DHHS Does Not Address Physician Shortage
The relationship between small communities in America and their doctors has taken on a sacred role in our society. And for good reason. Access to decent health care is a basic quality of life benchmark in America. That is why the rapidly worsening shortage of physicians in America is so scary to rural and inner city communities around the US that are facing ever-increasing difficulties attracting physicians.
So it might come as a shock to members of these communities that the US Department of Health and Human Services (HHS) is not only failing to meaningfully address this shortage, but is actually taking steps to make it more difficult for communities to recruit from the one pool of physicians that is open to working in medically underserved areas - immigrant doctors who now constitute 25% of the physicians currently training in the US. Most of these physicians come on a visa called a J-1 and are required to leave the US when their training is finished unless they can find a US or state health agency to sponsor them to work in an underserved community. American medical schools only produce enough physicians to fill 3/4 of the residency slots available so our hospitals comb the world for the best and brightest medical students to fill the remaining positions.
Actually, few immigration lawyers who regularly handle physician cases were probably surprised with the recent announcement of dramatic new restrictions on HHS' willingness to sign off on applications by underserved communities to recruit interested foreign-born, American-trained physicians. After all, HHS officials are widely reputed to have sought to thwart other government agencies who were willing to take on the responsibility of redressing physician shortages in medically underserved areas by issuing waivers for volunteering doctors. The agency was also successful in convincing the former US Information Agency to impose a requirement that federal J-1 physician waivers only be available to primary care physicians (even though there are severe shortages around the country in just about every specialty area). And HHS’ other waiver program for researching physicians is known as one of the toughest waiver programs in the country with only a few dozen cases approved each year. The agency charged with overseeing health care delivery in America has deliberately sought to undermine these programs which have been so successful in alleviating physician shortages in medically underserved areas. While HHS may publicly claim to have a program to place doctors in underserved area, the truth is that the program largely now exists only in name.
The story of the HHS’ current clinical waiver program began early last year when the US Department of Agriculture shut its successful but unfunded waiver program after eight years. A strong outcry from health care providers and patients in medically underserved areas resulted in members of Congress expressing their displeasure at abolition of a program that brought unprecedented quality health care to medically needy Americans. The White House responded by promising to find a new home for a national J-1 waiver program. When HHS expressed its interest in taking over the program, health care providers and their advocates throughout America were suspicious that the agency which had historically obstructed programs placing J-1 physicians in clinical positions was suddenly going to facilitate the location of the same physicians in medically underserved areas.
Sadly, their forebodings have turned into reality.
Although the HHS clinical program appeared at first to be workable when it opened this past June, the abrupt closure on September 30th again catapulted medically unserved America into a deepening crisis. The State 30 programs allowing state Health Departments to place some international physicians in their states have been helpful, but the 30 slot limit per state hardly is enough to make a serious dent in a physician shortage that experts believe is growing by the tens of thousands each year. So having a national program with the capacity to issue substantially more waivers is ever more critical.
When HHS shut the program down after just three months, rumors abound that HHS had double-crossed Congress and the White House and the agency had no plans to reopen the program. The rumors were nearly right. The new waiver program recently announced is so restrictive that it will be surprising if more than a few dozen waivers are granted per year. Communities must score a high 14 as a Health Professional Shortage Area in order to qualify. And for-profit clinics and hospitals are out. Only community health centers and rural health clinics qualify and many communities scoring 14 and higher don’t have these facilities.
An analysis of the before and after in two states that have traditionally relied on international medical graduates is telling. Mississippi is one of the country’s poorest states and is facing a critical physician shortage in every part of the state. Under the earlier program, 83 of Mississippi’s counties were eligible to apply for HHS physician waivers. Only 33 counties met the HPSA 14 score. And then only 25 of those counties have facilities qualifying under the new rules.
For Texas, the results are even more dramatic. Under the earlier rules, 231 counties qualified for HHS waiver processing. That number is whittled down to 46 when you factor in the HPSA minimum score. And only two dozen of those counties actually have qualifying facilities.
The American public should be angry as hell at this abdication of responsibility. This past week, the American Medical Association acknowledged that we have a nationwide physician shortage that could grow to a gap of as much as 150,000 over the next decade, particularly for specialists. There are only about 800,000 physicians in this county. So do the math. We need to do everything we can to get more American doctors trained. But every expert out there says that there is no way we can get enough medical schools online to meet the need for decades and that international medical graduates are an important part of the solution.
So how does the nation’s health agency act to ensure that Americans have the physicians they need. They all but kill the national waiver program by loading it up with requirements so onerous that only a small number of communities can apply. Furthermore, they operate under the arrogant assumption that international medical graduates have a gun to their head and will do anything to stay in America. Not so. They can and are voting with their feet and either going back to their home countries or other more welcoming nations. It is we who have the gun to our head. We’re facing the scary prospect of having to ration health care because there are not enough doctors and nurses to go around. We can't ignore the law of supply and demand. The shortage of doctors is already causing physician salaries to skyrocket and even when we're willing to shell out ever-growing amounts of money, we still can't get access to enough doctors. The communities HHS is supposedly helping are going to have a tougher and tougher time attracting doctors because they are simply becoming too expensive and unavailable.
In the three months the program was in existence earlier this year, only 43 cases were received. How many communities does HHS expect to help under the new rules? If the agency is truthful, it will admit that they will place a fraction of the number of cases the USDA or HUD did while their program was in place.
It is completely fair to expect HHS to really do something to address the physician shortage in this country and certainly not to take deliberate actions that exacerbate the shortage. HHS either needs to correct the program’s numerous deficiencies or relinquish its volunteered responsibility to another agency that is serious about getting international medical graduates to remain in the US when their training is finished.
Gregory Siskind is a partner in Siskind Susser's Memphis, Tennessee, office. After graduating magna cum laude from Vanderbilt University, he received his Juris Doctorate from the University of Chicago. Mr. Siskind is a member of AILA, a board member of the Hebrew Immigrant Aid Society, and a member of the ABA, where he serves on the LPM Publishing Board as Marketing Vice Chairman. He is the author of several books, including the J Visa Guidebook and The Lawyer's Guide to Marketing on the Internet. Mr. Siskind practices all areas of immigration law, specializing in immigration matters of the health care and technology industries. He can be reached by email at email@example.com.
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