SPEAKERS CONTENTS INSERTS
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27–608 PDF
2006
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
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Serial No. 109–111
Printed for the use of the Committee on the Judiciary
Available via the World Wide Web: http://judiciary.house.gov
COMMITTEE ON THE JUDICIARY
F. JAMES SENSENBRENNER, Jr., Wisconsin, Chairman
HENRY J. HYDE, Illinois
HOWARD COBLE, North Carolina
LAMAR SMITH, Texas
ELTON GALLEGLY, California
BOB GOODLATTE, Virginia
STEVE CHABOT, Ohio
DANIEL E. LUNGREN, California
WILLIAM L. JENKINS, Tennessee
CHRIS CANNON, Utah
SPENCER BACHUS, Alabama
BOB INGLIS, South Carolina
JOHN N. HOSTETTLER, Indiana
MARK GREEN, Wisconsin
RIC KELLER, Florida
DARRELL ISSA, California
JEFF FLAKE, Arizona
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MIKE PENCE, Indiana
J. RANDY FORBES, Virginia
STEVE KING, Iowa
TOM FEENEY, Florida
TRENT FRANKS, Arizona
LOUIE GOHMERT, Texas
JOHN CONYERS, Jr., Michigan
HOWARD L. BERMAN, California
RICK BOUCHER, Virginia
JERROLD NADLER, New York
ROBERT C. SCOTT, Virginia
MELVIN L. WATT, North Carolina
ZOE LOFGREN, California
SHEILA JACKSON LEE, Texas
MAXINE WATERS, California
MARTIN T. MEEHAN, Massachusetts
WILLIAM D. DELAHUNT, Massachusetts
ROBERT WEXLER, Florida
ANTHONY D. WEINER, New York
ADAM B. SCHIFF, California
LINDA T. SÁNCHEZ, California
CHRIS VAN HOLLEN, Maryland
DEBBIE WASSERMAN SCHULTZ, Florida
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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
LOUIE GOHMERT, Texas
LAMAR SMITH, Texas
ELTON GALLEGLY, California
BOB GOODLATTE, Virginia
DANIEL E. LUNGREN, California
JEFF FLAKE, Arizona
BOB INGLIS, South Carolina
DARRELL ISSA, California
SHEILA JACKSON LEE, Texas
HOWARD L. BERMAN, California
ZOE LOFGREN, California
LINDA T. SÁNCHEZ, California
MAXINE WATERS, California
MARTIN T. MEEHAN, Massachusetts
GEORGE FISHMAN, Chief Counsel
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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
The Honorable John N. Hostettler, a Representative in Congress from the State of Indiana, and Chairman, Subcommittee on Immigration, Border Security, and Claims
The Honorable Sheila Jackson Lee, a Representative in Congress from the State of Texas, and Ranking Member, Subcommittee on Immigration, Border Security, and Claims
WITNESSES
The Honorable Jerry Moran, a Representative in Congress from the State of Kansas
Oral Testimony
Prepared Statement
Mr. Edward Salsberg, Director, Center for Workforce Studies, Association of American Medical Colleges
Oral Testimony
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Prepared Statement
Mr. John B. Crosby, J.D., Executive Director, The American Osteopathic Association
Oral Testimony
Prepared Statement
Ms. Leslie G. Aronovitz, Director, Health Care, United States Government Accountability Office
Oral Testimony
Prepared Statement
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
Prepared Statement of the Honorable Kent Conrad, a U.S. Senator from the State of North Dakota
Prepared Statement of Gregory Siskind, Chairman, National Health Care Access Coalition
Letter to the Honorable Sheila Jackson Lee from Connie Berry, Manager, Texas Primary Care Office
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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[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.
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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.
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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.
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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.
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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.
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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.
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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.
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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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ATTACHMENT 1
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ATTACHMENT 2
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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.
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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
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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.
T3Physician 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.
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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
[Note: Image(s) not available in this format. See PDF version of this file for complete hearing record.]
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.
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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.
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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.
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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.
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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——
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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.
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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——
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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?
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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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