
Southwest Kansas hospital and have had no luck. However, through their
participation in the J-1 Visa Waiver program, they have been able to
attract foreign born physicians for the last 10 years. The J-1 Visa
program has helped the hospital provide quality care to their patients.
They had one doctor, originally from Romania, who stayed in the
hospital for six years and a current doctor from the Maldaise Islands
who they anticipate having a long term relationship with as well. The
J-1 Visa program has been a lifesaver to this hospital and the citizens
of Meade County.
Finally, the last success story I will highlight is the story of
the United Methodist Mexican-American Ministries which is located in
Garden City, Kansas. They are scheduled to receive their first J-1 Visa
doctor in August of this upcoming year. This community health clinic
provides care for many migrant and immigrant families who speak a
variety of languages including Spanish, German, and French. The new J-1
Visa doctor is originally from Peru and is highly educated, bi-lingual
and has tremendous references. The private medical community has been
supportive of the clinic's efforts to recruit a doctor as the need for
medical care is great in this area of Kansas. Without the J-1 Visa
program, this clinic would not be able to get a physician to treat
their patients.
People deserve quality health care regardless of their location.
The J-1 Visa Waiver program is helping many hospitals in my district
find qualified physicians for their communities and this increases the
quality of healthcare overall in Kansas. This is a well regarded, well
run program that is worthy of permanent reauthorization. The Physicians
for Underserved Areas Act is the way to make this happen.
Mr. Hostettler. Thank you, Congressman Moran.
Even though that I must admit that it is a blessing from
time to time to see your beaming face in front of this
Committee, that being said----
Mr. Moran. Mr. Chairman, I might remind you that I was on
the steering Committee that allowed you to come to the
Judiciary Committee. [Laughter.]
And I appreciate that very much because you were senior to
me in the House Agriculture Committee, and you allowed me to
become a Subcommittee Chairman when you departed. And I'm very
grateful for your--for your move.
Mr. Hostettler. And now we know ``the rest of the story.''
Mr. Salsberg?
TESTIMONY OF EDWARD SALSBERG, DIRECTOR, CENTER FOR WORKFORCE
STUDIES, ASSOCIATION OF AMERICAN MEDICAL COLLEGES
Mr. Salsberg. Good afternoon, Chairman Hostettler and
Ranking Member Jackson Lee and other Members of the
Subcommittee.
My name is Ed Salsberg. I'm the director of the Center for
Workforce Studies at the Association of American Medical
Colleges.
AAMC represents all 125 accredited U.S. allopathic medical
schools, nearly 400 teaching hospitals and health systems, and
94 academic societies.
I've been asked to address today the likely future supply
and demand for physician services and what our medical schools
and teaching hospitals are doing to assure an adequate supply
of physicians to meet America's needs.
Let me state at the outset that the AAMC and our members
are fully committed to assuring an adequate supply of well-
trained physicians to serve the Nation. Historically, U.S.
medical schools have responded to the needs of the public and
policymakers, especially when those needs have been clearly
articulated and supported by Government programs and policies.
In the 1960's and 1970's, the U.S. medical school
enrollment doubled in response to a national need and Federal
support. In the 1980's and 1990's, allopathic medical schools
responded to a series of Government reports that clearly
expressed concern about a pending surplus. And the schools are
now responding to growing evidence about a future shortage,
including the recent report by the National Council on Graduate
Medical Education.
While we believe our members will respond, we believe more
can be done, including in terms of Federal support for our
efforts. Forecasting future physician supply and demand is
extremely difficult. We're trying to look 10, 20 years out into
the future, and there are just many, many unknowns.
But based on our current analysis, we believe that the
Nation is likely to face a significant shortage in the future.
That's really reflecting both factors of supply and demand.
On the supply side, we know there are 250,000 active
physicians over the age of 55 that will be approaching age of
retirement. We know that there are reports of younger
physicians not interested in working the long hours that
physicians did in the past.
On the demand side, the Nation is growing rapidly, adding
25 million additional Americans every decade. We know that the
elderly will double between 2000 and 2030. That's critical
because the elderly use far more services than a younger
population.
And I think also the increasing wealth of the Nation and
the expectations of the baby boom generation lead us to
conclude the demand for health services, particularly physician
services, will be rising in the future and that the supply will
not be keeping up.
A comment about international medical school graduates who
are really a critical source of--component of the physician
workforce. International medical school graduates represent 25
percent of our active physicians in America and 25 percent of
the physicians in training.
As you mentioned, we are hearing of growing concerns
internationally about the impact of the migration of physicians
from less developed to more developed countries, and this is an
issue of concern.
The AAMC has recommended a number of actions to better
assure an adequate supply of physicians in the coming years.
First, last February, the association adopted a position of
recommending that U.S. medical schools increase their
enrollment by 15 percent.
We're now considering a recommendation to our members that
they increase enrollment by 30 percent. That would be equal to
about 5,000 additional graduates each year. We've seen some
response already, and I'll come back to that.
A second important step would be to raise the caps on
Medicare-funded GME positions. Our medical schools are
beginning to respond, but they're clearly concerned that in the
absence of an increase in the cap on residency positions, that
their efforts to increase the physician supply will not lead to
that end.
Third, we reiterated our commitment to the importance of
having a diverse, culturally diverse physician workforce that
reflects the Nation.
Fourth, we've recommended and feel it's critical that we
expand the National Health Service Corps. That really is
probably the most effective national strategy to assure
redistribution of physicians to underserved areas.
And fifth, we support efforts to expand data collection and
analysis on an ongoing basis to assure that the medical
community and the public are aware of what the future physician
workforce needs are.
In that regard, we are concerned with the elimination last
year of about 50 percent of title 7 funding, one of the only
sources of funding for medical education, including medical
education in rural communities. And also eliminated was the
support for the national center and the regional centers for
health workforce data collection.
Let me just note that the U.S. medical schools are
responding. More than half of the U.S. allopathic schools have
indicated their plans or serious consideration for expanding
over the next several years. We also expect to see five new
allopathic schools in the coming years.
Overall, we see about a 10 percent increase in U.S. medical
school enrollment in the pipeline now, and we hope to see more.
I think--in closing, I think U.S. medical schools have
begun to respond to the calls for an expansion. We could use
your support. A positive signal from the Federal Government,
such as the restoration of title 7 funding, lifting of the
Medicare GME caps, and expansion of the National Health Service
Corps would go a long way to inform and support the efforts of
U.S. medical schools to expand their capacity.
I thank you for the opportunity to speak to you today and
would welcome any questions.
[The prepared statement of Mr. Salsberg follows:]
Prepared Statement of Edward Salsberg
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Mr. Hostettler. Thank you, Mr. Salsberg.
Mr. Crosby?
TESTIMONY OF JOHN B. CROSBY, J.D., EXECUTIVE DIRECTOR, THE
AMERICAN OSTEOPATHIC ASSOCIATION
Mr. Crosby. Thank you very much, Mr. Chairman and Members
of the Committee.
The AOA is honored to be here, representing 56,000
osteopathic physicians in the United States, and we're honored
to be working with Congressman Pomeroy and Congressman Moran on
addressing these critical issues of access to health care in
rural America and other underserved areas.
Let me make clear at the outset, the AOA is not opposed to
H.R. 4997. We acknowledge the positive results from the J-1
visa and Conrad programs, and they've helped many rural
communities over the years.
What we are concerned about, however, is that policy
objectives today are not addressing U.S. osteopathic and
allopathic medical schools and their needs to better meet these
critical issues. Let me reiterate, the AOA is concerned that
U.S. graduate medical education programs are not prepared to
meet the physician workforce demands of 2020.
Right now, I'm not going to go over the statistics, but
there are about 96,000 residency positions in the United
States. By the year 2015, assuming there are still 24,000 PGY-1
programs around, M.D.s will need another 20,000 positions than
they have today, and D.O.s will need another 5,000 positions.
Mr. Chairman, you mentioned in your remarks that you were
interested in what the U.S. medical schools and physician
community were doing to address these needs. We have--in the
osteopathic community, since 1991, we have opened up 8 new
medical schools, and we have 6 additional medical schools on
the drawing board as we speak.
Since 1990, osteopathic physicians have grown in number by
67 percent. We represent 6 percent of all physicians in the
United States now, 8 percent of the military, and 22 percent of
all physicians practicing in rural and underserved parts of the
United States.
We have 23 colleges of osteopathic medicine right now. And
speaking of rural America and underserved areas, some of our
newest schools have gone into Appalachia, into the rural West.
We're working with Indian health centers, Eskimo populations,
and others.
And our newest school is probably going to be in Harlem,
New York, to meet the underserved needs of the inner city. So
we're very proud of what we have done in terms of making a
commitment to rural care.
There are several things you can do to address U.S. health
care needs in this regard. First of all, you can assist us in
helping to expand the class sizes and increase the number of
new medical schools, as Dr. Salsberg and others have advocated.
You can focus more attention on training primary care
physicians and general surgeons, largely through the Medicare
physician payment system, which right now has a bias against
those two areas of training and practice.
You can increase the training capacity in the United
States. As Dr. Salsberg said, we support the AAMC in
eliminating the cap from the Balanced Budget Act of 1997, which
limits the number of residency training programs for U.S.
trained physicians as we speak today.
You can provide financial assistance to rural hospitals who
would like to start up teaching programs. Right now, it takes
about 18 months before you get your first dollar from Medicare
if you want to start a teaching program. Provide them a loan.
Tie it to primary care. Target it to rural communities, and you
can do a lot to establish new training programs here in the
United States.
And again, as I said, tie it to primary care. You can
improve graduate medical education training programs that
foster training in rural settings, particularly nonhospital
settings. Congressmen Hulshof and Talent have introduced H.R.
4403, the ``Community and Rural Medical Residency Preservation
Act of 2005.'' Your support of that legislation would go a long
way.
And expanding scholarship and loan repayment programs to
provide incentives for physicians practicing in rural
communities would go a long way. Provide an annual tax credit
equal to the amount of interest that they pay on their student
loans, and also expand the current scholarship and loan
repayment program to allow physicians to fulfill their
commitment to rural communities on a part-time basis as well as
the full-time basis currently provided by law.
We are deeply appreciative of your leadership on this
critical issue. We welcome this opportunity to address these
concerns. And again, we do not oppose H.R. 4997, but we think
you can do a great deal to expand training for U.S. educated
osteopathic and allopathic physicians.
Thank you very much.
[The prepared statement of Mr. Crosby follows:]
Prepared Statement of John B. Crosby
Chairman Hostettler, Ranking Member Jackson Lee, and distinguished
members of the Committee. My name is John Crosby. I am the executive
director of the American Osteopathic Association (AOA). The AOA, which
represents the nation's 56,000 osteopathic physicians and 12,000
osteopathic medical students, is honored to be here today to discuss a
very important issue-access to physicians in rural and other
underserved communities. We believe that by increasing training and
workforce opportunities through recruitment and placement of U.S.
trained osteopathic physicians you can improve access to physician
services in rural communities and better address the global health
needs by encouraging U.S. trained foreign medical graduates to return
home to provide care to underserved populations.
We recognize that many communities face limited access to
physicians and physician services. This is especially true in rural
communities. We applaud the efforts made by state governments, the
federal government, Members of Congress, and rural communities to
increase physician access for their citizens.
For more than 130 years the AOA and the osteopathic profession have
been dedicated to educating and training the future physician
workforce. Consistent with our mission, we remain committed to
producing primary care physicians who will practice in rural and other
underserved communities. This mission has been a tenet of the
profession since it's founding in the late 1800's. Today, more than
sixty-five percent of all osteopathic physicians practice in a primary
care specialty (family medicine, internal medicine, pediatrics, and
obstetrics/gynecology). Each year, more than 65 million patient office
visits are made to osteopathic physicians.
Over the past fifteen years we have enjoyed tremendous growth.
Since 1990 the number of osteopathic physicians has increased sixty-
seven percent. Currently, osteopathic physicians represent six percent
of the total U.S. physician workforce and over eight percent of all
military physicians. However, twenty-two percent of osteopathic
physicians practice in a designated medically underserved area (MUA)
(Map 1). Throughout our history the osteopathic profession has placed
an emphasis on primary care and rural service. Our colleges of
osteopathic medicine have embraced this mission. Through the years, new
colleges of osteopathic medicine have been established in some of the
nation's most medically underserved regions (Map 2).
The issues facing our nation's rural health care system are
complex. We do not suggest that there are easy answers, but we do
believe that there are policies that would increase our ability to meet
these needs. The following pages outline several recommendations. These
recommendations promote the ability of the AOA and our allopathic
colleagues to meet the needs of rural communities without placing a
greater dependence upon international medical graduates. Additionally,
we believe that the implementation of these recommendations will allow
the U.S. medical education system to meet its responsibilities of
training international physicians who will return home and provide
quality of care to their citizens. As a result of these two missions,
we fulfill our joint goal of improving health care for all Americans
and sharing our expertise with other countries as a means of improving
global health.
INTERNATIONAL MEDICAL GRADUATES
The U.S. health care system is widely recognized as the most
advanced in the world. The rapid development of new diagnoses and
treatments outpaces those in other countries. We are the world's leader
in medicine and medical technology. In this role, we should share our
expertise with the world. For this reason, the AOA supports the
continued acceptance of international medical graduates (IMGs) into the
U.S. graduate medical education system. By training international
physicians, we can improve the health care delivery systems around the
world by improving the quality of the physicians. However, this
transfer of knowledge and skills cannot take place if international
physicians do not return to their home countries.
The United States should not be an importer of physicians.
Physicians should come to the U.S. to train and then return home. The
``brain drain'' in many countries is well documented. Many countries
lose their best and brightest young physicians to the United States and
other English-speaking countries. The AOA believes that policies should
facilitate the opposite result. International physicians should come
here to train and should not be encouraged to stay upon completion of
their training. In fact, we should require that they return to their
home countries and practice medicine for an extended period of time
before they are eligible to petition for a visa, J-1 or otherwise.
In 2006, almost 9,000 IMGs participated in the National Residency
Matching Program (NRMP). Of these applicants, approximately 6,500 were
not U.S. citizens and 2,500 were U.S. citizens who attended a foreign
medical school. Almost fifty percent of all IMGs match to first year
residency positions. In 2006, the total number of IMGs who matched to
first year positions increased to 4,382.
Of the 6,500 IMG participants who were not U.S. citizens, 3,151
(48.9%) obtained first year positions. 2006 was the fifth consecutive
year that the number of non-U.S. citizen IMGs matching to first year
positions increased. Of the 2,500 U.S. citizen IMG participants, 1,231
(50.6%) were matched to first year positions. 2006 was the third
consecutive year that the number of U.S. citizen IMGs matching to first
year positions increased. The total number of IMGs filling first year
residency positions will be much higher than the approximate 4,400 who
secured positions through the NRMP. Many IMGs are able to secure
residency training positions outside the match. All of these IMGs are
allopathic physicians (MDs) and none are osteopathic physicians (DOs).
PHYSICIAN WORKFORCE
Many experts now believe that the United States will face a
shortfall in its physician supply over the next twenty years. While
academic and policy experts debate the needs and expectations of the
future physician workforce, the AOA recognizes that we must begin to
educate and train a larger cadre of physicians, now. The time it takes
to educate and train a physician is, at minimum, seven years. This
means that a student accepted in the matriculating class of 2006 will
not enter the physician workforce until at least 2013. Due to the time
required to educate and train future physicians, we believe a
concentrated effort must be focused on increasing capacity over the
next five years. If handled appropriately, the country could increase
the physician workforce dramatically by 2020.
Reliance upon the J-1 Visa program is neither the most effective
nor the most desirable way to increase physician supply in rural
communities, although we recognize that the program can provide short-
term relief. The J-1 program is not capable of meeting the physician
workforce needs of our nation and should not be promoted for this
purpose. Yes, a few states and communities have physician services as a
result of the J-1 program. However, thousands of rural communities
remain without physician services. The AOA supports increasing our
capacity by adopting policies that encourage larger numbers of U.S.
educated and trained physicians to practice in rural and underserved
areas. An increase in U.S. educated and trained physicians, if properly
selected and trained, will lead to a more predictable and reliable
physician workforce and is more likely to produce larger numbers of
physicians who will practice in rural communities.
Currently, there are 23 colleges of osteopathic medicine. Twenty of
those are operating on 23 campuses. Three of those are in formation
having recently received pre-accreditation. In 2006, these colleges
will graduate approximately 2,925 new osteopathic physicians. In 2008,
the number of graduates will increase to 3,463. By 2013 the number of
osteopathic physicians graduating from colleges of osteopathic medicine
is projected to reach 4,706.
The AOA, like the Association of American Medical Colleges,
requires maintaining of quality educational standards while class sizes
are increasing. Additionally, we anticipate the establishment of at
least three additional colleges of osteopathic medicine over the next
four years. These new colleges, once established and accredited will
begin educating approximately 500 to 600 new students each. Once fully
enrolled, our current colleges, along with the new colleges of
osteopathic medicine, should produce an additional 1,000 physicians per
year. Assuming a predictable growth pattern, the osteopathic profession
should produce approximately 5,000 new physicians per year beginning in
2015.
RECRUITMENT AND PLACEMENT
Medical schools and colleges of osteopathic medicine traditionally
place significant emphasis on an applicant's academic achievement-grade
point average, undergraduate degree program, and scores on the Medical
College Admission Test (MCAT). While I would never suggest that the
academic standards required for admittance be lowered, I do recommend
that the nation's medical education institutions begin evaluating
``other'' factors. An evaluation of the student's life, including an
evaluation of where the student was raised, attended high school, and
location of family members, provides an indication of where a future
physician may practice. For example, an applicant from Princeton, New
Jersey is less likely to practice in a rural community than an
applicant from Princeton, Indiana. If the two applicants are equally
qualified, we should encourage our schools to matriculate the student
from Princeton, Indiana, an individual more likely to return to rural
southwest Indiana once education and training is completed.
Our medical education system must increase its efforts to promote
both primary care specialties and experience in rural practice
locations. Over the years, the role of the rural family physician
became less glamorous than that of the urban subspecialist. Far too
many medical school students want to be an ``ologist'' instead of a
general surgeon, family physician, general internist, or pediatrician.
Our nation's health care system needs specialists and subspecialists,
but we need far more primary care physicians. Our medical education
system must place greater emphasis on educating and training primary
care physicians and general surgeons. These physicians are more likely
to practice in a rural or small community hospital and are far more
likely to practice in rural America.
INCREASE TRAINING CAPACITY
Currently, there are approximately 96,000 funded residency
positions in the United States. Of these positions, international
medical graduates fill approximately ten percent. The number of
international medical graduates training in the United States has grown
steadily over the past decade. The number of funded residency positions
has been static since the late 1990's when Congress, as part of the
Balanced Budget Act of 1997, placed a limit or ``cap'' on the number of
residency slots any existing teaching program may have. With the
exception of a provision allowing for the establishment of a rural
training tract, these caps have been unaltered since their
establishment.
The residency cap was established at a time when the general
consensus was that the country had an adequate supply of physicians. We
now recognize this is not correct. The residency caps established by
the BBA limit the ability of teaching hospitals to increase training
programs, thus preventing responsible growth capable of meeting our
future physician workforce needs. The AOA encourages Congress to either
remove or increase the cap on the number of funded graduate medical
education training ``slots'' as established by the Balanced Budget Act
of 1997.
IMPROVE RURAL TRAINING PROGRAMS
There is an old saying in medical education circles that physicians
will practice within 100 miles of where they train. While the validity
of this saying either in a world that is flat or alternatively in an
era of globalization is unproven, its message rings true. Physicians
are more likely to practice in settings where they have the most
experience. While a majority of physician training takes place in the
hospital setting, it should not be limited to this setting. We need to
do more to expose medical students and resident physicians to different
practice settings during their training years.
A valuable component of graduate medical education is the
experience of training at non-hospital ambulatory sites. These sites
include physician offices, nursing homes, and community health centers.
Ambulatory training sites provide an important educational experience
because of the broad range of patients and conditions treated and by
ensuring that residents are exposed to practice settings similar to
those in which they ultimately may practice. This type of training is
particularly important for primary care residency programs since a
majority of these physicians will practice in non-hospital ambulatory
clinics upon completion of their training. This training also is
essential to improving access to care in rural communities.
Congress has long recognized that a greater focus should be placed
on training physicians in rural and other underserved communities. In
the 1990s, Congress began to fear that the current graduate medical
education payment formula discouraged the training of resident
physicians in ambulatory settings. This opinion was based upon the fact
that the payment formula only accounted for the resident training time
in a hospital setting. Through the Balanced Budget Act of 1997,
Congress altered the payment formula, removing the disincentives that
existed for training in non-hospital settings. We accomplished this
goal by allowing hospitals to count the training time of residents in
non-hospital settings for the purpose of including such time in their
Medicare cost reports for both indirect medical education (IME) and
direct graduate medical education (DGME) payments.
This change in the payment formula was designed to increase the
amount of training a resident physician received in non-hospital
settings, enhance access to care for patients in rural and other
underserved communities, provide an additional education experience for
residents who are considering practicing in rural communities, and
provide a recruitment mechanism for rural and underserved communities
in need of physicians.
The program appeared to be working as intended. However, in 2002
the Centers for Medicare and Medicaid Services (CMS) began
administratively altering the rules and regulations in respect to this
issue. As a result, CMS intermediaries began denying the time residents
spent in non-hospital settings. In many cases, hospitals were forced to
repay thousands of dollars as a result of this administrative change in
regulations. Many Members of Congress urged CMS to work with interested
parties to resolve this issue by developing new regulations that
clarify the appropriate use of non-hospital settings. Unfortunately,
these conversations have not produced policies that meet the original
intent of Congress as established in 1997. As a result, hospitals are
being forced to train all residents in the hospital setting,
eliminating the valuable educational experiences offered in non-
hospital training sites. Additionally, some teaching hospitals may be
forced to eliminate residency programs entirely as a result of current
CMS policies.
Allowing hospitals to receive payments for the time resident
physicians train in a non-hospital setting is sound educational policy
and a worthwhile public policy goal that Congress clearly mandated in
1997. Additionally, it is good for rural communities. For this reason,
the AOA encourages Congress to enact the provisions included in the
``Community and Rural Medical Residency Preservation Act of 2005''
(H.R. 4403).
H.R. 4403 would establish, in statute, clear and concise guidance
on the use of ambulatory sites in teaching programs. If enacted, it
will preserve the quality education of resident physicians originally
envisioned by Congress in 1997. The Medicare program should promote
quality graduate medical education, rather than impose unnecessary
barriers.
The AOA also encourages Congress to establish a new grant program,
operated by the Health Resource Service Administration (HRSA) that
would provide ``start-up'' funding for rural hospitals that seek to
establish new primary care residency programs. For many rural hospitals
the costs associated with starting a new residency program are
prohibitive. Due to CMS requirements, hospitals starting new residency
programs are not eligible for funding for at least 12 months. This lag
between the actual start-up date and the date of eligibility for
funding is cited as one of the main reasons more hospitals, especially
smaller hospitals, do not start teaching programs. The AOA believes
that numerous primary care residency programs at rural hospitals could
be established if financial assistance was available to offset the
associated costs.
EXPAND PROGRAMS THAT PROVIDE INCENTIVES FOR RURAL PRACTICE
There are numerous existing programs that provide scholarships and
loan repayment for physicians who choose to practice in rural
communities. These programs include the National Health Service Corps,
Public Health Service, Indian Health Service, and many programs
operated by state governments. The AOA supports these programs and
encourages Congress to continue funding them at levels that facilitate
greater numbers of physicians practicing in rural and other underserved
communities.
Additionally, we believe that some consideration should be given to
allow physicians to participate in the programs on a part-time basis.
There are numerous communities that need physician services, but they
may not need them full time. We believe that modifications should be
made to federal loan repayment and scholarship programs that allow
participants to repay on a part-time basis in exchange for a longer
term of service. For example, if a physician participates in the
National Health Service Corps and agrees to a three-year commitment in
a rural community--why not allow the physician the option of committing
to 4 or 5 year's service on a part-time basis. We believe this would
encourage more physicians to participate in these valuable programs
without jeopardizing the underlying mission.
The AOA also proposes a change in the tax code that would provide
physicians practicing in designated rural communities with a tax credit
equal to the amount of interest paid on their student loans for any
given year that they practice in such a community, or until their loans
are paid in full. Under current law, individuals may deduct up to
$2,500 in interest paid on student loans from their federal income
taxes. However, the income thresholds associated with this provision
often prevent physicians from qualifying. Our proposal would provide a
direct link between practice location and the tax credit. A physician
practicing in a rural Indiana who pays $8,000 in interest on her
student loans in year one would get an $8,000 tax credit for that year.
The program would continue until the physicians had retired her student
loan debt or when she departed the rural community. We believe that
this proposal provides a direct incentive to young physicians and would
assist in the recruitment and retention of physicians in rural
communities.
IMPROVE ECONOMICS OF MEDICINE
The current practice environment physicians face is challenging.
Over the past decade escalating professional liability insurance
premiums, decreasing reimbursements, and expanded regulations have made
the practice of medicine more frustrating for all physicians. These
issues are compounded in rural communities where physicians are often
in solo practice or small group practices, unable to benefit from
economies of scale that larger group practices in urban areas enjoy.
According to a 2004 Health Affairs study, more than half of all
practicing physicians are in practices of three or fewer physicians.
Three-quarters are in practices of eight or fewer. They face the same
economic barriers as every other small business in America. Costs
associated with staff salaries; health and other benefits, basic
medical supplies, and technology, all essential components of any
business, continue to rise at a rate that far outpaces reimbursements.
When facing deep reductions in reimbursements at the same time that
their operational costs are increasing, it is safe to project that most
businesses will not be able to continue operation. While most
businesses increase, or have the ability to increase, their prices to
make up the differential between costs and reimbursements, physicians
participating in Medicare cannot.
Physician Payment--Unless Congress acts, Medicare physician
payment rates will be cut by 4.6 percent on January 1, 2007. If
this cut is imposed, Medicare rates will fall 20 percent below
the governments measure of inflation in medical practice costs
from 2001-2007. If the projected cuts are implemented, the
average physician payment rate will be less in 2007 than it was
in 2001. Additionally, two provisions included in the Medicare
Modernization Act (MMA), which provide increased reimbursements
for physicians in rural communities, will expire over the next
two years.
In 2002, physician payments were cut by 5.4 percent. Congress
acted to avert payment cuts in 2003, 2004, 2005, and 2006
replacing projected cuts of approximately 5 percent per year
with increases of 1.6 percent in 2003, 1.5 percent in 2004 and
2005, and 0 percent in 2006. Even with these increases,
physician payments fell further behind medical practice costs.
Practice costs from 2002 through 2005 were about two times the
amount of payment increases. Since many health care programs,
such as TRICARE, Medicaid, and private insurers link their
payments to Medicare rates, cuts in other systems will compound
the impact of the projected Medicare cuts. Medicare cuts
actually trigger cuts in other programs.
Additional cuts in Medicare physician payments decrease
Medicare beneficiaries' ability to access to physician
services. A MedPAC survey conducted earlier this year found
that 25 percent of Medicare beneficiaries reported having
difficulties obtaining an appointment with a primary care
physician. These problems will only increase if additional cuts
are implemented. Additionally, reduced payments may prevent the
implementation and adoption of new health information
technologies.
Furthermore, reduced payments hamper the ability of
physicians to purchase and implement new technologies in their
practices. According to a 2005 study published in Health
Affairs, the average costs of implementing electronic health
records was $44,000 per full-time equivalent provider, with
ongoing costs of $8,500 per provider per year for maintenance
of the system. This is not an insignificant investment. When
facing deep reductions in reimbursements, it is safe to project
that physicians will be prohibited financially from adopting
and implementing new technologies.
Physician payments should reflect increases in practice
costs. In its 2006 March Report to Congress, the Medicare
Payment Advisory Commission (MedPAC) stated that payments for
physicians in 2007 should be increased 2.8 percent. Since 2001,
MedPAC has recommended that the flawed SGR formula be replaced
by a formula based upon increases in physician practice costs
minus a productivity adjustment, which would produce annual
updates equal to the Medicare Medical Economic Index (MEI).
Since its inception in 1965, a central tenet of the Medicare
program is the physician-patient relationship. Medicare
beneficiaries rely upon physicians for access to all other
aspects of the Medicare program. This relationship has become
compromised by dramatic reductions in reimbursements, increased
regulatory burdens, and escalating practice costs. Given that
the number of Medicare beneficiaries is expected to double to
72 million by 2030, now is the time to establish a stable,
predictable, and accurate physician payment formula that
reflects the cost of providing care.
Congress must act to reform the Medicare physician payment
formula. Continued use of the flawed SGR formula will have a
negative impact upon patient access to care. Additionally, the
AOA urges Congress to approve the ``Medicare Rural Health
Providers Payment Extension Act'' (H.R. 5118). This legislation
includes provisions that extend two important rural physician
payment provisions originally enacted through the MMA. H.R.
5118 extends, through 2011, a provision that provides equity in
how the Medicare program views and evaluates the work of
physicians regardless of geographic location. By establishing a
1.0 floor for the work geographic practice cost indices (GPCI)
under the Medicare physician fee schedule, the MMA reversed
years of inequities in payments between rural physicians and
those in larger urban communities. The AOA was equally pleased
that the MMA included a 5 percent add-on payment for physicians
practicing in recognized Medicare physician scarcity areas. We
believe that these are essential and positive Medicare payment
policies that should be extended, if not made permanent. Both
provisions will enhance beneficiary access and improve the
quality of care available.
Medical Liability Reform--As you know, the nation's medical
liability system is broken. In recent years physicians across
the nation have faced escalating professional liability
insurance premiums. According to the National Association of
Insurance Commissioners (NAIC), between 1975 and 2002 medical
liability premiums for physicians increased, on average, 750
percent. These premium increases are related directly to an
explosion in medical liability lawsuits filed against
physicians and hospitals and the rapid increase in awards. The
Government Accountability Office (GAO) confirms this. In a 2003
report, the GAO stated that losses on medical liability claims
are the primary driver of increases in medical liability
insurance premiums.
As a result of a broken medical liability system patients
face reduced access to health care, the overall costs of health
care increases, and the future supply of physicians is
threatened. Many physicians no longer provide services that are
deemed high-risk, such as delivering babies, covering emergency
departments, or performing certain surgical procedures. This
crisis also impacts primary care physicians, especially those
in rural areas who are often the only physician practicing in a
community. As a result, patients have seen a decrease in the
availability of physician services. Additionally, the medical
liability crisis has a significant impact upon the career
choices of future physicians. In a recent poll conducted by the
AOA, eighty-two percent of osteopathic medical students stated
that the cost and availability of medical liability insurance
would influence their future specialty choices, while 86
percent stated that it would influence their decision on where
to establish a practice once their training was complete. This
trend in career choices is disturbing and will have a long-term
impact upon the health care delivery system in the years ahead.
We applaud the leadership of this Committee and the House of
Representatives in approving the ``Help, Efficient, Accessible,
Low-Cost, Timely, Health Care Act'' (HEALTH Act) (H.R. 5). The
AOA believes that provisions included in H.R. 5 will prove
beneficial in stabilizing the nation's broken medical liability
system, thus improving access to physician services.
SUMMARY
Again, the AOA appreciates the opportunity share our views on this
important issue. We remain committed to working with Congress to enact
legislation that will ensure access to quality physician services for
all Americans, regardless of where they reside. In closing we would
like to highlight five recommendations made in our testimony that we
believe will lead to improved global health, increase the availability
of U.S. trained physicians, improve the quality of training for future
physicians, and improve the recruitment and retention of physicians in
rural communities.
1. International Medical Graduates should be encouraged to
return to their home countries to establish practices and,
ultimately, improve the quality of care in those health care
systems. The United States should not be an importer of
physicians, thus contributing to the ``brain drain'' of other
countries. By maintaining existing policy that requires IMGs to
return home for two years before petitioning for a visa, we are
fulfilling a noble mission of improving the health care needs
of many countries.
2. Congress should consider eliminating the cap on available
and funded residency positions in the U.S. This cap hinders the
ability of osteopathic and allopathic medical schools to
educate and train larger numbers of physicians. To meet the
health care needs of our growing population we must have the
capacity and financing to train a larger number of physicians.
3. Congress should enact the ``Community and Rural Medical
Residency Preservation Act of 2005'' (H.R. 4403). This
legislation would establish, in statute, clear and concise
guidance on the use of ambulatory sites in graduate medical
education programs. If enacted, it will preserve the quality
education of resident physicians originally envisioned by
Congress in 1997.
4. Congress should amend the tax code to allow physicians
practicing in rural communities an annual tax credit equal to
the amount of interest paid on their student loans. We believe
that this proposal provides a direct incentive to young
physicians and would assist in the recruitment and retention of
physicians in rural communities. Additionally, Congress should
revise current scholarship and loan repayment programs to allow
physicians to fulfill their commitment on a part-time basis.
5. Congress should reform the Medicare physician payment
formula by eliminating the sustainable growth rate and
replacing it with a more equitable and predictable payment
structure. Additionally, Congress should enact the ``Medicare
Rural Health Providers Payment Extension Act'' (H.R. 5118),
extending much need payment incentives for physicians
practicing in rural communities.
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Mr. Hostettler. Thank you, Mr. Crosby.
Ms. Aronovitz?
TESTIMONY OF LESLIE G. ARONOVITZ, DIRECTOR, HEALTH CARE, UNITED
STATES GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Aronovitz. Good afternoon, Mr. Chairman and Mr.
Lungren.
I am pleased to be here today as you discuss the States'
authority to request J-1 visa waivers for foreign physicians to
practice in the Nation's underserved areas.
My remarks today are based on preliminary findings from our
ongoing work, which reviews the number of J-1 visa waivers
requested by States and physicians practice locations and
specialties, States' activities to monitor compliance with
waiver agreements, and the States' views on the adequacy of the
30 waiver per State limit.
As Ms. Lee mentioned, our work is based on a survey of 50
States, the District of Columbia, Puerto Rico, Guam, and the
Virgin Islands. I should mention that we also surveyed the
three Federal agencies that requested J-1 visa waivers on
behalf of States in the last few years.
In summary, we found that J-1 visa waivers remain a major
means of placing physicians in underserved areas, with more
than 1,000 waivers requested in each of the past 3 years for
physicians to practice in nearly every State. We also found
that in fiscal year 2005, States made more than 90 percent of
the J-1 visa waiver requests, with the 3 Federal agencies
making up the rest.
Every State, except Puerto Rico and the Virgin Islands,
made requests last year, though the number varied considerably
among the States. For example, about a quarter of the States
requested the maximum of 30 waivers, while another quarter or a
little bit over--about 29 percent of them--requested 10 or
fewer waivers.
Collectively, the States requested 956 waivers, or about 60
percent of the total that were available to all the States
collectively.
In terms of demographics, about 44 percent of the States'
waiver requests were for physicians to practice only primary
care, and about 41 percent were for physicians to practice only
specialties, such as cardiology. More than three quarters of
the requests were for physicians to work in hospitals or
private practices.
Regarding monitoring, while States do not have an explicit
responsibility for monitoring and overseeing the physicians
compliance with waiver agreements, most reported conducting at
least some monitoring activities. For instance, requiring
periodic reports on whether the intended population in these
facilities were actually being served or conducting site
visits.
Regarding States' views on the 30 waiver limit, about 80
percent of the States, including many that requested close or
all of the waivers--the 30 waiver limit--felt that the 30
waiver limit was adequate for their needs. However, 7 States
reported that this limit was less or very much lower than what
they needed.
When asked--when we asked the States if they needed more
waivers, interestingly, 7--excuse me, 11 States said that they
needed a total of 200 more waiver physicians. And this included
4 States that said the limit was adequate, but they still
reported needing more physicians.
Regarding distribution of unused waivers, of the 44 States
that did not request their 30 waiver limit--10 States did, 44
did not--25 of those 44 States said that they would be willing
to have their unused waiver allotments redistributed at least
either willing or willing under certain circumstances.
And for example, some of these circumstances involve their
willingness if they were--if it were--it depended on the timing
of the distribution. They would not want it done in the first
half of the year, when there was a chance that they still might
be able to attract some physicians toward the end of the year.
Others said they wanted to be sure that their needs were
met before they would give up their waivers. Others advocated
for a regional distribution approach, while still others
mentioned possible compensation, perhaps an exchange of unused
waiver allotments for more flexibility for the waivers that
they did use.
Finally, several States mentioned that they would not want
redistribution in 1 year to affect the number of waivers that
they received to be able to ask for in another year.
In contrast to these 25 States, 14 States reported that
they would not be willing to have their unused waiver
allotments redistributed, and they were very concerned about
the reduction in the number of physicians seeking to practice
in their States. They felt that if, in fact, physicians knew
that there was a redistribution program, they might wait until
a more preferred location in another State cropped up before
they applied for the position in a less desirable State.
What remains unclear and what we could not determine is
whether any redistribution approach would simply move waiver
physicians from one State to another or instead increase the
overall pool of physicians seeking waivers to work in
underserved areas.
I'm happy to elaborate on my findings or answer any other
questions that you may have.
[The prepared statement of Ms. Aronovitz follows:]
Prepared Statement of Leslie G. Aronovitz
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Mr. Hostettler. Thank you very much, Ms. Aronovitz.
At this time, we will turn to questions from the panel.
First of all, Ms. Aronovitz, you state that there has been a 40
percent decline in the past 10 years of physicians using the J-
1 visa to come to the U.S. for medical training. Can this be
attributed to increased usage of the H-1B visa?
Ms. Aronovitz. We don't really know. There are no data that
really break out the physicians using H-1Bs and J-1s
specifically for that comparison.
But a lot of the States who have answered our survey and
other work we've done have contemplated different reasons. And
one of the reasons that some States believe there is a
reduction is the fact that H-1B visas are being used. So that
is a valid thought on the part of very many people.
Mr. Hostettler. Thank you.
Congressman Moran, as you testified, the J-1 visa has been
instrumental in providing physicians to underserved areas all
across your district. The National Health Services Corps, as
you know, through HHS provides loan repayment for U.S. citizen
health care providers who agree to work in rural areas as well
as scholarships to individuals who will dedicate time of
service in rural areas.
Is your experience with that program such that you believe
that that could be expanded ``in lieu of'' the J-1 visa
program? Do they complement one another? How would you----
Mr. Moran. Mr. Chairman, I was about to answer your
question ``yes'' until you said ``in lieu of.'' I do think that
both programs are very important. They attract, they focus on
additional resources to provide health care providers, but
they're two different populations. They serve the same
population, but you're dealing with different applicants,
different types of physicians, folks who come to the health
care profession in different ways.
And so, both are very important to us. I would not at all
diminish the role that the National Health Service plays in
helping provide physicians, encouraging physicians to locate in
underserved areas. But I don't envision, based upon even the
testimony we've heard today, the number of physicians that are
available from U.S. medical schools remains so tight that I
think it takes both programs and even more to meet the needs of
underserved areas.
So clearly not in lieu of and any way that we can expand
and create a greater incentive. One of the things--we have our
own State program as far as loan repayment for physicians
through a State law. And many physicians have discovered that
they can have their loans paid off through recruitment process
if they'll locate to a more urban or suburban setting.
And so, with the loan program opportunities that are there,
I think that just because more money can be made elsewhere,
we're inducing a number of our physicians to--even though they
have the loan program--to have their loan paid off by a
community that's recruiting them to a different setting.
Mr. Hostettler. Thank you.
Mr. Crosby, as you note in your testimony, one of the goals
of the osteopathic profession is training primary care
physicians for rural areas. How do you recruit and attract
students to your colleges and specifically to serve rural
areas?
And a second question would be do you believe that the J-1
visa waiver program for physicians should be expanded, as some
have suggested, if not here, then elsewhere?
Mr. Crosby. I really couldn't comment on the second
question in terms of expansion of the J-1 program itself. But
again, if there's a more specific question in terms of
supporting that, I'd be happy to address it.
With respect to your first question, I'll just give you the
example, Mr. Chairman, one of our newest schools is in
Pikeville, Kentucky, the heart of Appalachia. And what they do
is through the application process, try to recruit entering
osteopathic medical students from the region who want to go
into primary care and pledge to stay in that part of the
country to practice medicine.
And about 80 percent of the students coming in want to go
into primary care, and they've graduated two classes now, and
80 percent are staying in Kentucky, northern Tennessee, West
Virginia, to do just that. So if you tie the application
process and you screen the applicants with the right mind set,
I think you can achieve those goals.
Mr. Hostettler. Thank you.
Mr. Salsberg, is it fair to say that a number of qualified
potential medical students are turned down each year because
there is a shortage of medical school slots?
Mr. Salsberg. Yes, we think there are many Americans who
would be qualified to go to allopathic medical schools if we
expand our capacity. That's one of the reasons we've
recommended the expansion among our members.
Mr. Hostettler. Thank you.
The Chair recognizes the gentlelady from Texas, Ms. Jackson
Lee, for 5 minutes.
Ms. Jackson Lee. I thank the Chair very much.
I think I want to be clear on the record that I do not
believe the J-1 visa is a replacement for the growing need of
physicians here in the United States. And I do think it's
important that even beyond the jurisdiction of this Committee,
that we focus the Congress on what is obviously a rising need
that will reach, I think, a crisis level sometime over the next
decade. And that is, of course, the need for doctors across
America.
At the same time, I think that we have solutions that we
can address and utilize as we speak, and so I think it's
important to look at the immediacy of the problem and address
it accordingly.
Congressman Moran, you've heard me make several points
which I am interested in, and I will have a document to submit
from the--and I ask unanimous consent to submit the statement
of the National Health Care Access Coalition into the record,
Mr. Chairman.
Mr. Hostettler. Without objection.
Ms. Jackson Lee. And I'll also take some quotes from this.
But would you support a redistribution of the unused visa
waiver shots--slots, rather?
Mr. Moran. Well, I was interested in the testimony of the
GAO. I do think, and I wouldn't want to admit that my State is
one of those that would consider itself a less desirable
location. But I do know that there is a fear among some States
that if redistribution is allowed, that physicians are less
likely to locate in what at least a physician considers to be a
less desirable location for practice.
I think this is--on the other hand, I think that it's
important that those States who desperately need additional
physicians and--have access to those physicians. So I think
there is a way----
Ms. Jackson Lee. We have to fix it, so that we don't--we
don't----
Mr. Moran. We don't want to discourage the least--``the
least desirable'' locations from being----
Ms. Jackson Lee. Allegedly. Allegedly.
Mr. Moran. Allegedly. But we also need to recognize there
is a demand in States. Texas has to be an example. It's just
such a large State, that 30 in Kansas is much more beneficial
than 30 in Texas.
Ms. Jackson Lee. Absolutely. And I will cite some evidence
of that. But let me also get your thoughts because this is what
this Committee will have to address. The Chairman mentioned it.
The movement away from J-1 visas to the H-1B visas, and do you
have some thoughts on how we can legislatively address that
question because it is a real concern?
Mr. Moran. Well, I've not given a lot of thought to the H-
1B visa issue. It is a competitor to this program, and the
distinction is that it doesn't meet the needs of underserved
areas. And so, from my perspective, we--for reasons of access
to health care and reasons of health care costs--we need more
physicians serving patients in the United States.
And so, I wouldn't want to take away from the physicians
that come here under the H-1B. But clearly, we've got to focus
the efforts at those areas of the country, urban cities and
rural America, that desperately need physicians.
I think that, generally, we're going to find that the more
prosperous areas of the country will be able to obtain
physicians, and so the competition between the two programs I
think has to be--the balance of that has to be in favor of
those places that are underserved. It's a life and death issue.
Ms. Jackson Lee. Having the Texas Medical Center near and
around my congressional district and parts of it in my
congressional district, the distinction is important. The J-1
visa is temporary, and I think whatever reform we do--whether
it's an extension and other aspects that we need to reform, we
should focus on that--that they go to underserved areas and
they are immediate.
H-1B visas are individuals in on research, post docs,
specialties that allow them to go to the choice areas. In fact,
the medical centers and prime hospitals and others use H-1B
visas to get the talented of the talented.
Not in any way to deflect on the J-1, but they are in a
different category, and I think we should note that. So that we
don't undermine the value that J-1 visas have, and there is
that distinction that should be made.
Mr. Moran. We can't blur that distinction because we will
lose the effectiveness of the J-1 visa program.
Ms. Jackson Lee. I agree with you. Let me ask Ms.
Aronovitz. You didn't get a sense, and you're in the midst of a
study, or have you----
Ms. Aronovitz. Yes. We have--we do have our results. We
haven't analyzed them fully yet. But we do have some
preliminary results.
Ms. Jackson Lee. Then the basic--you get a sense that those
who are participating or States that are participating view the
J-1 visa as a positive asset to improving or assisting them in
health care in their States, respective States?
Ms. Aronovitz. Most definitely. And as I said, most every
State last year used at least one of their visa waiver slots.
Ms. Jackson Lee. So you did not come away, though you're
still analyzing, with a massive call for elimination?
Ms. Aronovitz. That's correct.
Ms. Jackson Lee. Mr. Chairman, may I ask unanimous consent
to put the statement--I asked that. But also--and I will quote
from them, the Texas Department of State Health Services. I ask
unanimous consent to put that letter in the record as well.
Mr. Hostettler. Without objection.
The Chair recognizes the gentleman from California for 5
minutes. Mr. Lungren?
Mr. Daniel Lungren of California. Thank you very much, Mr.
Chairman.
Mr. Moran, I was not in Congress when this program was
first established, but it obviously was established on a
temporary basis. Was that because it was to be a pilot project?
Was that because there was a thought that this need for
underserved areas would be a stopgap in that somehow we were
going to, through other mechanisms, provide for these
underserved areas? What was the nature of the short term or
sunset of it?
Mr. Moran. Mr. Lungren, I have the same excuse that you do.
I was not in Congress when the program was started, and there
may be others that have the expertise at the table to answer
your question.
The Conrad 20 program in 1994, I think, was an effort to
give States an opportunity that they did not have, and the
Federal Government's process was so slow and cumbersome for the
J-1 visa program administered by Federal agencies that my guess
is that Congress said let's try this. Let's see how it works.
And I think the results today, 10 years later, is it is
important and vital.
I also know that in the timeframe which I was here, part of
the issue was related to the extension followed post 9/11,
followed 9/11. And there was interest in making the program
temporary so that we could determine that the necessary
security risks were being evaluated by now our Department of
Homeland Security to make certain that those visas that were
being approved in no way were causing any threat to the
national security.
So I think we've been through a series of times in which
Congress wants to see how the program is working. And then,
most recently, it's been let's make certain that there are no
security risks involved in the program.
Mr. Daniel Lungren of California. In my first tenure as a
Member of Congress, I recall we were dealing with the question
of underserved areas at that time. And there was some question
as to why these were underserved areas. I mean, we don't want
to use the word ``choice'' areas versus ``nonchoice'' areas.
And one of the things that I recall being discussed at that
time was that physicians like to be kept up to date in their
profession. That they are assisted in doing that by being
surrounded by other physicians, by quality medical staffs, by
having some access to teaching hospitals, if at all possible.
And so, in some ways, people were suggesting at that time
or a number of voices suggested at that time we needed stopgap
measures to have doctors go for short periods of time to
underserved areas, knowing they wouldn't stay there for a long
time.
But there was the hope expressed that with technology in
the future, that physicians might look at some of these areas
as the choice areas for living purposes and that technology
would allow them to fill that gap of information and reflection
and exposure to colleagues and to outstanding teaching
hospitals and teaching centers.
I guess my question would be to all of you on the panel, if
you would give me some idea as to whether that last thought has
proven to be unsuccessful or that it has, in fact, proved that
we can attract more physicians to these areas that were
previously underserved. And I'm talking about rural areas, as
opposed to inner city right now.
And that would help me in looking at the legislation as to
whether or not when we make it permanent, we're making it
permanent because we think this is going to continue to be a
problem forever. Or is this--have we not seen any change in
terms of attracting doctors to the more rural areas in spite of
the fact that they now have these technological fixes in a
sense to be able to keep up with the practice, be exposed to
new possibilities in medicine and so forth?
Mr. Moran. Mr. Lungren, I can only speak from my
experience, and I've worked with communities to recruit
physicians. It does not seem to me that circumstances are
getting any better, that the challenge is just as great as it
has been in the past, and it's related to not only the issue
that you suggest about the desire of collaboration with other
physicians.
It's issues related to lifestyle and the sense of
physicians today do not want to be on-call 7 days a week, 24
hours a day. And that's often the necessary practice in a small
community. It's much easier----
Mr. Daniel Lungren of California. They're not going to
Tuesday to Thursday schedules, are they?
Mr. Moran. We have not gone to Tuesday to Thursday
schedules. But with the arrival of advanced nurse
practitioners, physician assistants, I think that's the one
bright spot that I see as far as attracting and retaining
physicians in rural America. We have additional assistant help.
We do have telemedicine that's available in my State. It's
more now used for some consultation with experts, specialists
at the University of Kansas School of Medicine. But more likely
than not and perhaps unfortunately, it's used for continuing
medical education for not only physicians, but nurses. It has
not become a replacement for hands-on physician practice.
Mr. Hostettler. The gentleman's time has expired. Without
objection, the gentleman will be yielded an additional 2
minutes for the rest of the panel to respond.
Mr. Crosby. Congressman, I think you raise a very good
point. Technology offers a lot of promise in rural areas. Our
own organization now provides 9 hours of credit for continuing
medical education programs that doctors can get over the
Internet. And their access to the latest information from the
New England Journal of Medicine to a news-breaking development
with pharmaceuticals or whatever is immediate access.
However, there are also I think a changing environment in
terms of just lifestyle. I met--I was in Des Moines last week.
I met a young doctor who had started out in Phoenix, got fed up
with managed care, and has relocated to rural Iowa just because
he wanted a different style of practice, which was very
attractive to him.
The one thing that I don't think you can answer in terms of
rural areas with technology or not is the whole sense of
camaraderie, which you mentioned in your opening remarks.
Another young physician that the National Health Service
Corps sent out to an island off of Alaska would see 90 patients
a day, but he couldn't last more than 2 weeks without having to
fly to the mainland just to see other physicians, talk to them
about things that had come up in his practice, and basically
cope with that emotional stress of being out there alone
without anybody else to fall back on if you need it.
But technology will answer a lot of questions over time. It
already is.
Ms. Aronovitz. One thing I can add is in our survey, we
actually asked States whether they've seen an increase or a
decline in interest in J-1 visa waiver physicians applying to
the different States, and it was an open-ended question, and
only 21 States chose to answer the question.
But of the 21, 15 States said that they've seen a definite
decline in interest or in the number of applications by J-1
visa physicians or visa holders. Six States, on the other hand,
said they've actually seen an increase specifically in
nonprimary care areas, like specialists.
But two-thirds of the ones that answered really did see a
decline, and some actually attribute it to the possibility that
physicians were coming for graduate medical education on H-1Bs.
Mr. Salsberg. You know, the problems of physician
distribution have been with us for a long time and are likely
to be with us for a long time. And as I mentioned earlier, I
think looking at the comprehensive situation, looking at the
National Health Service Corps is really the best strategy.
Relying on J-1 visa physicians, who are making an important
contribution but are a shrinking number, has to be of concern
as the number of underserved areas, about 20 percent of
Americans live in federally designated underserved areas. So
the J-1 stream is clearly not going to be a sufficient stream
in looking at the whole question of how can we help address
maldistribution is really what we would recommend.
Mr. Hostettler. I thank the gentlemen.
The Chair will now entertain a second round of questions,
and I will ask just one question in that second round. And that
is of you, Ms. Aronovitz.
You note in your testimony that, in 1995, the number of
waivers for foreign physicians exceeded the number of
physicians participating in the National Health Service Corps
that I mentioned earlier, the primary means for providing
physicians to underserved areas.
Was there a decline in the usage of the NHSC, the National
Health Services Corps, as a result of the increased usage of
the waiver program, or does your data--can your data tell you
that?
Ms. Aronovitz. We have--we don't have enough detailed data
to really understand some of the implications. But clearly, we
haven't seen that strong a relationship or that correlation.
And in fact, now we see that J-1 visa waiver physicians
represent about one and a half times the number of National
Health Service Corps doctors that are in the field.
Mr. Hostettler. Thank you. That's helpful.
The Chair recognizes the gentlelady from Texas for purposes
of second round of questions.
Ms. Jackson Lee. Thank you, Mr. Chairman, and I should be
narrow in my comments.
I think the answer to your last question really has to do
with what has been noted by the National Health Care Access
Coalition, which is the numbers suggest that we need to expand
to 200,000 doctors, and that there are currently only fewer
than 800,000 doctors and that there will be a growing shortage
over the next, as I indicated, couple of decades. So we're
facing a shortage, and I think there have been many suggestions
here that we could utilize.
Mr. Crosby, I just--what is the training of your physicians
in your specialty?
Mr. Crosby. Osteopathic physicians have the exact same
training as allopathic physicians. Go to 4 years of medical
school. Perhaps an internship, and then 3 or 4 or 5 years of
residency training.
We deliver babies. We do neurosurgery. We provide
osteopathic manipulative treatment. The whole scope of care is
available through osteopathic physicians, and we're proud to
have one of our medical schools in the Forth Worth/Dallas area.
Sorry it's not in Houston.
Ms. Jackson Lee. And the name of it?
Mr. Crosby. The Texas College of Osteopathic Medicine,
affiliated with the University of North Texas.
Ms. Jackson Lee. And I think, as I listen to you, I think
you even with the expanded ideas that you've offered, and I
happen to support a lot of them----
Mr. Crosby. Thank you.
Ms. Jackson Lee [continuing]. That you still fall in a
category that what you're wanting, we've got to produce more?
Mr. Crosby. Yes.
Ms. Jackson Lee. And you have my wholehearted support on
that issue, and I'm going to be studying your testimony quite
extensively because I think there can be some cross-
pollenization between, though one might not think, Judiciary
and the Energy and Commerce.
I think that does not speak to or speak against the
immediacy of the J-1 visa, which I want to keep in a temporary
framework.
And I will offer then simply, Mr. Chairman, the suggestions
made by the coalition for health care access coalition--the
National Health Care Access Coalition, which is recommending
permanently authorize the Conrad program, increase the size of
the Conrad program to 40 slots per State, and allow unused
slots to be used by States that need them. And again, I think
we can do so by making sure that we have the right kind of
structure that it is not abused.
I then want to make note that there are six pages here of
States and actual facilities that are asking for J-1 visas, and
they do include the great State of Indiana and the great State
of Texas.
I also want to make note of a comment from--that was
written in the Denver Post, reported on a Dr. Amanpour, and the
quote is that the doctor's importance is described. ``He's
keeping us alive. The doctor's fantastic. Without a physician,
our nursing home is in jeopardy.''
And one of the victims of small numbers of doctors are
nursing homes. Very few and I would say competent, qualified,
or either people right on the edge might not want to go in that
direction, and our senior citizens need health care. And so, my
question is to Dr. Salsberg.
Do you see the need of the parallel of these temporary
visas for use as well as the growth that we need to do in our
medical profession here in the States?
Mr. Salsberg. Definitely. I mean, we definitely need to
encourage expansion of U.S. medical schools to meet current and
future medical needs. The concern on the J-1 program, as you
know, was that that was a program designed to assist, as the
Chairman said, less educated--assist physicians obtain
education in America, training in America that could be of use
to less developed parts of the world.
And so, I think we need an awareness of those concerns. And
AAMC is looking at what can we do to assist other parts of the
world in terms of improving their medical education and
training. So it really should be a two-way street of what can
we do to help them.
Ms. Jackson Lee. Absolutely. And we hope that it is a two-
way street as they come and utilize and that they take their
training back to the nations, particularly developing nations.
My last point is to cite from the Texas Department of State
Health Services, and just to show you the starkness of the
need. Looking at specialties in 2004, there are approximately
228 physicians per 100,000 population for the United States.
While in Texas, the ratio was 155 physicians per 100,000, or 30
percent below the national average.
Although we, as I said, want to reinforce the value of our
home-trained physicians, we also know that the immediate need
is to try to solve some of these problems and, of course, Texas
has asked for 50 even above the 40 that's been recommended.
But I close by simply saying to Congressman Moran, do you
feel comfortable that we can so structure the J-1 program that
we answer a lot of the concerns that have been expressed here
today?
Mr. Moran. I have little doubt that if we work together as
Members of Congress and with the profession, our States, that
we can find a satisfactory solution. That doesn't solve the
demands for physicians, but moves us in the right direction so
that more people can receive adequate health care.
Ms. Jackson Lee. I thank you, and I thank the Chairman. I
think this was an important hearing. I thank the GAO for the
work that they're still doing and the witnesses that were here
today.
I yield back, Mr. Chairman.
Mr. Hostettler. I thank the gentlelady.
I want to thank the panel of witnesses for your input and
contribution to the record. It's been most helpful, and to
advise Members that they have 5 legislative days to make
additions to the record.
The business before the Subcommittee being completed, we
are, without objection, adjourned.
[Whereupon, at 3:10 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Material Submitted for the Hearing Record
Prepared Statement of the Honorable Sheila Jackson Lee, a
Representative in Congress from the State of Texas, and Ranking Member,
Subcommittee on Immigration, Border Security, and Claims
This is a legislative hearing on the Physicians for Underserved
Areas Act, H.R. 4997, which was introduced by Congressman Jerry Moran
on March 16, 2006. It would make the J-1 Visa Waiver Program permanent.
The J visa is used for one of the educational and cultural exchange
programs. It has become a gateway for foreign medical graduates to gain
admission to the United States as nonimmigrants for the purpose of
graduate medical education and training. The visa most of these
physicians enter under is the J-1 nonimmigrant visa.
The physicians who participate in the J-1 visa program are required
to return to their home country for a period of at least two years
before they can apply for another nonimmigrant visa or legal permanent
resident status, unless they are granted a waiver of this requirement.
In 1994, Senator Kent Conrad established a new basis for a waiver
of this requirement with an amendment to the Immigration and
Nationality Act. It was known then as, ``The Conrad State 20 Program.''
It permitted each state to obtain waivers for 20 physicians by
establishing that they were needed in health professional shortage
areas, known as ``HPSAs.''
On November 2, 2002, the Conrad 20 program was extended to 2004,
and the number of waivers available to the states was increased to 30.
This program, which is now referred to as the ``Conrad 30''or ``State
30'' program, expired on June 1, 2004. On December 3, 2004, it was
reinstated and extended to June 1, 2006, which is only a few weeks from
now. Congressman Moran's Physicians for Underserved Areas Act would
eliminate the need for future extensions by making the program
permanent.
When the Conrad 30 program was established in 1994, most of those
studying the supply of physicians in the United States were concerned
about the distribution of physicians, as opposed to the total number of
doctors being trained. It is now generally recognized that we are
facing a severe physician shortage. The Health Policy Institute
estimates that the shortage could grow to as much as 200,000 by 2020,
an astounding possibility in view of the fact that the physician
population in the United States currently is only about 800,000.
The failure to forecast this severe physician shortage may explain
why from 1980 until last year no new medical schools opened in the
United States. According to the Health Policy Institute, the United
States needs to produce an extra 10,000 physicians per year over the
next decade and a half in order to meet the demands of the country.
This number assumes that the number of foreign educated physicians will
remain constant.
Senator Conrad and I asked the General Accountability Office (GAO)
to do a survey of state views on the Conrad 30 program. All 50 states
filled out a GAO questionnaire and promptly returned it to GAO. One of
the GAO investigators will testify about the results of the survey, so
I will just point out a few key findings.
Approximately 80% of the states reported that the annual limit of
30 waivers per state is adequate. Only 13% reported that it is
inadequate. Eleven states estimated that they need between 5 and 50
more waiver physicians, which would total 200 more waiver physicians.
In FY2005, 44 states did not use all of their allotted waivers. The
total of the unused waivers for that year was 664. Of these 44 states,
25 reported they were willing, or willing under certain circumstances,
to have their unused waiver allotments redistributed. These states had
a total of 398 unused waiver allotments in FY2005.
The J-1 visa waiver program has been in effect now for more than a
decade. In addition to being a good source of additional physicians, it
ensures that the additional physicians will go where they are most
needed, health professional shortage areas in both rural and urban
settings. I urge you therefore to support Congressman Moran's
Physicians for Underserved Areas Act to make the program permanent.
Thank you.
__________
Prepared Statement of the Honorable Kent Conrad, a U.S. Senator from
the State of North Dakota
Mr. Chairman, thank you for this opportunity to testify on the
``Conrad State 30'' program as you discuss its reauthorization. I
appreciate your interest in addressing the physician shortage in the
United States with programs such as this.
When the Conrad 20 program was enacted, approximately 85 percent of
North Dakota's counties were designated, either in part or in total, as
health professional shortage areas (HPSAs). The purpose of this program
was to increase the supply of physicians to rural America. This very
successful program has since been expanded to the Conrad State 30. It
is heavily relied upon by a majority of the states, especially rural
states like North Dakota.
Before the Conrad 20 program was created, North Dakota's hospitals
and clinics had to use the federal J-1 visa waiver, which required a
federal agency to certify the need for a physician. On one occasion, a
facility in North Dakota was forced to use the Coast Guard as the
interested federal agency. I was grateful that the Coast Guard, which
has a small station in LaMoure, was willing to assist the local
community in obtaining a needed medical professional. But relying on
the Coast Guard to decide if a town in North Dakota needed a physician
made no sense.
That is why I authored the Conrad State 20 program. It allows an
interested State agency to make the determination that previously could
only be made by a Federal agency. Not only are States more qualified to
confirm health shortage areas, the program also uses HHS designated
shortage areas as a baseline requirement, with the exception of five
waivers that can go to physicians who will be placed in a facility that
largely treats patients from HPSAs. Since 1994, this program has cut in
half the number of family practice physician vacancies in North Dakota.
It is critically important to rural hospitals and clinics in my state
and across the country that this program be reauthorized.
However, a serious drop in Conrad State 30 applications has North
Dakota hospitals deeply concerned. For instance, St. Luke's Hospital in
Crosby, ND, reports that it used to have as many as 150 J-1 physician
applications for an opening. Now, it has had a five-month vacancy, and
only a handful of candidates have applied. Many users of the program
believe the shrinking pool of J-1 visa waiver doctors is due to foreign
physicians turning to H-1B visas in lieu of J-1 visas for their
graduate medical education.
Like Chairman Hostettler, my constituents have noticed the
disparity in how J-1 physicians in residency are treated compared to
those on H-1B visas. Residents on J-1 visas must go home and contribute
to their country's underserved for two years, or stay here and
contribute to ours for three. But those on H-1B visas are excepted from
either requirement; they are free to practice anywhere in the United
States when they complete their residency programs. I believe we need
to explore options to level the playing field, such as requiring
residents on H1-B visas to serve three years in underserved areas.
I would also like to take this opportunity to express my strong
concerns about proposals to re-distribute unused waivers from states
like North Dakota to states that use all 30 of their Conrad 30 slots.
With a shrinking overall pool of J-1 visa waiver doctors, any proposal
to redistribute unused slots risks further reducing the number of these
doctors who will apply to serve in North Dakota. In the words of Tioga
Medical's President, ``By allowing physicians to wait for the
redistribution of slots to occur, a physician can opt to wait for
states that may be more lucrative in weather conditions, culture, or
other amenities.'' He is right. According to the Government
Accountability Office, redistribution would likely benefit a handful of
more populous states to the detriment of very rural states with
facilities that have the most difficulty with recruitment.
The Conrad 30 program has made a very real contribution to
augmenting the physician supply in rural areas that need qualified
primary care physicians and specialists in critical areas of medicine
such as diabetes, cardiology and orthopedic medicine, just to name a
few. However, eighty-one percent of North Dakota's counties remain
HPSA-designated some twelve years later. With the physician shortage in
this country projected to reach 200,000 by 2020, the Conrad 30 program
is needed now more than ever.
Since its inception, we have had to reauthorize this program many
times--every two years since 2000. Such uncertainty is unnecessary. Our
rural areas need to know they can count on this program for years to
come. I urge the Committee to support the Physicians for Underserved
Areas Act to permanently authorize this critical program for rural
America and ask that the articles that I've included with my testimony
be submitted for the record.
ATTACHMENT
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Prepared Statement of Gregory Siskind, Chairman, National Health Care
Access Coalition
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Letter to the Honorable Sheila Jackson Lee from Connie Berry, Manager,
Texas Primary Care Office
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