SPEAKERS CONTENTS INSERTS
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THE HEALTH PROFESSIONAL SHORTAGE AREA NURSING RELIEF ACT OF 1997
WEDNESDAY, NOVEMBER 5, 1997
House of Representatives,
Subcommittee on Immigration and Claims,
Committee on the Judiciary,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:13 a.m., in room 2237, Rayburn House Office Building, Hon. Lamar Smith (chairman of the subcommittee) presiding.
Present: Representatives Lamar Smith, Ed Bryant, and Melvin L. Watt.
Also present: Representative Bobby L. Rush.
Staff present: George Fishman, counsel; Judy Knott, staff assistant; and Martina Hone, minority counsel.
OPENING STATEMENT OF CHAIRMAN SMITH
Mr. SMITH. The Subcommittee on Immigration and Claims will come to order. We welcome you all. We welcome your interest in the subject at hand today. After I make an opening statement, we will proceed to our first witness and a colleague of ours here in Congress.
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Today we will consider H.R. 2759,(see footnote 1) the Health Professional Shortage Area Nursing Relief Act of 1997, which was introduced by Representative Bobby Rush.
Because of a shortage of nurses in the late 1980s, Congress passed the Immigration Nursing Relief Act of 1989. That act created for a period of 5 years the H–1A temporary visa program for registered nurses. When the H–1A program sunsetted, the House of Representatives decided against extending it. There does not appear to be a national nursing shortage today, so perhaps there is no need to revive the H–1A program itself.
However, a number of hospitals with unique circumstances are still experiencing great difficulty in attracting American nurses. Hospitals serving mostly poor patients in crime-ridden neighborhoods have special difficulties, and in fact, some hospitals in rural areas also have those same problems.
Representative Rush's bill has been drafted very narrowly to help precisely these kinds of hospitals. It would create a new temporary registered nurse visa program, designated H–1C, that would provide up to 500 visas a year and that would sunset in 5 years.
To be able to petition for an alien, an employer would have to meet 4 conditions. First, the employer would have to be located in the health professional shortage areas designated by the Department of Health and Human Services. Second, the employer would have to have at least 190 acute care beds. Third, a certain percentage of the employer's patients would have to be Medicare patients; and, fourth, a certain percentage of patients would have to be Medicaid patients.
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Today we will hear from the bill's author, Representative Rush, and a number of hospitals regarding H.R. 2759. We will also hear from the administration and from the American Nurses Association. Our goal should be that set out by the Immigration Nursing Relief Advisory Committee created by the Immigration Nursing Relief Act of 1989: We need to ''balance both the continuing need for foreign nurses in certain specialties and localities for which there are not adequate domestic registered nurses and the need to continue to lessen employers' dependence on foreign registered nurses and protect the wages and working conditions of U.S. registered nurses.''
The Ranking Member of the subcommittee, Mr. Watt, will be joining us, I think, momentarily. He has two other conflicts this morning, a Banking Committee meeting and a full Judiciary Committee meeting. As is often the case, we have to run around from one hearing or meeting or markup to another, so we will proceed. Unless there are other members who might have an opening statement, Mr. Bryant, we welcome you, and if you have an opening statement, we would be happy to hear it.
Mr. BRYANT. Thank you, Mr. Chairman. I don't have a formal opening statement, but I am among that crowd that is shuffling between meetings today, and I will have to leave shortly after I finish my statement to get to the next appointment.
But I want to commend my colleague, Mr. Rush, for this bill. I certainly support the concept of it. I understand, having been through these battles in the last Congress over the extension of this program.
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What I learned was that overall, we have nurses, maybe in excess at this point, it is cyclical, but that probably of more concern to me, representing both an urban and rural area, is the distribution of those nurses. Unfortunately, some of the rural areas do have shortages that this particular type of extension program could address. I will be supporting it.
I like what I have seen in the bill. It seems to be a little bit tighter drawn this year, and I commend him for bringing this bill and also the Chair for having the hearing today. Thank you.
Mr. SMITH. Thank you, Mr. Bryant.
We will proceed to hear from our colleague, Bobby Rush. Congressman, we welcome you this morning, we appreciate the legislation you have introduced, as I already mentioned in my opening statement, and we look forward to your statement now as well.
STATEMENT OF HON. BOBBY L. RUSH, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS
Mr. RUSH. Thank you, Mr. Chairman, and I certainly want to just thank you so much for calling this important hearing today. I will try to be brief in my remarks. I know that there are some potential witnesses here who are from the hospitals and from the administration, and I am sure you want to get to them also.
I greatly appreciate the opportunity to appear before this committee today. Last week I introduced legislation, H.R. 2759, the Health Professional Shortage Area Nursing Relief Act of 1997. My goal in introducing such legislation is simple: to assist the underserved communities of this Nation in providing adequate health care for its residents.
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However, I must confess that my goal for this legislation is not totally altruistic. I represent the First Congressional District of Illinois, which includes a community known as Englewood. The St. Bernard Hospital is a small community hospital located in Englewood. The Englewood community was a thriving area of middle class families and bustling businesses, but much has changed. This area has experienced a sharp economic trauma similar to that which has occurred in urban areas across this nation. The following will reflect this change:
St. Bernard Hospital has the second highest number of patients suffering from drive-by shootings in Chicago. Last year the emergency room had 31,000 visits. The percentage of Medicaid patients is 50 percent and the percentage of Medicare patients is 35 percent. Over the last year, the amount of charity care has increased over 100 percent, from $3 million to $7 million.
The issue of immigrant nurses is a touchy one, one which, if I had my wish, I would prefer to avoid. Nevertheless, St. Bernard Hospital and other hospitals across the Nation are experiencing nursing shortages. Although the numbers indicate that no shortage of nurses exists nationally, there are pockets of areas which do experience a scarcity of health care professionals. Through my legislation, I seek to assist such communities.
The Emergency Nursing Relief Act of 1989 created the H–1A visa program in order to allow foreign educated nurses to work in the United States. The rationale for the H–1A program, as acknowledged by the AFL–CIO, the American Nurses Association and others, was to address spot shortage areas. St. Bernard Hospital, which has been located in the Englewood area since 1904, utilized the H–1A program to maintain an adequate staff level of nurses.
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The H–1A program was vital to St. Bernard's continuing existence. In the past, due to nursing shortages, St. Bernard hired temporary nurses. As a result, St. Bernard's nursing expenditures increased by approximately $2 million in an effort to provide health care to its patients in the year 1992 alone. Because of this additional cost, St. Bernard Hospital came close to closing its doors.
The H–1A visa program expired on September 30 of this year. As a result, no program currently exists that would assist hospitals such as St. Bernard in their efforts to maintain and retain qualified nurses. My legislation seeks to close the gap created by the expiration of the H–1A program.
This legislation would address critical shortages, improving health care need areas. H.R. 2759 prescribes that any hospital which seeks to hire foreign nurses under these provisions must meet the following criteria: One, be located in a health professional shortage area; two, have at least 190 acute care beds; three, have a Medicare population of 35 percent; and, 4, have a Medicaid population of at least 28 percent.
As one who has always fought for the American worker, I wanted to ensure that this proposal did not have a detrimental effect on American nurses. Thus, my legislation seeks a cap on the number of new visas that may be issued each year, in order to ensure that this bill will serve as a mechanism to meet the health care needs of our citizens and not be used as a convenient loophole, to be used in order to obtain admission to the United States.
Processing requirements of the H–1A program were incorporated into this legislation. These requirements require employers to attest that the hiring of foreign nurses will not adversely affect the wages and working conditions of registered nurses, and authorizes the Secretary of Labor to oversee the process and to provide penalties for noncompliance.
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Mr. Chairman, as you know, health care is indeed a basic human right. The hallmarks of a civilized nation are health care, education, and democracy. The state of health care is of grave concern in my district. Hospitals have closed, city health clinics are closing, payments for Medicare and Medicaid have been cut back.
The legislation we will consider today is aimed at helping hospitals which have not shut down, hospitals which are still serving their communities, helping these hospitals keep their doors open to the communities that they serve. This legislation, as a practical matter, will help hospitals such as St. Bernard in the neighborhood of Englewood, in my district, keep their doors open.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Rush follows:]
PREPARED STATEMENT OF BOBBY L. RUSH, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS
Thank You, Chairman Smith for calling this important hearing today. I greatly appreciate the opportunity to appear before this committee today.
Last week I introduced legislation, H.R. 2759, the Health Professional Shortage Area Nursing Relief Act of 1997. My goal in introducing such legislation is simple—to assist the underserved communities of this nation in providing adequate health care for its residents.
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However, I must confess that my goal for this legislation is not totally altruistic. I represent the First Congressional District of Illinois which includes a community known as Englewood. St. Bernard Hospital is a small community hospital located there. The Englewood community was once a thriving area of middle class families and bustling businesses. Much has changed. This area has experienced a sharp economic trauma similar to that which has occurred in urban communities across this nation. The following will reflect this change: St. Bernard Hospital has the second highest number of patients suffering from drive-by shootings in Chicago; last year the emergency room had 31,000 visits; the percentage of Medicaid patients is 50% and the percentage of Medicare patients is 35%; over the last year the amount of charity care has increased over 100% from $3 million to $7 million.
The issue of immigrant nurses is a touchy one, one which, if I had my wish, I would prefer to avoid. Nevertheless, St. Bernard and other hospitals across the nation are experiencing nursing shortages. Although the numbers indicate that no shortage of nurses exists nationally, there are pockets of areas which do experience a scarcity of health professionals. Through my legislation, I seek to assist such communities.
The Immigration Nursing Relief Act of 1989 created the H–1A visa program in order to allow foreign educated nurses to work in the United States. The rationale for the H1–A program, as acknowledged by the AFL–CIO, the American Nurses Association and others, was to address spot shortage areas. St. Bernard Hospital, which has been located in the Englewood community of my district since 1904, utilized the H1–A program to maintain an adequate nursing staff level. The H1–A program was vital to St. Bernard's continued existence. In the past, due to nursing shortages, St. Bernard hired temporary nurses. As a result St. Bernard's nursing expenditures increased by approximately $2 million in an effort to provide health care to its patients in 1992. Because of this additional cost, St. Bernard came close to closing its doors.
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The H1–A visa program expired on September 30th of this year. As a result, no program currently exists that would assist hospitals such as St. Bernard in their effort to retain qualified nurses.
My legislation merely seeks to close the gap created by the expiration of the H1–A program. This legislation will address critical shortages in proven health care need areas. H.R. 2759 prescribes that any hospital which seeks to hire foreign nurses under these provisions must meet the following criteria: (1) be located in a Health Professional Shortage Area; (2) have at least 190 acute care beds; (3) have a Medicare population of 35%; and (4) have a Medicaid population of at least 28%.
As one who has always fought for the American worker, I wanted to ensure that this proposal did not have a detrimental effect on American nurses. Thus, my legislation sets a cap on the number of new visas that may be issued each year. In order to ensure that this bill would serve as a mechanism to meet the health care needs of our citizens and not a convenient loophole to be used in order to obtain admission to the U.S., processing requirements of the H1–A program were incorporated into this legislation. These requirements require employers to attest that the hiring of foreign nurses will not adversely affect the wages and working conditions of registered nurses and authorizes the Secretary of Labor to oversee the process and provides penalties for non-compliance.
Health care is a basic human right. The hallmarks of civilized nations are health care, education, and democracy.
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The state of health care is of grave concern in my district. Hospitals have closed. City health clinics are closing. Payments for Medicare and Medicaid have been cut back.
The legislation we are considering today is aimed at helping hospitals which have not shut down—hospitals which are still serving their communities—helping these hospitals keep their doors open to the communities they serve.
This legislation, as a practical matter, will help hospitals such as St. Bernard, in the neighborhood of Englewood, in my district, keep their doors open.
Mr. SMITH. Thank you, Mr. Rush. One quick comment, and then we will go to Mr. Watt for his questions first, since he has a markup going on right now, in fact, in the Banking Committee.
Mr. Rush, I wanted to not only thank you for your comments but also acknowledge, and you wouldn't mind my saying this, that it is not many Members of Congress who have a hearing on a bill that was only introduced a week ago. We want, I think, therefore to acknowledge the ready assistance that you and I have had from our Chairman, Mr. Hyde, and his interest in this legislation and in remedying the shortage of nurses in the Chicago area, as well.
Mr. RUSH. Yes.
Mr. SMITH. So I wanted to share the credit with Mr. Hyde in that regard. Now the gentleman from North Carolina, Mr. Watt, is recognized.
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Mr. WATT. Thank you, Mr. Chairman, and thank you for allowing me to go ahead of you in the questioning, in trying to accommodate my schedule.
Let me first of all apologize to my colleague, Mr. Rush, for being late, and apologize in advance to the other panel members, members of the other panels, because I am going to have to leave. But I did want to come over and was especially trying to get here to hear my colleague's testimony on this bill, because I know he has worked on it and has tried to craft a bill that will try to address a problem, and kind of tiptoed through the tulips, so to speak.
This is a very, very difficult area, and I think the question I would ask really you started to touch on in your opening comments: How do you justify creating a special program, immigration program, to bring in people who are not yet within the confines of the country, when there is not an overall shortage of nurses within the confines of the country?
Wouldn't it be more reasonable to try to incentivize, in some way, relocation of nurses from other areas of the country who are already here, than to do this? How could we do that? Are there ways that that might be done?
Wouldn't it be more reasonable if we could come up with a way to underwrite some of the extra costs that that might occasion, assuming that your $2 million figure is correct, that is going to result in higher costs to hire people from other areas? But that is the function of supply and demand in a number of different areas.
And finally, and I am asking because I am talking randomly here and thinking randomly, finally, the limitation, while it certainly has appeal, the cap, while it certainly has appeal, seems to me possibly to add to the notion that this might be able to be addressed in some other way, because you are talking about a relatively small number of people that would be authorized under this bill and be eligible under the cap anyway. Given that very small number of people, it argues well, yes, we should make an exception; but it also argues, well, that perhaps with some innovative thinking within our own country we might be able to find a way to address the problem internally, without tinkering with the immigration laws.
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So I know I put a lot on the table and this is a very, very difficult area, and I don't know that I have strong feelings for or against the bill. But those questions just kind of cry out for some kind of response, and I will shut up and let you respond.
Mr. RUSH. Well, thank you very much, Mr. Watt. Your questions are quite appropriate, and let me first of all say that I do share your concern for the issue being redressed with American nurses as opposed to having immigrant nurses come in. However, I must say that this problem, particularly in certain urban areas, has not just been a problem that was recognized in the last few years. This is a longstanding problem.
Mr. WATT. But that is also true of physicians in medically underserved areas.
Mr. RUSH. Absolutely, right.
Mr. WATT. So that would also argue for an exception for physicians, I take it, at some point.
Mr. RUSH. Well, I am not going to go there at this point. As you indicated very aptly, this was a very narrowly designed piece of legislation, and we have literally been trying to dance through a lot of tulips and dodge raindrops all at the same time, so we wanted to narrowly craft this particular legislation.
I just want to say that not only has this problem been a problem that has been around for a long time and has not been addressed by any other vehicle, other than the H–1A visa extension program; I would say that, additionally, that I am not sure whether or not there is an adequate political resolve to create incentives for people, to force us to deal with additional incentives for nurses to locate in areas where there might be indeed a perception and also a reality of certain occupational hazards.
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I had a meeting with some of the officials from St. Bernard's last night and we were just going over some of the issues. Quite frankly, there are other hospitals, you know, in Chicago, who can compete for nurses, American nurses, because of the fact that their work demands are not as great, their perception of safety issues are not as concerned. So as a result there is a reluctance, an overall reluctance among nurses, for the most part, to actually work in certain hospital areas.
There have been attempts across the board to provide nurses, or to ask nurses or to recruit nurses into St. Bernard's and the hospitals like St. Bernard's over a period of time, and there just is a reluctance to do that, and the incentives would have to be quite significant, financial incentives would have to be quite significant in order to get them to work in hospitals like St. Bernard's. I mean, any time, as I indicated in my opening statement, you have 30,000 emergency room visits per year, that means that, you know, your work demands on nurses would be double that in a normal routine, regular hospital.
Mr. WATT. Mr. Chairman, I am going to yield back and give you an opportunity to ask Mr. Rush questions so that he won't have to come back, unless he just wants to come back.
Mr. SMITH. Thank you, Mr. Watt.
Mr. Rush and other friends who are here, we have a journal vote so we will have to leave in about 5 minutes, but we would like to finish up if we could with Mr. Rush, as Mr. Watt has just suggested.
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He asked a question and you gave a response that anticipated some of the questions that I might have asked. As I understand it, you are going to give us reassurances that this isn't going to negatively impact American nurses because of the limited scope of the legislation, which is to say 500 nurses, and it is sunsetted.
I know in a few minutes the American Nurses Association is going to voice concerns about the working conditions of nurses. I am just wondering out loud, perhaps if we paid them more and tried to recruit them more effectively, if we might not have solved the problem.
A couple of questions: How many hospitals do you think will benefit from your legislation?
Mr. RUSH. At present, I believe that there are two, two hospitals that would be the primary beneficiaries of this particular legislation.
Mr. SMITH. Okay. I thought it could be anywhere from 2 to 30, but I will take your word for it.
Mr. RUSH. A minimum of 2 at this point.
Mr. SMITH. A minimum of 2, and there may be as many as 30, as I understand. You were getting into, a few minutes ago, explaining why you thought that St. Bernard's was having such a difficult time attracting nurses, and you said sometimes people just don't want to work in certain areas or in certain hospitals. I know that must be a problem with St. Bernard's and at least one or more others.
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It seems to me that there are a number of things we can do to make their working situations more attractive but I guess my question is, if nurses locally or from nearby won't work in the hospital, what makes us think that foreign nurses might want to work in that hospital? Is it just because of their search for jobs or is there more to it than that?
Mr. RUSH. I think primarily it is the fact that they probably can earn more or they do earn more working in American hospitals, and if this is an opportunity to work in a hospital in this Nation, then they would jump at that opportunity.
Mr. SMITH. My last question is that I believe the American Nurses Association has some suggested changes to the legislation which are more or less technical in nature, and I don't know if they have spoken with you or if you are aware of the changes that they suggested, but I would like to recommend that we take a look at those changes and see if that might be acceptable to you along the way.
Mr. RUSH. Absolutely, Mr. Chairman.
Mr. SMITH. Thank you, Mr. Rush. I don't have any other questions, and we appreciate you being here.
Mr. RUSH. Thank you so much.
Mr. SMITH. I should officially say we are going to stand in recess for about 15 minutes, and I will return immediately after this vote.
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[Recess.]
Mr. SMITH. The Subcommittee on Immigration and Claims will reconvene.
Thank you for waiting. We do not expect any more votes now for the next hour, so I hope we can get to the next two panelists and to the rest of our panelists before noon.
I have invited Representative Rush to join us up here. He would like to hear the testimony of the witnesses that we have coming up as well, and in the absence of Mr. Watt, who cannot come back because of a Banking Committee conflict, we do welcome our colleague up front here.
Let us go to our second panel, which consists of Neil Sampson, and I will introduce you on your way up. Mr. Sampson is Acting Associate Administrator for Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services.
Mr. Sampson, welcome. And would you introduce the person you are with?
STATEMENT OF NEIL H. SAMPSON, ACTING ASSOCIATE ADMINISTRATOR FOR HEALTH PROFESSIONS, HEALTH RESOURCES AND SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Mr. SAMPSON. Yes, sir. Mr. Chairman, I am Neil Sampson, as you said, the Acting Associate Administrator for Health Professions in the Health Resources and Services Administration, and with me is John Fraser from the Department of Labor.
Mr. SMITH. Go on and proceed as you would. Thank you.
Mr. SAMPSON. HRSA is the access agency that administers the safety net programs providing health services to the uninsured and vulnerable individuals in our Nation. Within HRSA, the Bureau of Health Professions provides national leadership to assure that a health professions work force is there to meet the health care needs of the public.
Mr. Fraser, who is accompanying me, has submitted testimony for the record and is available to answer any questions related to the testimony. I personally want to thank you for the opportunity to discuss the issue of nursing supply in the United States and how to deal with selected areas and institutions which may have some difficulty in recruiting nurses.
We have recently completed the Sixth National Sample Survey of Registered Nurses and are beginning to analyze the data from that survey. Among the findings that we have from the survey, which data reflect the period of March, 1996, the registered nurse population, which includes foreign-trained nurses in the United States, totaled almost 2.6 million, an increase of more than 300,000 individuals since our previous survey in March of 1992.
The RN population grew at an average annual rate of about 3.4 percent between those dates, the highest growth rate since the November 1980 National Sample Survey of Registered Nurses. Some 82.7 percent of the RN population is employed in nursing.
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Since the nursing shortage of the late 1980s, admissions to basic nurse programs have increased from 103,000 in the 1988–89 academic year to almost 130,000 in the 1993–94 academic year. In 1994–95, this trend seems to have either leveled off or a slight decline.
Graduations, however, from nursing schools have increased annually from their lowest point in that 1988–89 period of about 62,000 to the highest point in the 1994–95 academic year of 97,000 graduates, an increase in that period of time of more than 50 percent.
The changing employment picture is evident from the survey data. The total number of employed RNs increased 14 percent between 1992 and 1996; however, the number in hospitals increased only 3 percent. About 60 percent of the 2.1 million employed RNs were working in hospitals in 1996, as compared to almost 67 percent who were working in hospitals in 1992. The change reflects a shift towards ambulatory and long-term care positions.
The average salary, which we found out from the survey, for staff nurses working in hospitals in 1992 was $36,618. In 1996 it was $40,097, which if we adjust for inflation, comes out to about $35,874 in '92 dollars. This may be one of the reasons why there may be pockets of recruitment problems.
In 1996 there were 1,516 basic RN programs of nursing in the United States. Illinois ranked fifth in the number of nursing programs, with 73. New York had the most, at 100; followed by California, with 96; Pennsylvania with 84; and Texas with 77.
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In 1996, 110,000 nurses employed or residing in the U.S. received their basic nurse education in a foreign country. In '88, prior to the passage of legislation providing for H–1A visas, there were approximately 73,000 such RNs. This is a 51-percent increase in the number of foreign-trained nurses compared to the 26-percent increase in all RNs during that same period of time.
Almost three-quarters, 72 percent, of the 110,000 foreign-trained and foreign-educated RNs in 1996 came from four countries. The largest single group, about 43 percent, or 47,400, came from the Philippines; 19 percent, or 21,400, came from Canada; 10 percent, or 11,500, from the U.K.; and 9 percent, or almost 10,000, from India.
The best information currently available indicates that there is no national shortage of registered nurses. There are a few areas in which specialty and locality shortages persist. Factors such as increased numbers of graduating nurses and changing demands for registered nurses associated with the movement to managed care have remedied any overall shortage.
Back in 1989, the Immigration Nursing Relief Act created the H–1A visa classification for nonimmigrant registered nurses. The H–1A program was a 5-year pilot program that expired September '95. When the program expired, we did not see any justification for extending the special visa category. Our view remains the same today with regard to creating new categories.
The written testimony submitted by the Department of Labor will outline already existing programs to allow foreign nurses to enter and work in the U.S. to meet specialty or locality shortages, as well as local steps to make unfilled job opportunities more attractive, such as improved salaries and benefits, improved work schedule flexibility and enhanced educational training opportunities.
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The Department of Health and Human Services will continue to monitor nursing supply and demand as well as nursing admissions under the other available immigration programs. We thank you for the opportunity to address this issue with you today.
[The prepared statement of Mr. Sampson follows:]
PREPARED STATEMENT OF NEIL H. SAMPSON, ACTING ASSOCIATE ADMINISTRATOR FOR HEALTH PROFESSIONS, HEALTH RESOURCES AND SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Chairman, I am Neil H. Sampson, Acting Associate Administrator for Health Professions in the Health Resources and Services Administration (HRSA). HRSA is the access agency that administers the safety net programs providing health care services to the uninsured and vulnerable individuals in our nation. Within HRSA, the Bureau of Health Professions provides national leadership to assure a health professions workforce that meets the health care needs of the public. I understand that the Department of Labor has submitted testimony for the record and that a representative of the Department of Labor is present today to answer questions related to their testimony.
Thank you for the opportunity to discuss the issue of nursing supply in this country, and how to deal with selected areas and institutions which may have some difficulty recruiting nurses. We have recently completed the Sixth National Sample Survey of Registered Nurses, and are beginning to analyze the data from that survey. Among major findings:
In March 1996, the registered nurse population (including foreign nurses) in the United States totaled almost 2.6 million, an increase of more than 300,000 individuals since March 1992. The RN population grew at an average annual rate of 3.4 percent between those dates, the highest growth rate shown since the November 1980 National Sample Survey of Registered Nurses. Some 82.7 percent of the RN population is employed in nursing.
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Since the nurse shortage of the late 1980's, admissions to basic nurse programs increased from 103,025 in 1988–89 to 129,897 in 1993–94. In 1994–95, this trend changed somewhat and the number of admissions has decreased slightly.
Graduations from nursing schools have increased annually from their lowest point in 1988–89 at 61,660 to their highest point in 1994–95 of 97,052 graduates, an increase of more than 50 percent.
The changing employment picture is evident from the survey data. The total number of employed RNs increased 14 percent between 1992 and 1996. However, the number in hospitals increased only 3 percent. About 60 percent of the 2.1 million employed RNs were working in hospitals in 1996 compared to almost 67 percent in 1992. This change reflects the shift toward ambulatory and long term care positions.
The average salary for a staff nurse working in a hospital in 1992 was $36,618 and in 1996 was $40,097, which if adjusted for inflation is $35,874 in 1992 dollars.
In 1996 there were 1,516 basic RN programs of nursing in the U.S. Illinois ranked fifth in the number of nursing programs at 73. New York had the most at 100, followed by California with 96 programs, Pennsylvania with 84 and Texas with 77.
In 1996, 110,000 RNs were employed or residing in the United States who received their basic nursing education in a foreign country. In 1988, prior to the passage of legislation providing for the H–1A visas, there were an estimated 73,000 such RNs. This is a 51-percent increase in the number of foreign-trained nurses compared to a 26-percent increase in all RNs during that period.
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Almost three-quarters, 72 percent, of the 110,000 foreign-educated RNs in 1996 came from four countries. The largest single group, about 43 percent, or 47,400, came from the Philippines. Nineteen percent, or 21,400 came from Canada; 10 percent, or 11,500, from the United Kingdom, and 9 percent, or almost 10,000, from India.
The best information currently available indicates that there is no national shortage of registered nurses. There are a few areas in which specialty and locality shortages persist. Factors such as increased numbers of graduating nurses and changing demand for registered nurses associated with the movement to managed care have remedied any overall shortage.
Back in 1989, the Immigration Nursing Relief Act (INRA) created the H–1A visa classification for nonimmigrant registered nurses. The H–1A program was a five-year pilot program that expired September 1, 1995. When the program expired, we did not see any justification for extending this special visa category. Our view remains the same today with regard to creating new categories.
The written testimony submitted by the Department of Labor will outline already existing programs to allow foreign nurses to enter and work in the U.S. to meet specialty or locality shortages, as well as local steps to make unfilled job opportunities more attractive, such as improved salaries and benefits, improved work schedule flexibility and enhanced educational and training opportunities.
The Department of Health and Human Services will continue to monitor nursing supply and demand, as well as nursing admissions under the other available immigration programs. Thank you for the opportunity to address this issue with you today.
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Mr. SMITH. Thank you, Mr. Sampson. I do have a couple of questions, and one goes to that part of your opening statement that you just mentioned about a minute ago where you stated that, ''there are a few areas in which specialty and locality shortages exist.''
Would a temporary visa program, such as the one Mr. Rush has outlined in this bill, be a good vehicle to deal with shortages in just those kinds of areas or not?
Mr. SAMPSON. What we have found is that there are distribution problems in many of the health professions, nursing being one of those, and we have in our programs looked at ways of trying to improve these opportunities of distribution, which include preferences for nurse training programs whose graduates go to practice in underserved areas, in shortage areas. There are also loan programs to students who will get repayment and loan forgiveness for working in underserved areas.
We have found that these programs and incentives help to fill shortages in underserved areas.
Mr. FRASER. Mr. Smith, if I could just add a thought to that.
Mr. SMITH. Would you introduce yourself again?
Mr. FRASER. Yes, John Fraser, with the Wage and Hour Division at the U.S. Department of Labor. We have submitted a written statement for the record but would save you some time by not going through it.
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Mr. SMITH. I appreciate that.
Mr. FRASER. In addition to what Mr. Sampson laid out, we have to remember that there are four programs in existing immigration law through which foreign nurses can be brought into the United States. So I think those two factors, the steps that you and Mr. Watt were asking about earlier and the existence of these other immigration programs, raise very substantial questions about the need for this program.
Mr. SMITH. As you gleaned from Mr. Watt's and my questions earlier, we are concerned about the working conditions and the wages of nurses. But I guess my question is, when you have a program this narrow, where you are talking about, at most, 500 people in specific locations, is that going to adversely impact the overall wages or the overall working conditions of nurses across the country?
Mr. FRASER. Probably not by itself, but Mr. Sampson's outlined changes of a 50 percent increase in addition to the supply, declines in real wages in the last few years in the nursing profession, and the existence of all these other programs, all these other vehicles for foreign nurses to be brought into the United States, all together that poses that real potential.
Mr. SMITH. I think if we keep the program narrow and restrict it, as it has been restricted, we can minimize those types of adverse impacts. At least that would be my view.
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Maybe more directly, has the administration taken a position on this bill or do you expect to take a position on the bill?
Mr. SAMPSON. We have not at this point, no, sir.
Mr. SMITH. Thank you.
Let me ask this question: At the present time, are there any programs in place that would address the problems experienced by St. Bernard? And relating to this is the fact that the current programs do not allow for the efficient processing of nurses, and timeliness is also a problem here.
Mr. SAMPSON. If I understand the first part of it, my answer would be, problems such as at St. Bernard reflect local problems, not national shortages. As the Congressman in his testimony noted, issues such as safety and working conditions may have an adverse effect on being able to attract and retain U.S. graduates to those areas. Those are the kinds of approaches and incentives that we would propose in the bureau.
For the programs that we support, we have incentives, preferences for working in underserved areas, such as inner city and rural areas. The bill, as drafted, probably would not affect too many rural areas.
Mr. SMITH. You have answered the second part of my question somewhat. Let me go to the first part, which is, are there any specific programs that exist now that would solve the problems of St. Bernard? And, if so, why have they not solved the problem?
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Mr. SAMPSON. You mean at this particular institution?
Mr. SMITH. Yes.
Mr. SAMPSON. In that area, we do support nursing training programs.
Mr. SMITH. What are those four programs mentioned specifically a while ago? And then, why are we not able to take advantage of any of those programs to solve the problem?
Mr. FRASER. There are two parts to the answer to the question, Mr. Smith. The first is what steps can be taken.
As you and Mr. Watt were asking, to give nurses greater incentives under the immigration programs there are, as I said, four existing provisions in law that can be utilized. The first of those is the permanent employment-based immigration program. The third preference employment-based immigrant program allows for employers to bring in skilled workers from foreign countries, including nurses.
Nurses do not require labor certification from the Department of Labor. There is no backlog or oversubscription in that category, either in terms of the ceilings on the category or the per country limitations, that would apply to the traditional sending countries for registered nurses. So the existing employment-based immigrant program is available.
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There are three nonimmigrant programs that are available. Although the H–1A program has expired, there are the temporary entry provisions of the North American Free Trade Agreement that address the temporary entry of citizens of Mexico and Canada. Canadian nurses have come in fairly substantial numbers. I think the estimates from HHS are somewhere in the 1,400 to 1,500 range of Canadian nurses who come to work in the United States.
And there are two other nonimmigrant provisions, the H–1B provision, which is available if the job itself requires a graduate degree. Not all nursing positions do, and many staff nursing positions do not, but some nursing specialty occupations do require a Bachelor's Degree.
And there is the H–2B nonimmigrant program, which is available for temporary nursing jobs, and there are many of those in the health care industry.
Mr. SMITH. Let me follow up on my question in this respect. Are you saying that this hospital, St. Bernard, and other hospitals in the same category, would be able to take advantage of some of these programs and need to apply for nurses from these programs?
Mr. FRASER. Much more likely to be able to use the permanent program.
Mr. SMITH. I do not know the answer of whether they have done so or not, but maybe we could find out. I am also advised failure to implement section 343 has blocked the nurses' access to the EB–3 provision. Is that the case as well?
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Mr. FRASER. That is an issue, as I understand it, Mr. Chairman, that is between the Department of Justice, INS and the Trade Representative. I am not familiar with where that stands, but my understanding is that that is a temporary situation in terms of the availability of EB–3B section, yes, sir.
Mr. SMITH. The other response on my part is to emphasize that, as I understand this bill, it would bring nurses in only temporarily to serve temporary problems, not permanently.
I think a lot of the concerns that you have would be significant if nurses were going to be in the country forever. But if we are having nurses who are only in the country for a short period of time to solve a short-term problem, maybe that impact would not be so great.
Mr. FRASER. And that is certainly a legitimate concern, Mr. Chairman, although I think we know from the history of these programs that that is really not the way they work.
Nonimmigrant programs tend to be feeders for permanent immigration. That is true with the H–1B program. It was certainly true with the H–1A program. As Mr. Sampson indicated, the population of foreign-educated nurses in the United States increased something like 40,000 over the last decade, and that almost certainly is a result of the existence and increased utilization of the H–1A program.
So it sounds like you are dealing with a short-term temporary problem, but you end up dealing with a permanent population.
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Mr. SMITH. Unfortunately, I have made that case in other instances myself, so I will not argue that. But I would simply respond if the bill is implemented as intended, that that problem would be resolved. I have spoken with Mr. Rush, and there are changes in this legislation that I think we can make to make sure it is implemented in the way it is intended.
Let me see if there are any other questions.
Mr. Sampson, thank you very much. I appreciate you both being here, and we will move on to the next panel.
Let us welcome our panel, three witnesses: Ron Campbell, Vice President, Patient Care Services, Saint Bernard Hospital and Health Care Center, Chicago, Illinois, accompanied by Ron Shapiro; also, Cheryl Peterson, Associate Director for Federal Government Relations, American Nurses Association; and Mark Stauder—is that the correct pronunciation?——
Mr. STAUDER. Yes, sir.
Mr. SMITH [continuing]. President and Chief Operating Officer, Mercy Regional Medical Center, Laredo, Texas.
We welcome you all, and we will start with Mr. Campbell.
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STATEMENT OF RON CAMPBELL, VICE PRESIDENT, PATIENT CARE SERVICES, ST. BERNARD HOSPITAL AND HEALTH CARE CENTER, CHICAGO, IL
Mr. CAMPBELL. Good morning. My name is Ron Campbell. I am Vice President of Patient Care Services for Saint Bernard Hospital and Health Care Center in Chicago, Illinois. On behalf of the hospital, I would like to thank Chairman Smith and other members of the committee for the opportunity to appear before you regarding H.R. 2759. With me are Ron Shapiro, Immigration Counsel for the Hospital, and Steve Nemerovski, Regulatory Counsel for the Hospital. Following my presentation, I will be most happy to answer any questions you have, and I have asked Mr. Shapiro and Mr. Nemerovski to assist me in that regard.
H.R. 2759 is a bill about a few special acute care hospitals that, because of geography and demographics, have a very difficult time attracting health care professionals. It is not a bill about nursing shortages and it is not about increasing immigration.
Although it is difficult for us to attract all kinds of health care professionals, there are some existing opportunities under the immigration laws to deal with physicians and technicians. However, following the sunset of the Immigration Nursing Relief Act of 1989, there is no existing opportunity under the immigration law to supplement the hiring of American nurses. This is contrary to stated congressional intent that the H–1B program be made available to nurses.
Saint Bernard is located on the south side of Chicago in the Englewood community. Unfortunately, high rates of crime and high poverty rates equal 31,000 visits to our emergency room per year, which makes us the second largest for the Chicago Fire Department's ambulance runs in the city.
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St. Bernard is Englewood's only remaining hospital and has a patient base almost entirely of poverty care or charity care. St. Bernard not only provides all the health care for area residents, including offices for the majority of physicians that practice in Englewood, but offers a great number of outreach and community-related services. It is also by far the largest employer in Englewood.
We are considered by the State of Illinois as one of the safety net hospitals in Chicago, and we are one of only a handful of hospitals recognized by the Illinois Department of Public Aid for special financial recognition for our role in delivering quality care to the indigent in the inner city of Chicago.
We almost closed our doors in 1992 because of our inability to attract registered nurses. Notwithstanding aggressive recruitment practices prior to the hospital learning of and taking advantage of the Immigration Nursing Relief Act of 1989, the only alternative to nurse vacancies other than overtime for existing staff was to hire nurses through nurse registries. However, nurse registries cost up to $55 an hour, and the nurses do not provide any type of stability or continuity of care. The extra cost of nurse registries exceeded $2 million a year, a number that is unsustainable.
St. Bernard is committed and attempts to hire as many American nurses as possible. We pay prevailing wage, recruit actively, and maintain training programs for local nursing schools. Our difficulty in recruiting American nurses is perhaps best demonstrated in the poor results of an extended advertising campaign earlier this year.
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Between April and September two different ads, one blind and one descriptive, were run consecutively in the Chicago Sunday Tribune. Over the 5-month period, approximately 200 applications were received. Of these, 145 respondents, almost 75 percent, declined to interview when they learned the position is located in Englewood. Twenty-two respondents were not qualified. The remaining 33 were interviewed, and of these 31 were offered positions, but of these only 15 applicants accepted positions. Therefore, the results of the expensive and extensive recruiting effort produced only 15 new hires, a number insufficient to cover normal attrition.
Our primary goal is to recruit and retain American workers, specifically American nurses. H.R. 2759 will be available to us merely as a safety valve, although an extremely critical safety valve. We ask for your support of H.R. 2759. Unless H.R. 2759 is passed, the future of St. Bernard's will again be at risk, and along with it all the other much needed health care services and benefits the hospital provides for the Englewood community of Chicago.
I would be more than happy to answer any questions that you may have. Thank you again for the opportunity to speak before this committee.
Mr. SMITH. Thank you, Mr. Campbell.
[The prepared statement of Mr. Campbell follows:]
PREPARED STATEMENT OF RON CAMPBELL, VICE PRESIDENT, PATIENT CARE SERVICES, ST. BERNARD HOSPITAL AND HEALTH CARE CENTER, CHICAGO, IL
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St. Bernard Hospital and Health Care Center: The Case for H.R. 2759
St. Bernard Hospital and Health Care Center, (''St. Bernard'') founded in 1904, is located on the South side of Chicago in the Englewood Community. It is the only remaining hospital in an area with a census in excess of 100,000 and the patient base is almost entirely poverty care or charity care. The patient to physician ratio is 3,636 to 1. As discussed below, St. Bernard not only provides all of the health care for area residents, including offices for the majority of physicians that practice in Englewood, but offers a great number of outreach and community-related services. It is also, by far, the largest employer in Englewood.
St. Bernard almost closed its doors in 1992, primarily because of its inability to attract health care professionals, most importantly registered nurses. Notwithstanding aggressive recruitment practices, prior to the hospital learning of and taking advantage of the Immigration Nursing Relief Act of 1989, the only alternative to nurse vacancies other than overtime for existing staff, was to hire nurses through nurse registries. However, nurse registries provided nurses at extremely high rates, often as high as $35 to $55 an hour, and the nurses provided under this scenario did not provide any type of stability or continuity of care. It is estimated that the impact from the extra cost of nurse registries exceeded $2,000,000 per year, a number that is not sustainable.
The problem was solved, in part, by hiring qualified foreign nurses and housing them in the hospital's convent. Even that solution often proved to be half a loaf because, as soon as the initial contract periods ended, we often lost their services to other hospitals.
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Although St. Bernard is committed to and attempts to hire as many American nurses as possible, foreign nurses are greatly needed to supplement the employment base. The hospital pays prevailing wage, recruits actively, maintains training programs for local nursing schools and is known for its quality medical care.
St. Bernard's difficulty in recruiting American nurses is perhaps best demonstrated in the poor results of an extended advertising campaign earlier this year. Between April and September, two different ads (one blind and one descriptive) were run consecutively in the Sunday Chicago Tribune. Over the five month period, approximately 200 applications were received. Of these, 145 respondents (almost 75%) declined to interview when they learned the position is located in the Englewood area of Chicago. Twenty-two respondents were not qualified. The remaining 33 were interviewed and, of these, 31 were offered positions; but, of these, only 15 applicants accepted positions. Therefore, the results of this expensive and extensive recruiting effort produced only 15 new hires; a number insufficient to cover normal attrition.
The hospital provides clinical training for nursing students from Kennedy King College, Daley College, Malcolm X College, Chicago State University and Olive Harvey College. St. Bernard has been working with these programs in the development of incentives that could attract the nurses to work within this community. We hope to see results from these efforts beginning in December, 1997 and May, 1998. However, the benefits from these efforts will be limited to openings for beginning nurses.
The hospital continually seeks to upgrade both the delivery of heathcare and the community in general. Three family medical clinics, open six days per week, have been established in the community and staffed with physicians of various specialties. A fourth clinic is currently in the process of being opened. A physician referral program is in place to assist those who need to find a private physician and, as stated above, the hospital has arranged to house the practices of all physicians because safety concerns prevent any physician from maintaining an independent office.
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Pre-natal classes for expectant mothers, postpartum classes and parenting classes are available throughout the year. Ultra sound exams for patients from the Board of Health are provided.
The hospital provides free screening for blood pressure, cholesterol, diabetes, podiatry, sickle cell and vision exams. Free school physicals and inoculations are provided for school-age children. Speakers are provided for school functions on a regular basis. School children are frequent tour groups in the hospital. The hospital participates in and sponsors numerous health fairs throughout the area. There are social workers available in the hospital to aid patients in determining their needs both in the hospital and upon discharge. Clothes are made available for those patients in need.
Wellness clinics on diabetes, eye care, OB, Pediatrics and Podiatry are available on the first floor of the institution. An outpatient pharmacy was opened for the convenience of the community residents. Our physicians visit senior housing facilities in the area on a regular basis. Classes in CPR are scheduled. Meeting rooms within the hospital are provided for community usage at no charge to the participants.
St. Bernard is now in the process of sponsoring a project for affordable housing in Englewood. This is part of our objective to reach out to and assist the community area residents in their search for a safer and healthier life.
Perhaps one of the hospital's most important contributions to the community is the opportunity for employment. As previously stated, we are the single largest employer in Englewood.
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However, unless H.R. 2759 is passed, the future of St. Bernard will again be at risk and, along with it, all of the services and benefits that the hospital provides to the Englewood community.
Mr. SMITH. Miss Peterson.
STATEMENT OF CHERYL A. PETERSON, ASSOCIATE DIRECTOR FOR FEDERAL GOVERNMENT RELATIONS, AMERICAN NURSES ASSOCIATION
Ms. PETERSON. Mr. Chairman and Members of the committee, my name is Cheryl Peterson. I am a registered nurse and the Associate Director for Federal Government Relations of the American Nurses Association. I appreciate the opportunity to participate in this hearing on H.R. 2759, the Health Professional Shortage Area Nursing Relief Act of 1997.
First, I would like to thank the many members of this committee who, in the fall of 1995, were supportive of halting an effort to restore the H–1A visa. At that time, like now, ANA did not believe the H–1A visa was needed. As a result of the changing health care environment, the increasing numbers of new graduate nurses entering the nursing market, and Canadian nurses entering under the North American Free Trade Agreement, ANA believed we had a sufficient number of registered nurses to meet the needs of the U.S. health care system. We continue to believe this is so.
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However, ANA recognizes there may be a problem of distribution of the nursing workforce and recognizes that some geographical areas may have difficulty recruiting registered nurses. ANA is committed to assuring the availability of registered nurses to support a health care system that ensures access to quality health services.
We recognize that St. Bernard Hospital is the only tertiary care facility that services the Englewood community of Chicago. The Illinois Nurses Association has raised legitimate concerns about the level of staffing at St. Bernard and the impact that poor staffing has on both quality of patient care and the recruitment and retention of registered nurses. ANA urges St. Bernard to continue the dialogue with the Illinois Nurses Association on issues related to appropriate staffing of registered nurses which is absolutely essential to maintaining the safety and quality of patient care.
ANA knows from previous experience with the H–1A nursing visa that such visas are subject to abuse. Numerous cases involving H–1A nurses resulted in civil penalties and the payment of back wages for failure to pay prevailing wage as was required under the law. In addition, there were reports of substandard working conditions and threats of retaliation against nurses who dared to complain about their pay and working conditions. Through discussions on this legislation, ANA has sought to strengthen protections afforded registered nurses and limit the application to facilities which truly have difficulty in recruiting and retaining registered nurses.
Now I would like to focus on a few provisions which are of particular importance to ANA.
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First and foremost, ANA believes that all registered nurses entering the United States, whether they enter on a temporary nonimmigrant visa, like the H–1C visa, or as a result of a trade agreement, such as NAFTA, must be prescreened as prescribed under section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996. This prescreening is essential to ensuring that a basic level of competency is maintained for the ongoing safety and quality of patient care provided here in the United States.
Currently, the necessary regulations to implement section 343 are under consideration at the Office of Management and Budget. The regulatory process for this section has been unnecessarily prolonged. I would urge every member of the this committee to contact OMB and request that section 343 regulations be approved for publication in the Federal Register.
ANA strongly believes that the application of this bill must be limited. Only hospitals located in a health professional shortage area, with at least 190 beds and a defined reimbursement percentage under Medicare and Medicaid for inpatient services, are eligible. ANA would adamantly oppose any efforts to broaden the application of this bill.
There are numerous provisions included which seek to protect the foreign-educated nurse. Of note, employers hiring H–1C visa nurses must pay the prevailing wage. ANA is very pleased the bill includes a provision requiring advanced disclosure of detailed information on the neighborhood, hospital and working conditions under which the nonimmigrant will be working.
For domestic nurses, they must have been notified within 30 days that their facility intends to bring in an H–1C visa registered nurse. The hospital is ineligible to participate if there is a labor dispute in progress, if the facility has laid off registered nurses within the previous year, or if the use of H–1C visa nurses is intended to influence an election for union representation.
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As proposed, the legislation retains the essential prescreening requirements contained within section 343. It is narrowly constructed as only to apply to hospital facilities which are most likely to have difficulty in recruiting registered nurses, and contains critical protections for both domestic and foreign registered nurses.
Thus, the ANA has decided not to oppose the proposed legislation. However, I must reiterate that we will adamantly oppose any amendments which seek to broaden the application of this visa or would lessen the protections afforded registered nurses under this measure.
Again, I thank the committee for the opportunity to participate in these deliberations and remain available for any assistance that I and the American Nurses Association can provide the committee.
[The prepared statement of Ms. Peterson follows:]
PREPARED STATEMENT OF CHERYL PETERSON, MSN, RN, ASSOCIATE DIRECTOR FOR FEDERAL GOVERNMENT RELATIONS, AMERICAN NURSES ASSOCIATION
Mr. Chairman and members of the Committee, my name is Cheryl Peterson, MSN, RN. I am a registered nurse and the Associate Director for Federal Government Relations at the American Nurses Association. I appreciate the opportunity to participate in this hearing on H.R. 2759, the Health Professional Shortage Area Nursing Relief Act of 1997.
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The American Nurses Association is the only full-service professional organization representing the nation's two million registered nurses. ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, and by working closely with the U.S. Congress on health care issues affecting nurses and the public. In addition, ANA serves as the United States representative to the International Council of Nursing.
First, I would like to thank the many members of this committee who, in the Fall of 1995, were supportive in halting an effort to restore the H–1A visa. At that time—like now—ANA did not believe that the H–1A visa was needed. As a result of the changing health care environment, the increasing numbers of new graduate nurses entering the nursing market and Canadian nurses entering under the North American Free Trade Agreement, ANA believed that we had a sufficient number of registered nurses to meet the needs of the U.S. health care system. We continue to believe that there are a sufficient number of domestic registered nurses, however; ANA recognizes that there may be a problem of distribution of the nursing workforce and recognizes that some geographical areas may have difficulty recruiting registered nurses.
Having said this, ANA continues to believe that the nursing community, in cooperation with the Department of Health and Humans Services and the Department of Labor, must work to address the root causes for the instability of the nursing workforce that has led to swings in the supply and demand of registered nurses. Over reliance on foreign educated nurses by the hospital industry serves only to postpone real efforts to address the nursing workforce needs of the United States. In addressing the issue of supply, it is critical that all avenues which feed into the supply of registered nurses must be considered, especially the increasing use of trade agreements, along with the domestic production of registered nurses.
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ANA has long advocated that all U.S. citizens and residents must have access to health care services. During the health care reform debate, this principle was—and continues to be—a cornerstone for the nursing community. The next iteration of this debate focused on objective measures of the quality of health care. Changes in the structure and composition of the nurse workforce prompted concern in the nursing community regarding patient safety and the quality of care provided to patients in hospitals. This concern is especially prevalent where practical or vocational nurses and unlicensed staff are asked to assume responsibilities previously performed by registered nurse staff. Ultimately, we must strive for a mix of domestic registered nurses and other health care providers who are educated to meet the demands of the future health care system supplemented with foreign educated nurses who are also adequately educated to handle very acutely ill patients, the majority of patients treated in tertiary care facilities today.
ANA remains committed to assuring the availability of registered nurses to meet the health care needs of the community. We recognize that St. Bernard Hospital is the only tertiary care facility that services the Englewood Community on the South Side of Chicago. As already noted, our commitment is to support a health care system that ensures access to quality health services. The Illinois Nurses Association has raised legitimate concerns about the level of staffing at St. Bernard and the impact that poor staffing has on both quality of patient care and the recruitment and retention of registered nurses. ANA urges St. Bernard to continue the dialogue with the Illinois Nurses Association on issues related to appropriate staffing of registered nurses which is absolutely essential to maintaining the safety and quality of patient care. We believe that this will be necessary if St. Bernard's is going to reduce its reliance on foreign educated nurses.
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While ANA considered our position on H.R. 2759, we looked to our recent history under the H–1A Visa. ANA knows from past experience under the H–1A nursing visa that such visas are subject to abuse and misuse. Numerous cases involving H–1A nurses have resulted in civil penalties and the payment of back wages for failure to pay prevailing wage as was required under the law. In addition, there were reports of substandard working conditions and threats of retaliation against nurses who dared to complain about their pay and working conditions. Through discussions on this legislation ANA has sought to strengthen protections afforded registered nurses and limit the application to facilities which truly have difficulty in recruiting and retaining registered nurses.
First and foremost, ANA believes it is absolutely essential that all registered nurses entering the United States whether they enter on a temporary, nonimmigrant visa, like the H–1C visa, or as a result of a trade agreement, such as the Trade NAFTA visa, must be prescreened as prescribed under Section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996. ANA considers this basic prescreening to be essential to ensuring that a basic level of competency is maintained for the ongoing safety and quality of patient care provided here in the United States. The prescreening process includes a predictor examination, English proficiency testing and review of the license in the home country to ensure that it is unencumbered.
Currently, the necessary regulations to implement Section 343 are under consideration at the Office of Management and Budget. The regulatory process for this Section has been unnecessarily long. I would urge every member of this committee to contact OMB and request that the Section 343 regulations be approved for publication in the Federal Register.
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In addition, to complying with the prescreening under Section 343, the H–1C visa nurse would have to pass the National Council Licensure Examination for Registered Nurses (NCLEX–RN), nursings' basic national licensure examination. Failure to pass the NCLEX examination would be grounds for the nurse to be returned to her home country. This element is particularly important for we know that under the H–1A nursing visa program, foreign educated nurses who failed the NCLEX were often kept on as unlicensed aides or technicians while still in the United States on the H–1A visa.
Hospitals seeking to bring foreign educated nurses into the United States under the H–1C visa would have to file an attestation—which must be renewed annually—with the Department of Labor indicating their intent to utilize foreign educated nurses and that they meet the criteria established to define a participating facility under this provision. As currently drafted, only hospitals located in a Health Professional Shortage Area with at least 190 beds and a defined reimbursement percentage under Medicare and Medicaid for inpatient services are eligible. ANA would oppose any effort to broaden the application of this bill. In particular, we would oppose the inclusion of nursing contractors, registries and agencies under this bill. As noted in the March 1995 report of the Immigration Nursing Relief Advisory Committee to the Secretary of Labor, ''the exploitation of foreign registered nurses is considerably greater with contract agencies than with major health care organizations that are heavily regulated and receive constant scrutiny.'' The Committee noted numerous anecdotal reports of contractors bringing in foreign educated nurses after requiring the payment of large sums of money and without firm commitments from hospitals to engage their services.
Efforts to protect both the foreign educated nurses and domestic nurses have been built into this legislation. Of particular note, employers hiring H–1C nurses must pay the prevailing wage and establish a recruitment and retention program designed to decrease their reliance on foreign educated nurses. In addition, the H–1C nurse is eligible to join or organize a union. ANA is particularly pleased that the bill includes a provision requiring advanced disclosure to the H–1C nurse of detailed information on the neighborhood, hospital, and working conditions under which the nonimmigrant will be working.
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For domestic nurses, they must be notified within thirty days that their facility has filed an attestation with the Department of Labor and intends to bring in H–1C registered nurses. The attesting hospital is ineligible if there is a labor dispute in progress, if the facility has laid off registered nurses within the previous year, or if the use of the H–1C nurse is intended to influence an election for union representation. As noted earlier, facilities are required to establish recruitment and retention programs which ANA believes can create an environment that facilitates quality nursing care.
Other significant provisions include:
cap of 500 visas annually;
process for filing a complaint with the Department of Labor, including civil penalties; and,
automatic sunset of the H–1C program after five years.
ANA continues to work with the interested parties in clarifying the language with regard to steps taken under the recruitment and retention program (Sec. 2(b)(2)(B)(v)). We believe that current language could be misconstrued and interpreted that only one element is necessary in establishing a recruitment and retention program. We realize that it is unlikely that a hospital would not employ more than one strategy in trying to recruit and retain nurses, however; we believe that this language should be altered or struck from the bill.
ANA continues to be concerned about the absence of a provision which discusses the ability of the H–1C visa holder to move to another facility. I understand that this is addressed in similar temporary, nonimmigrant programs and will work to clarify this concern.
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As proposed, the legislation retains the essential prescreening requirements contained within Section 343, is narrowly constructed as only to apply to hospital facilities which are most likely to have difficulty in recruiting registered nurses, and contains critical protections for both domestic and foreign registered nurses. Thus, the ANA has decided not to oppose the proposed legislation. However, I must reiterate that we will adamantly oppose any amendments which seek to broaden the application of this visa or would lessen the protections afforded registered nurses under this measure.
Again, I thank the Committee for the opportunity to participate in these deliberations and remain available for any assistance that I and the American Nurses Association can provide to the Committee.
Disclosure Statement
In compliance with House Rule XI, 2(g)(4) the curriculum vitae/resume of Cheryl A. Peterson, MSN, RN is attached. Ms. Peterson does not presently receive any federal grants nor has she received any federal grants within the past two fiscal years. The American Nurses Association (ANA) has not received any federal grants from the Department of Justice and the Department of Labor. ANA did receive in fiscal year 1995 $1,968,647 in grants and awards for projects with the Centers for Disease Control and Prevention, National Institute of Mental Health, Office of Disease Prevention and Health Promotion, Public Health Service, Division of Nursing, Nursing Special Projects and the Substance Abuse Mental Health Services Administration, Center for Mental Health Services; in fiscal year 96 we received a total of $962,219 in grants and awards for projects with the Centers for Disease Control and Prevention, National Institute of Mental Health, Division of Nursing, Nursing Special Projects, and Substance Abuse Mental Health Services Administration, Center for Mental Health Services.
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Mr. SMITH. Thank you, Ms. Peterson.
Mr. Stauder. And let me say we have been talking a lot about St. Bernard Hospital today, but we should think in terms of Mercy Regional Medical Center in Laredo as well.
I might say I have been to Laredo many times, obviously, being from Texas. I have a lot of friends in Laredo, and I appreciate what you must be facing there as well. So please continue.
STATEMENT OF MARK STAUDER, PRESIDENT AND CHIEF OPERATING OFFICER, MERCY REGIONAL MEDICAL CENTER, LAREDO, TX
Mr. STAUDER. Chairman Smith and members, thank you very much. I am going to speak candidly and frankly and not specifically to my submitted written comments. I would like to try to respond to some of the issues that have been brought up today.
I am Mark Stauder, President and CEO of Mercy Regional Medical Center in Laredo, Texas. Mercy Regional Medical Center is a 325-bed community hospital sponsored by the religious Sisters of Mercy. We are a Catholic not-for-profit hospital. We have been serving the three-county area of Webb, Zapata and Jim Hogg Counties for 103 years. We are located on the Mexican border, and the closest substantial U.S. cities are San Antonio and Corpus Christi, which are each about 150 miles north of Laredo.
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The current population of Laredo, of the tri-county area, and most of that population resides in Laredo, is 175,000 people. We are the second fastest growing city in the U.S., and have been so for the last three consecutive years. Our population is forecasted to grow in year 2000 to a population of 200,000 and in the year 2005 to a population of 240,000 people. So we do have a lot of issues that we will deal with, not just serving the current community and the current population but looking forward to that aggressive growth.
Mercy Regional Medical Center currently provides 70 percent of the regional health care services. Twenty-five percent of the population in Jim Hogg, Zapata and Webb counties are uninsured populations. That group of population is served by the Sisters of Mercy and Mercy Regional Medical Center.
Currently our efforts to recruit nurses have included using 10 to 15 nationally recognized recruiters to recruit nurses from the entire United States. Our rates of pay are 5 percent higher than the prevailing wage rates in our region, including San Antonio and Corpus Christi. We currently also offer tuition reimbursement systems within the organization to promote continued education of licensed vocational nurses going back to school and becoming RNs, other nursing assistants and other employees, encourage them to become registered nurses.
We do have one local community college in Laredo, Laredo Community College, that does have a 2-year diploma degree nursing program. They are currently graduating approximately 25 students a year. Twenty-five students a year does not maintain equilibrium when we look to out-migration, young adults leaving Laredo for the bigger Texas communities, as well as other reasons for leaving the work force. Our current need for registered nurses is between 85 and 100 RNs, and that is a fairly large percentage of our 385 nurses.
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In prior years, Mercy Regional Medical Center has been a large user of foreign nurses. Throughout the years, at any given time we would have approximately 60 foreign-educated RNs working at Mercy Regional Medical Center. And as you can see, I think we have committed a tremendous amount of resources.
I might also add we also have sign-on bonuses for our registered nurses. We are committed to providing quality of care at Mercy and we are attempting to bring nurses from across this country. We have a sign-on bonus currently, and have had for at least a year. If nurses are willing to sign a 4-year contract, they are given a sign-on bonus of $6,000. If they are willing to sign a 3-year contract, we have a sign-on bonus of $4,000.
We have used Canadian nurses in a limited way within the recent past. We currently have about seven Canadian nurses working at Mercy. What we have found, though, is south Texas is a long way from Canada, and many of the Canadian nurses who come, they come, they are young women and men, they stay with us six months, twelve months, and get very homesick and want to go home.
That concludes my remarks. I thank this committee, and I urge you to please consider the passage of this legislation, and I would be happy to respond to questions.
[The prepared statement of Mr. Stauder follows:]
PREPARED STATEMENT OF MARK STAUDER, PRESIDENT AND CEO, MERCY REGIONAL MEDICAL CENTER
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Mercy Regional Medical Center: The Case for H.R. 2759
Mercy Regional Medical Center, established in 1984 in Laredo, Texas, is a 326 bed acute care facility which serves the county area of Webb and Zapata counties. Laredo's location on the Mexican border also presents the necessity of caring for acutely ill patients from Mexico.
The mission of Mercy is to provide quality health care to all residents of this geographic area, regardless of financial ability to pay; and as such Mercy represents approximately 80% of the services to the indigent and charity care in the region.
The need for additional Registered Nursing staff became acute in 1993. The reason for this was the opening of numerous home health agencies and the fact that the local college was unable to graduate a sufficient number of candidates for employment. Although aggressive recruitment efforts were made, the hospital's only option became the use of ''travel'' or ''temporary'' agency nurses who asked rates of $37 per hour. These nurses failed to provide consistency, frequently staying a few days and moving on to the next assignment. The financial impact of such hiring practices was approximately $2,750,500; the impact on permanent resolution to the staffing crisis was nil. Recruitment was not limited to the use of temporary or travel nurses; Mercy has used between 10–15 professional recruiters in addition to a full time staff recruiter. Nurses have been reluctant to relocate to what is perceived as a ''remote part of the country.''
The staffing problem was temporarily resolved by the hiring of qualified foreign registered nurses. These nurses have provided professional and caring services; however, many leave after the initial contract period ends to join staffs at other hospitals.
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Mercy continues to have difficulty in its recruitment efforts. Even though Mercy has advertised nationally and in areas in this country which have been impacted by managed health care in an effort to attract qualified registered nurses from these areas, and even though it is offering substantial sign-on bonuses ($6,000), it currently has eighty-two Registered Nurse vacancies out of a total nursing staff of 365 full time equivalents. Mercy continues to use professional recruiters and has begun to utilize the Internet for recruitment purposes. Mercy's services have also expanded to include open heart surgery, rehabilitation, neurosurgery, and a skilled unit.
Mercy is the second largest employer in the Laredo, Texas area. It is also the largest of two hospitals. Significant strides have been taken by Mercy to improve the quality of health care in this area. Mercy has expanded its services to include the addition of seventy physicians who have opened offices in all areas of an ambulatory surgery and diagnostic center in north Laredo; full service clinics in the sound and mid center of town; and have begun building a replacement hospital facility to open in late 1998.
Medical care is accessible to all Laredoans, regardless of ability to pay. Wellness fairs have addressed the concept of prevention. Additionally, Mercy has acquired a mobile van which reaches the ''colonies'' which are heavily populated with indigent persons with poor access to health care. The mobile van, as well as the clinics, provide pre-natal classes, as well as regular exams to both men and women, including breast exams, mammograms, and pap smear exams.
Diabetes is prevalent in this predominantly Hispanic community. Mercy has joined community efforts in addressing the needs of diabetics. Classes are regularly given to the newly diagnosed diabetic, as well as to the chronic diabetic patients. Services include hyperbaric for the treatment of open wounds due to diabetes.
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When the H–1A visa waiver was granted in 1993, Mercy took full advantage and immediately began to recruit foreign nurses. To date, we have or have had approximately 84 foreign nurses in our employ. In addition, we currently utilize approximately 25 agency nurses per day to help us meet our staffing needs.
The loss of the opportunity to hire foreign nurses will be very detrimental to us. Even with our current staff of foreign nurses, our vacant positions remain quite high. Attempting to staff Mercy Regional Medical Center without access to foreign nurses would be overwhelming and would be devastating to patient care.
Mr. SMITH. Thank you, Mr. Stauder. Let me direct my questions to you first.
You mentioned that if you could, you would try to hire an additional, I think 85 to 100 nurses. You also mentioned that you had, I think, contracted with 15 recruiters. How successful were those recruiters? How many nurses did you get out of how many?
Mr. STAUDER. I would say that there are a lot of resumes that get sent back and forth. We have been reasonably successful with our recruiting efforts. We probably recruit four to five nurses a month.
But what we do find, too, is that south Texas is very unique and many nurses who come down and who do interview do not feel like Laredo is the appropriate community for them. And many of them who do come down, do not fit in and collaborate with the community and they usually do not stay very long.
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Mr. SMITH. Has the hospital tried to use some of these other categories of visas that we have talked about a minute ago, or not? And if so, what has been its experience?
Mr. STAUDER. We have tried. We have used local counsel in Texas, and what we have found in general is that it is a very extended, protracted, complicated and not very productive process.
Mr. SMITH. I hope they are listening. We will try to see if we cannot do something about that at another time, outside the scope of this bill.
Mr. Campbell, you mentioned your experience a little bit with trying to hire nurses. If this legislation was implemented, how many nurses would you expect to try to hire under its provisions?
Mr. CAMPBELL. We are looking somewhere around 30 nurses.
Mr. SMITH. Thirty or so?
Mr. CAMPBELL. Yes.
Mr. SMITH. And have you tried specifically to work through these other visa categories to try to attract nurses?
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Mr. CAMPBELL. Yes, we have. I would defer that question to Mr. Shapiro, who is our immigration counsel.
Mr. SMITH. Mr. Shapiro, if you would respond, please.
Mr. SHAPIRO. Mr. Chairman, I would like to respond with respect to each of those issues, immigrant and nonimmigrant visa categories.
With respect to the employment-based, three, the immigrant visa application, initially to file the immigrant visa petition with the INS regional service center having jurisdiction, the northern service center up until recently had a five-month processing time for employment-based immigrant visas, Form I–140. Recently that has been cut to maybe a two- to three-month processing time, but still we have initially, when you file the application, anywhere, as I said, from two to five months. Let us take an average of three months.
After the application is approved, it would have to go to the NVC, National Visa Center, to be forwarded to the appropriate consulate. NVC processing time in the NVC center located in New Hampshire takes approximately anywhere from two to four months.
Now the application is with the consulate. Let us take, for example, Manila. Consulate processing takes traditionally five to six months. Add to that there are additional problems, so now we have approximately over 12 to 13 months in processing.
Section 343, with respect to immigrant visas, has prohibited the issuance of immigrant visas both to individuals who are within the United States, in the adjustment process, as well as coming to the United States through consulate processing. The law was enacted in September of 1996. Fourteen months later, in November of 1997——
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Mr. SMITH. Mr. Shapiro, is that all to say you agree with Mr. Stauder that the process is protracted, complicated and not very efficient?
Mr. SHAPIRO. In one word, yes, it is not practical.
Let me go on to the next category. The TN visa is a viable alternative except for the problem that St. Bernard has not been able to attract Canadian individuals; and as for the same problem with Mercy Hospital, that individuals attracted under the TN processing, Canadians, do not wish to stay in that area. Although the TN, we would recognize that is an alternative that exists.
Mr. SMITH. By the way, you just said St. Bernard. Is my southern accent getting in the way?
Mr. SHAPIRO. I always said St. Bernard until Sister Elizabeth, and I never want to argue with Sister Elizabeth.
Mr. SMITH. That is good enough for me, too.
Mr. SHAPIRO. She told me once, Mr. Chairman, St. Bernard is a dog, we are the hospital. St. Bernard, in other words.
Mr. SMITH. Fair enough. Okay.
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Mr. SHAPIRO. Although, I guess, in deference, we use both terms.
The H–1B program, which is the primary focus, in response to an H–1B petition filed on behalf of a registered nurse, the response back from the Immigration and Naturalization Service which I have in front of me, the Department of Labor Occupation Outlook Handbook 1994–95 on page 176 stated that there are three major educational paths to nursing: Associate Degree, Bachelor of Science Degree, and, of course, ADN program in community colleges.
It goes on to further say that nurses with a Bachelor of Science degree may qualify to perform the services—however, most nursing positions do not require a Bachelor's Degree—and it must be established that the position requires the specialized knowledge, et cetera, et cetera, as evidenced by the attainment of a Bachelor's Degree.
As the committee is aware, the H–1B program in the statute states that an H–1B specialty occupation is a program that requires the attainment of at least, or I should say an occupation that requires at least the attainment of a Bachelor's or higher degree to perform the occupation and, two, the alien who is being sponsored to perform the position has that degree.
Immigration has taken the position that, as a general rule, registered nurse positions, since they do not require a Bachelor's Degree but rather an Associate Degree, do not qualify for the issuance of an H–1B visa. They have said, though, under the regs, ''If you could establish that your hospital only requires for the registered nurse position a 4-year degree, then we might consider it.''
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But then this is our problem. As Mr. Campbell indicates, the hospital is actively recruiting American workers, and within the community they have only Associate Degrees. So in order to be successful on the H–1B program, we would have to then stop hiring our American workers, who we desperately wish to hire, who have only the Associate Degrees.
That would be a paradox and an irony, that to bring in our H–1B's, to be successful with immigration, we would have to stop hiring our American workers. That is not a consequence, or I should say that is not a solution that is viable.
Mr. SMITH. I understand. Thank you Mr. Shapiro.
Miss Peterson, let me direct some questions to you. How would you respond to what has been said, which is to say, how would you recommend that these two hospitals solve their nursing shortages?
Ms. PETERSON. I do think there are probably some problems in the facilities. Now, I have not visited either one of these facilities, although both the Texas Nurses Association and the Illinois Nurses Association have been in communication and have been working with both of the hospitals.
I think that one of the concerns that probably nurses face when they go to these types of communities may be one of safety in the workplace, and I would encourage the hospitals that they may need to look at stronger security programs.
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In terms of the other issues, it could be working conditions. Is there adequate staffing? Do they feel like this is an environment where they can provide quality nursing care that does not make them liable under the fact that they have a license that holds them accountable? Are they working in an environment that allows them to provide the kind of quality care that they need to be able to provide, or safe care at the very least?
So I think that those are the issues that are what are going to attract nurses; that if there is adequate staffing, if there is a safe environment for them to be able to work, then they would work there.
Mr. SMITH. One last question: What recommendations would you have, if any, for changes in this legislation? I understand that the ANA has some recommendations, and if you would outline those to us.
Ms. PETERSON. Well, we appreciate the work that has been done thus far and really appreciate the Congressman's willingness to accommodate some of the recommendations, and I think that many of them have already been incorporated into the bill.
I think what we are looking at now is just some concerns about the ability to be able to move from one place to the other. That was originally in the bill. I have been assured that that is in other provisions of the nonimmigrant visa bill.
Mr. SMITH. Let me follow up on that. As I understand it, the problem now is that were these foreign nurses to be hired, the minute they get their green card there would be nothing to prevent them from going across town and taking advantage of a better offer, thereby leaving the hospital in the same position it was in before.
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There are precedents for trying to address that, as we have before in other pieces of legislation. So I assume that that is something you would support, some kind of a time period that the nurses would be required to abide by and stay at that particular facility?
Ms. PETERSON. As long as the facility is meeting the working conditions that have been laid out in the bill; that they have met the requirements in the bill. I certainly would not want to see a registered nurse that would be forced to stay in a hospital or a facility that is not meeting the requirements and then facing a more undesirable situation than previously she had been in.
Mr. SMITH. Thank you, Ms. Peterson. Let me see if there are any other questions that we can think of up here.
Ms. PETERSON. If I might, sir, just add one more thing, there is a provision that talks about looking to the regulation under the H–1A. We would say that that is to be looked at as a basis for the development of the regulations under this provision, but that we would not want to see that be misconstrued as a restoration of the H–1A, but only as a vehicle or a basis for INS to use in drafting and developing the regulations under the provision.
Mr. SMITH. I understand. I also understand, just to conclude, that while you do not oppose this legislation, there may be ways to improve it. But you do not oppose it?
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Ms. PETERSON. That is correct.
Mr. SMITH. Lastly, let me say Mr. Watt has asked the record be kept open so he and others can submit written questions to you all, so you can expect some, I think, and if you can get that to us as quickly as possible.
If there are no other comments or observations and questions, we thank you for your input and expertise and we look forward to the next step of this legislation.
[Whereupon, at 11:54 a.m., the subcommittee adjourned.]
A P P E N D I X
Material Submitted for the Hearing Record
PREPARED STATEMENT OF JOHN R. FRASER, ACTING WAGE AND HOUR ADMINISTRATOR, EMPLOYMENT STANDARDS ADMINISTRATION, U.S. DEPARTMENT OF LABOR
Mr. Chairman and Members of the Subcommittee: Thank you for the opportunity to submit for today's hearing record the views of the Department of Labor on the need for and advisability of a new temporary foreign nurses program under the Immigration and Nationality Act (INA), as would be established by the proposed ''Health Professional Shortage Area Nursing Relief Act of 1997'' (H.R. 2759).
The information and views presented in our statement supplement the testimony of the representative of the Department of Health and Human Services (HHS) that you heard today. Based in part on the Department of Labor's experience administering the now-expired H–1A temporary foreign nurses program, our statement sets forth reasons why—in the Department's considered view—a new temporary foreign nurses program is neither necessary nor advisable.
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Mr. Chairman, there are several reasons why we believe legislation to establish a new temporary foreign nurses program should not be enacted. I will briefly summarize each of these reasons.
No National Shortage of Nurses Exists
The testimony of the Department of Health and Human Services offers the best information currently available indicating that there is no national shortage of registered nurses (RNs). This has been the case for some time, as I will explain.
The Immigration Nursing Relief Act (INRA) of 1989 created the H–1A visa category for nonimmigrant (temporary foreign) RNs. the H–1A program was a five-year pilot program that expired on September 1, 1995. The INRA program was enacted to address a perceived nationwide nursing shortage in the mid-1980s. However, by the time INRA was enacted, the national shortage of the mid-1980s had begun to abate. And there is no evidence that a nationwide shortage of nurses is developing. On the contrary, as the HHS data reveal, there is no nationwide shortage of nurses and any recruitment problems that do exist are confined to certain localities or in certain nursing specialty areas—a very narrow problem that can be addressed without expanding current immigration law.
The INRA mandated the establishment of an Immigration Nursing Relief Advisory Committee which—in its 1995 report—unanimously agreed that there was no national nursing shortage and that the H–1A program should not be continued or extended in its current form.
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Employers Already Have Access to Foreign Nurses
To meet specialty or locality shortages, current law already allows foreign nurses to enter and work in the U.S. under four separate existing programs. These include:
as permanent employment-based immigrants.
as temporary workers under the temporary entry provisions of the North American Free Trade Agreement (NAFTA).
as temporary workers under the H–1B provisions of the INA if the job requires a bachelor's degree (or equivalent).
as temporary workers under the H–2B provisions of the INA if the job itself is ''temporary'' (less than one year) in duration.
It is significant to note that an unlimited number of Canadian nurses may enter the U.S. under the NAFTA temporary entry provisions. Visas, petitions, and attestations are not required for entry of Canadian nurses, and there is no maximum length of stay. The same will eventually be true for nurses from Mexico under the NAFTA.
The availability of these existing immigration programs begs the question of why yet another special program would be needed.
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Special Legislation Not Appropriate
A narrowly drawn new program to address a ''perceived'' local shortage in the nursing profession can only make our immigration law more complex and confusing.
Need for Special Nurses Program Already Rejected
Finally, it should be pointed out that the House of Representatives has recently considered extending the H–1A program and rejected the notion. In the full House Judiciary Committee mark-up of H.R. 2202 on October 24, 1995, Congressman Bryant (R., TN) offered an amendment to reinstate the H–1A program for an additional six months; the Committee rejected even this short-term extension as unnecessary. A similar amendment was offered on the floor of the House on March 21, 1996, and it was overwhelmingly defeated again. Nothing has occurred since those votes that would warrant a reversal of these actions.
CONCLUSION
In summary, as the Health and Human Services Department's data indicate, there is no overall shortage of nurses in this country. The data show that the shortages that exist are confined to certain localities or in certain nursing specialty areas. In our view, the way to overcome these shortages is not through creation of a new foreign nurses program, which some may see as an avenue to obtain nursing staff at lower cost than if domestic nurses were hired. We believe the first step that needs to be taken of address any current local shortage of nurses is to make the unfilled job opportunities more attractive for domestic workers, such as through increased salaries and benefits, improved work schedule flexibility, and enhanced training and educational opportunities. And where these steps fail, the other mechanisms which I have already described as available in existing law can be used to meet staffing needs. There is simply no justification for yet another immigration program for foreign nurses.
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INSERT OFFSET FOLIOS 1–13 HERE
53–246
1997
THE HEALTH PROFESSIONAL SHORTAGE AREA NURSING RELIEF ACT OF 1997
HEARING
BEFORE THE
SUBCOMMITTEE ON
IMMIGRATION AND CLAIMS
OF THE
COMMITTEE ON THE JUDICIARY
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTH CONGRESS
FIRST SESSION
ON
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H.R. 2759
NOVEMBER 5, 1997
Serial No. 69
Printed for the use of the Committee on the Judiciary
For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
COMMITTEE ON THE JUDICIARY
HENRY J. HYDE, Illinois, Chairman
F. JAMES SENSENBRENNER, Jr., Wisconsin
BILL McCOLLUM, Florida
GEORGE W. GEKAS, Pennsylvania
HOWARD COBLE, North Carolina
LAMAR SMITH, Texas
STEVEN SCHIFF, New Mexico
ELTON GALLEGLY, California
CHARLES T. CANADY, Florida
BOB INGLIS, South Carolina
BOB GOODLATTE, Virginia
STEPHEN E. BUYER, Indiana
SONNY BONO, California
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ED BRYANT, Tennessee
STEVE CHABOT, Ohio
BOB BARR, Georgia
WILLIAM L. JENKINS, Tennessee
ASA HUTCHINSON, Arkansas
EDWARD A. PEASE, Indiana
CHRISTOPHER B. CANNON, Utah
JOHN CONYERS, Jr., Michigan
BARNEY FRANK, Massachusetts
CHARLES E. SCHUMER, New York
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
STEVEN R. ROTHMAN, New Jersey
THOMAS E. MOONEY, Chief of Staff-General Counsel
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JULIAN EPSTEIN, Minority Staff Director
Subcommittee on Immigration and Claims
LAMAR SMITH, Texas, Chairman
ELTON GALLEGLY, California
SONNY BONO, California
WILLIAM L. JENKINS, Tennessee
EDWARD A. PEASE, Indiana
CHRISTOPHER B. CANNON, Utah
ED BRYANT, Tennessee
MELVIN L. WATT, North Carolina
CHARLES E. SCHUMER, New York
HOWARD L. BERMAN, California
ZOE LOFGREN, California
ROBERT WEXLER, Florida
CORDIA A. STROM, Chief Counsel
EDWARD R. GRANT, Counsel
GEORGE FISHMAN, Counsel
MARTINA HONE, Minority Counsel
C O N T E N T S
HEARING DATE
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November 5, 1997
TEXT OF BILLS
H.R. 2759
OPENING STATEMENT
Smith, Hon. Lamar, a Representative in Congress from the State of Texas, and chairman, Subcommittee on Immigration and Claims
WITNESSES
Campbell, Ron, Vice President, Patient Care Services, St. Bernard Hospital and Health Care Center
Peterson, Cheryl, RN, Associate Director for Federal Government Relations, American Nurses Association
Rush, Hon. Bobby, a Representative in Congress from the State of Illinois
Sampson, Neil, Acting Associate Administrator for Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services
Stauder, Mark, President and Chief Operating Officer, Mercy Regional Medical Center
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LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING
Campbell, Ron, Vice President, Patient Care Services, St. Bernard Hospital and Health Care Center: Prepared statement
Peterson, Cheryl, RN, Associate Director for Federal Government Relations, American Nurses Association: Prepared statement
Rush, Hon. Bobby, a Representative in Congress from the State of Illinois: Prepared statement
Sampson, Neil, Acting Associate Administrator for Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services: Prepared statement
Stauder, Mark, President and Chief Operating Officer, Mercy Regional Medical Center: Prepared statement
APPENDIX
Material submitted for the record
(Footnote 1 return)
See Appendix, pp. 31 to 43, for text of the bill.