[House Report 109-715] [From the U.S. Government Publishing Office] 109th Congress Report HOUSE OF REPRESENTATIVES 2d Session 109-715 ====================================================================== PHYSICIANS FOR UNDERSERVED AREAS ACT _______ December 5, 2006.--Committed to the Committee of the Whole House on the State of the Union and ordered to be printed _______ Mr. Sensenbrenner, from the Committee on the Judiciary, submitted the following R E P O R T [To accompany H.R. 4997] [Including cost estimate of the Congressional Budget Office] The Committee on the Judiciary, to whom was referred the bill (H.R. 4997) to permanently authorize amendments made by the Immigration and Nationality Technical Corrections Act of 1994 for the purpose of permitting waivers of the foreign country residence requirement with respect to certain international medical graduates, having considered the same, report favorably thereon with amendments and recommend that the bill as amended do pass. The amendments are as follows: Strike all after the enacting clause and insert the following: SECTION 1. SHORT TITLE. This Act may be cited as the ``Physicians for Underserved Areas Act''. SEC. 2. WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT WITH RESPECT TO INTERNATIONAL MEDICAL GRADUATES. Section 220(c) of the Immigration and Nationality Technical Corrections Act of 1994 (8 U.S.C. 1182 note; Public Law 103-416) (as amended by section 1(a)(1) of Public Law 108-441) is amended by striking ``June 1, 2006.'' and inserting ``June 1, 2008.''. SEC. 3. EFFECTIVE DATE. The amendment made by section 2 shall take effect as if enacted on May 31, 2006. Amend the title so as to read: A bill to extend for 2 years the authority to grant waivers of the foreign country residence requirement with respect to certain international medical graduates. Purpose and Summary H.R. 4997 reauthorizes for two years the program whereby aliens who participate in medical residencies in the United States on exchange program visas (known as ``J'' visas) do not have to leave the U.S. at the conclusion of their residencies to reside abroad for two years if they agree to practice medicine for three years in an area designated by the Secretary of Health and Human Services (``HHS'') as having a shortage of health care professionals.\1\ --------------------------------------------------------------------------- \1\ This program is sometimes referred to as the ``Conrad 30'' program, after Senator Conrad, the original author of the program. --------------------------------------------------------------------------- Background and Need for the Legislation Aliens who participate in medical residencies in the United States on ``J'' exchange program visas must generally leave the U.S. at the conclusion of their residencies to reside abroad for two years before they can be eligible for permanent residence or status as ``H-1B'' or ``L'' visa nonimmigrants.\2\ The intent behind this policy is to encourage American-trained foreign doctors to return home to improve health conditions and advance the medical profession in their native countries. --------------------------------------------------------------------------- \2\ Immigration and Nationality Act Sec. 212(e)(iii). --------------------------------------------------------------------------- In 1994, Congress created a waiver (until June 1, 1996) of the two-year foreign residency requirement when a state department of public health requested it for foreign doctors who committed to practice medicine for no less than three years in a geographic area or areas designated by the Secretary of HHS as having a shortage of health care professionals.\3\ The number of foreign doctors who could receive the waiver was limited to 20 per state. In 1996, Congress extended the waiver to June 1, 2002.\4\ In 2002, Congress extended the waiver until June 1, 2004.\5\ At the same time, the numerical limitation on waivers was increased to 30 per state. --------------------------------------------------------------------------- \3\ See the Immigration and Nationality Technical Corrections Act, Pub. L. No. 103-416, Sec. 220 (1994). \4\ See the Illegal Immigration Reform and Immigrant Responsibility Act, Pub. L. No. 104-208, Sec. 622 (1996). \5\ See the 21st Century Department of Justice Appropriations Authorization Act, Pub. L. No. 107-273, Sec. 11018 (2002). Section 11018 incorporated the language of H.R. 4858, which was reported by the House Judiciary Committee on June 24, 2002, and passed the House on June 25, 2002. --------------------------------------------------------------------------- In late 2004, Congress extended the waiver until June 1, 2006.\6\ The extension allows five of each state's 30 waivers to go to doctors not practicing medicine in areas designated by the Secretary of HHS as having a shortage of health care professionals, as long as the doctors receiving the waivers agree to serve patients living in such areas. Also, if a physician seeking a waiver will practice specialty medicine, there must be a shortage of health care professionals able to provide services in that specialty to the patients who will be served by the physician. Finally, the extension exempts physicians from the H-1B numerical cap. --------------------------------------------------------------------------- \6\ See Pub. L. No. 108-441. --------------------------------------------------------------------------- The waiver requirements are as follows: the Secretary of Homeland Security may authorize a waiver upon the request of an interested U.S. government agency or a director of a state department of public health (or its equivalent) as in the public interest \7\ if: --------------------------------------------------------------------------- \7\ See INA Sec. 212(e). --------------------------------------------------------------------------- (1) In the case of an alien who is otherwise contractually obligated to return to a foreign country, the government of such country furnishes the U.S. government with a statement in writing that it has no objection to a waiver; (2) The alien demonstrates a bona fide offer of full-time employment at a health facility or health care organization and that employment has been determined by the Secretary of Health and Human Services to be in the public interest; (3) The alien agrees to begin employment within 90 days of receiving the waiver, and agrees to continue to work for not less than three years (unless the Secretary determines that extenuating circumstances exist, such as closure of the facility or hardship to the alien, which would justify a lesser period of employment at such facility or organization, in which case the alien must demonstrate another bona fide offer of employment at a health care facility or health care organization for the remainder of the three-year period); and (4) The alien agrees to practice medicine for the three- year period only in the geographic area or areas which are designated by the Secretary of HHS as having a shortage of health care professionals (except in the case of a request by the Department of Veterans Affairs or in the case of a request by an interested Federal agency to employ the alien full-time in medical research or training) or in a medical facility that serves patients who live in medically underserved areas (up to 5 waivers per state). H.R. 4997 reauthorizes in its present form the waiver program for physicians who receive training in the United States on a J-visa and agree to practice in underserved areas until June 1, 2008. Hearings The Subcommittee on Immigration, Border Security, and Claims held one day of hearings on H.R. 4997 on May 18, 2006. Testimony was received from: Congressman Jerry Moran; Edward Slasber, the Center for Workforce Studies; John B. Crosby, the American Osteopathic Association; and Leslie G. Aronovitz, the United States Government Accountability Office. Committee Consideration On September 27, 2006, the Committee met in open session and ordered favorably reported the bill H.R. 4997 with an amendment by voice vote, a quorum being present. Vote of the Committee In compliance with clause 3(b) of rule XIII of the Rules of the House of Representatives, the Committee notes that there were no recorded votes during the committee consideration of H.R. 4997. New Budget Authority and Tax Expenditures Clause 3(c)(2) of rule XIII of the Rules of the House of Representatives is inapplicable because this legislation does not provide new budgetary authority or increased tax expenditures. Congressional Budget Office Cost Estimate In compliance with clause 3(c)(3) of rule XIII of the Rules of the House of Representatives, the Committee sets forth, with respect to the bill, H.R. 4997, the following estimate and comparison prepared by the Director of the Congressional Budget Office under section 402 of the Congressional Budget Act of 1974: September 28, 2006. Hon. F. James Sensenbrenner, Jr., Chairman, Committee on the Judiciary, House of Representatives, Washington, DC. Dear Mr. Chairman: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 4997, the Physicians for Underserved Areas Act. If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is Mark Grabowicz. Sincerely, Donald B. Marron, Acting Director. Enclosure. H.R. 4997--Physicians for Underserved Areas Act CBO estimates that implementing H.R. 4997 would result in no significant net cost to the federal government. The bill would affect direct spending, but we estimate that any effects would be insignificant. H.R. 4997 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act and would not affect the budgets of state, local, or tribal governments. Until June 1, 2006, foreign students attending medical school in the United States were permitted to remain after graduation if they agreed to work for at least three years in certain regions of the country considered to be underserved by physicians or if they accepted employment with certain federal agencies. That program was limited to 30 individuals a year for each state that participated in the program. Under current law, such individuals must return to their native countries. H.R. 4997 would reestablish this program through June 1, 2008. Based on the participation of foreign medical students in those employment programs in recent years, CBO expects that the bill's provisions would affect fewer than 2,000 persons annually. The Bureau of Citizenship and Immigration Services (CIS) would collect fees to provide work permits for those individuals. CIS fees are classified as offsetting receipts (a credit against direct spending). The agency is authorized to spend such fees without further appropriation, so the net impact on CIS spending would be insignificant. The CBO staff contact for this estimate is Mark Grabowicz. This estimate was approved by Robert A. Sunshine, Assistant Director for Budget Analysis. Performance Goals and Objectives The Committee states that pursuant to clause 3(c)(4) of rule XIII of the Rules of the House of Representatives, H.R. 4997 would extend for two years the program whereby aliens who participate in medical residencies in the United States on ``J'' exchange program visas do not have to leave the U.S. at the conclusion of their residencies to reside abroad for two years if they agree to practice medicine for three years in an area designated by the Secretary of Health and Human Services as having a shortage of health care professionals. Constitutional Authority Statement Pursuant to rule XI, clause 2(1)(4) of the Rules of the House of Representatives, the Committee finds the authority for this legislation in Article I, section 8 of the Constitution. Section-by-Section Analysis and Discussion The following discussion describes the bill as reported by the Committee. Sec. 1. Short title This bill may be cited as the ``Physicians for Underserved Areas Act.'' Sec. 2. Waiver of foreign country residency requirement with respect to international medical graduates This section extends for two years the program whereby aliens who participate in medical residencies in the United States on ``J'' exchange program visas do not have to leave the U.S. at the conclusion of their residencies to reside abroad for two years if they agree to practice medicine for three years in an area designated by the Secretary of Health and Human Services as having a shortage of health care professionals. Sec. 3. Effective date This section makes the amendments in Section 2 effective as if they had been enacted on May 31, 2006. Changes in Existing Law Made by the Bill, as Reported In compliance with clause 3(e) of rule XIII of the Rules of the House of Representatives, changes in existing law made by the bill, as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, existing law in which no change is proposed is shown in roman): SECTION 220 OF THE IMMIGRATION AND NATIONALITY TECHNICAL CORRECTIONS ACT OF 1994 SEC. 220. WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT WITH RESPECT TO INTERNATIONAL MEDICAL GRADUATES. (a) * * * * * * * * * * (c) Effective Date.--The amendments made by this section shall apply to aliens admitted of the United States under section 101(a)(15)(J) of the Immigration and Nationality Act, or acquiring such status after admission to the United States, before, on, or after the date of enactment of this Act and before [June 1, 2006.] June 1, 2008. Markup Transcript BUSINESS MEETING WEDNESDAY, SEPTEMBER 27, 2006 House of Representatives, Committee on the Judiciary, Washington, DC. The Committee met, pursuant to notice, at 10:09 a.m., in Room 2141, Rayburn House Office Building, the Honorable F. James Sensenbrenner, Jr. (Chairman of the Committee) presiding. Chairman Sensenbrenner. The Committee will be in order. A working quorum is present. I would like to note that this will likely be the final Committee markup during the 109th Congress, and my last as Chairman. Additionally, this will be the last markup for several esteemed members of the Committee who are planning to move on from the halls of Congress. I would like to recognize each of these individuals and to thank them for their service to the nation and to this Committee. Chairman Henry Hyde will be retiring at the end of this year after 31 years of service representing the 6th District of Illinois. He has been a member of the Judiciary Committee throughout his entire congressional tenure, and, as we all know, he served very capably as Chairman from 1995 to 2001, and as Chairman of the International Relations Committee for the past 6 years. He leaves an impressive legacy, particularly as a forceful advocate for the rights of the unborn, and will be greatly missed. We all wish him well as he moves on to the good life, to find his life after Congress. Congressman William Jenkins will also be retiring at the end of this Congress. He has served on the Committee since 1997 when he began his congressional career. Thank you for your excellent service, and we wish you well. Congressman Mark Green is currently running to be governor of the great state of Wisconsin. He has been a valuable member of the Committee, and I trust that he will ably serve my fellow Wisconsinites and me as governor. And good luck to you. In addition, three Committee staff are set to retire at the end of the year: our majority chief clerk Tish Schwartz, publishing clerk Joseph McDonald, and our office manager Michele Utt. Together, they have over 81 years of combined Hill experience. And thank you all for your years of dedication and hard work. Now, we ain't done yet, so it is time to start on in. [Intervening business.] Chairman Sensenbrenner. The next item on the agenda is H.R. 4997, the ``Physicians for Underserved Areas Act,'' for purposes of markup. And I move its favorable recommendation to the House. Without objection, the bill will be considered as read and open for amendment at any point. [The bill, H.R. 4997, follows:]Chairman Sensenbrenner. The chair recognizes the gentleman from Indiana, Mr. Hostettler, the Chairman of the Immigration Subcommittee, for 5 minutes to explain the bill. Mr. Hostettler. Thank you, Mr. Chairman. Today, we are considering H.R. 4997, the ``Physicians for Underserved Areas Act.'' This legislation authored by our colleague, Jerry Moran of Kansas, reauthorizes the J-1 Visa Waiver Program for physicians who agree to work in underserved areas, which expired on June 1 of this year. Under current law, foreign doctors may come to the United States to complete their residency training. Many do so using the J-1 visa, which is for cultural exchange and training programs. One of the requirements for physicians who use the J visa is that the participant return to his or her home country for 2 years upon completion of the training program in the United States. The purpose of this foreign residency requirement is to encourage American-trained physicians to return to their country and improve medical conditions there. Since 1994, Congress has waived the 2-year foreign residency requirement for physicians who agree to work in an underserved area of the United States, as designated by the Department of Health and Human Services. Each state receives 30 such waivers per year. The waiver program allows states to recruit foreign-born physicians to areas that are unable to recruit sufficient numbers of American physicians. Many communities that might otherwise have no access to medical services now have physicians nearby as a result of this program. It also responds to an overall shortage of physicians in the United States, a shortage that seems to be growing. Several months ago, the Subcommittee on Immigration, Border Security, and Claims examined this legislation, and it was apparent to me that there is in fact a growing physician shortage in the United States. However, the J visa waiver program is only a temporary fix to a much larger problem. Congress must also focus on other ways to address the shortage. Medical training programs in the United States should be sufficiently expanded so that we are training more American physicians here in the United States. I plan to offer an amendment on behalf of myself and Ranking Member Sheila Jackson-Lee that would reauthorize the program for 2 years, rather than permanently. The physician shortage in the United States is a multifaceted problem, and I believe we should revisit the issue from time to time so that we don't lose sight of the real problems that need to be addressed. A 2-year reauthorization will also give us the opportunity to address problems faced by larger states like Texas, where the need for waivers each year exceeds 30, without disadvantaging small states. By reauthorizing the waiver program through this legislation, we will provide states with some relief to the physicians shortage they are currently facing, but it is a temporary fix to a much larger problem. I am hopeful that this Committee and other Committees of jurisdiction will work to find ways to educate and train greater numbers of American physicians, and reduce our reliance on foreign physicians. I yield back the balance of my time. Chairman Sensenbrenner. The gentleman from Michigan, Mr. Conyers, is recognized for 5 minutes. Mr. Conyers. Mr. Chairman, I rise in support of H.R. 4997. I am pleased that we are considering the bill to extend the J-1 Visa Waiver Program for another 2-year period. This visa waiver program is critically important to bringing essential medical services to residents of underserved rural and urban areas, including parts of my own district in Detroit. The J-1 program allows some foreign doctors who have completed their medical training in the United States to remain here to practice medicine for 2 years, if they will serve patients in the regions of the country that the Federal Government defines as medically underserved. These tend to be less-affluent urban areas with high population densities and insufficient medical services from general practitioners and specialists, as well as rural areas that are far from medical centers and may have trouble attracting enough doctors to meet the community's needs. These communities are particularly desperate for physician services because of the growing national shortage of doctors our own country is facing. A recent Los Angeles Times article detailed the looming crisis quite well, in medical care in the United States as demand for medical services explodes. The article noted industry fears that shortages may become even more severe over the next decade due to the flat medical school enrollments, aging baby boomers, and the high number of doctors headed for retirement. While some communities enjoy a glut of physicians, one in five Americans live in rural or urban areas with so few doctors that the Federal Government has classified these regions as medically underserved. It is these Americans that foreign doctors assist when they get a J-1 visa to practice medicine in communities that don't have enough American doctors. I do believe we need to make improvements in this program so that it better meets the needs of the underserved. Right now, some states who receive J-1 doctors through the Conrad 30 Program don't use their allotment of 30 waivers each year, while other states find that 30 waivers are insufficient to meet the medical needs of their communities. In addition, some states may not need 30 waivers, but other states have trouble recruiting all of the doctors they need. The result is that some citizens are still unable to get essential medical care. We need a plan that ensures that states having trouble recruiting enough doctors will be able to fill their allotment for J-1 doctors, and secondly, ensures that states which fill their annual allotment of J-1 doctors can get more of them to meet their needs, without impinging on any other state. In this way, the needs of all states, and most importantly all of the citizens in underserved areas, can be met until our medical schools in this country are able to increase the number of graduates to meet our domestic needs. I am pleased that the Subcommittee Chairman Hostettler and Ranking Member Jackson-Lee are mutually pledged to work on a solution to these additional problems in the coming Congress. I look forward with them and other colleagues in the House and Senate to improve, extend and sustain this vital visa program in the near future. I return the balance of my time. Chairman Sensenbrenner. Without objection, all members' opening statements will appear in the record to this point. [The prepared statement of Ms. Jackson-Lee follows:] Prepared Statement of the Honorable Sheila Jackson-Lee, a Representative in Congress from the State of Texas, and Member, Committee on the Judiciary Foreign doctors who want to receive medical training in the United States on J visas are required to leave the country afterwards. They must return to their countries for two years before they can receive a visa to work in the United States as physicians. In 1994, Congress established a waiver of this requirement. The waiver applies to doctors who will commit to practicing medicine for no less than three years in a geographic area designated by the Secretary of Health and Human Services as having a shortage of health care professionals. The waiver program has been successful for more than a decade. It permits each state to obtain waivers permitting up to 30 of these physicians to work in medically underserved areas. It is not a permanent program. It sunsetted June 1, 2006. The Physicians for Underserved Areas Act, H.R. 4997, would reinstate the program and make it permanent. The amendment that Rep. Hostettler and I are offering would provide for a two-year extension instead of making the program permanent. Rep. Hostettler has agreed to work with me next year on devising a way to redistribute unused visa waivers. A distribution problem was revealed by a study that Rep. Hostettler and I asked the General Accountability Office (GAO) to conduct. According to the GAO study, the system of providing up to 30 waivers per state is not working well. A substantial percentage of the states do not need 30 waivers a year. There were 664 unused waivers in FY2005. Other states need more than 30 waivers a year for their medically undeserved areas. The states that reported needing more than 30 waivers only want between 5 and 50 more physicians. Their needs can be met by redistributing some of the unused waivers, but this must be done carefully. Some states expressed concern to GAO about redistributing unused waivers. They are afraid that physicians would wait and apply to the more popular states that would be receiving the redistributed waivers. This problem has to be resolved before we can move forward with the development of a redistribution plan. I urge you to vote for the amendment to H.R. 4997 that would provide for a two-year extension and give us time for consideration of modifications in the program. Thank you. Chairman Sensenbrenner. Are there any amendments? The gentleman from Indiana, for what purpose do you seek recognition? Mr. Hostettler. I have an amendment at the desk. Chairman Sensenbrenner. The clerk will report the amendment. The Clerk. ``Amendment to H.R. 4997, Offered by Mr. Hostettler of Indiana and Ms. Jackson-Lee of Texas. Page 2, strike lines 7 and 8 and insert the following''---- [The amendment by Mr. Hostettler and Ms. Jackson-Lee follows:]
Mr. Hostettler. Mr. Chairman, I ask unanimous consent that the amendment be considered as read. Chairman Sensenbrenner. Without objection, so ordered. The gentleman is recognized for 5 minutes. Mr. Hostettler. I thank the Chairman. Mr. Chairman, this amendment reflects an agreement between myself and Congresswoman Jackson-Lee, the Ranking Member of the Immigration Subcommittee. As you have pointed out, her opening statement will be made a part of the record. Our colleague, Ms. Jackson-Lee, is in Houston, attending the funeral of fallen Houston Police Officer Rodney Joseph Johnson, who was slain in the line of duty. This amendment reauthorizes the J Visa Waiver Program for an additional 2 years, as opposed to a permanent reauthorization. By authorizing the program for 2 years, Congress will have time to further examine needed changes to the program and address those changes only after careful consideration. I hope you will join me in supporting this bipartisan amendment. And I yield back the balance of my time. Chairman Sensenbrenner. The gentleman from Michigan? Mr. Conyers. Mr. Chairman, I rise in support of the amendment. Chairman Sensenbrenner. The gentleman is recognized for 5 minutes. Mr. Conyers. I notice that both our Ranking Member and the Subcommittee member are in agreement. I agree with the amendment. I also ask unanimous consent to add into the record the Los Angeles Times article about the looming crisis. Chairman Sensenbrenner. Without objection. [The article follows:]
Mr. Conyers. I turn back the rest of my time. Chairman Sensenbrenner. The question is on agreeing to the amendment offered by the gentleman from Indiana, Mr. Hostettler. Those in favor will say ``aye.'' Opposed, ``no.'' The ayes appear to have it. The ayes have it. The amendment is agreed to. Are there further amendments? If there are no further amendments, a reporting quorum is present. The question occurs on the motion to report the bill, H.R. 4997, favorably, as amended. All in favor will say ``aye. Opposed, ``no.'' The ayes appear to have it. The ayes have it. The motion to report favorably is agreed to. Without objection, the bill will be reported favorably to the House in the form of a single amendment in the nature of a substitute, incorporating the amendment adopted here today. Without objection, the staff is directed to make any technical and conforming changes. And all members will be given 2 days, as provided by the House rules, in which to submit additional, dissenting, supplemental or minority views. [Intervening business.] Chairman Sensenbrenner. For what purpose does the gentleman from Texas seek recognition? Mr. Smith. Mr. Chairman, I would like unanimous consent to speak out of turn for 1 minute. Chairman Sensenbrenner. Without objection. Mr. Smith. Mr. Chairman, you are not expecting this, but it occurs to me that you were nice enough a few minutes ago to pay tribute to three members of this Committee who are leaving. I thought this might also be an appropriate time to, frankly, pay tribute to you and your leadership of the full Committee. You have, frankly, many legacies. We all know and feel how much of a workhorse this Committee has been. I checked not too long ago and determined that the Judiciary Committee is second only to one other Committee in the number of bills it has sent to the House floor not under suspension. That is, again, a tribute to your leadership. Furthermore, you have fought for all of your jurisdiction in ways that give a new standard to your cause. You and Mr. Conyers have done a great job in protecting that jurisdiction. Finally, Mr. Chairman, as I think everyone knows, you are an acknowledged top negotiator, one of the best that has ever served in the House, and we appreciate your efforts in that regard, too. Also, your emphasis on oversight should not be overlooked. There are many times where we have passed legislation and we really don't follow up to make sure that it is being implemented in the way we intended. You have done a superb job in making sure that that oversight has been done, and done in constructive ways. And finally, Mr. Chairman, I don't know if Phil Kiko is here, your chief of staff, but he has certainly been an able support to you and an excellent chief of staff and has helped all of us achieve our goals. So just know that your many years of service have been appreciated, and we hope to have your skills available to us in the next Congress. [Applause.] Chairman Sensenbrenner. I thank the gentleman from Texas. And let me remind him and the other members and those in the audience that the Constitution says that the statements of the gentleman from Texas cannot be questioned in any other place. [Laughter.] The purpose for which this markup has been called having been completed, without objection, the Committee stands adjourned. [Whereupon, at 10:50 a.m., the Committee was adjourned.]