September 2, 2016

Immigration Reform Can Help Ease the Rural Health Crisis



With an estimated shortfall of 90,000 physicians by 2025, which will leave already doctor-strapped rural America without critical health care resources, the United States is in the midst of a healthcare crisis. Luckily there is a solution: recruit foreign doctors to fill the gap. The legislature should act to reduce burdens on International Medical Graduates (IMGs) to provide healthcare to Americans and encourage them to work in rural areas by reforming the Conrad 30 J-1 Visa Waiver program.

Currently, around 10,000 J-1 nonimmigrant medical visas are awarded per year to IMGs to complete their medical residencies at teaching hospitals in the United States. After completing their medical residency, these newly minted doctors must return home for at least two years before applying for another visa to the United States.

That is, unless they will work in a rural community. The Conrad 30 Visa Waiver gives IMGs the opportunity to bypass the two-year period as long as they work in poorly funded, generally rural areas of the country. At the end of the program, participants and their families are eligible to apply for other resident visas. Sounds like a great deal, doesn’t it?

Well, maybe. Although these rural areas benefit tremendously from IMG placement, doctors and their families almost never stay past three years. Retention rates of physicians in these needy area are low (40% after five years, and dwindling after that), thereby only temporarily contributing to chronically underserved populations.

A Rural Health Research Center report shows that a major factor in low retention rates of medical professionals is that they don’t integrate well, either because they are not accepted by the community, or because they don’t adapt well to the rural lifestyle. Ultimately, when the program ends, so does their stay. The same study says overstretched state health officials who run these programs do not have the time to maintain adequate relationships with the doctors, contributing to their poor retention rates. This lack of communication, support, and oversight can lead to abuse of the physicians by employers, which happened to several Conrad recipients in Nevada in the early 2000s.

For these reasons, the alternative H-1B visa is growing in popularity among IMGs. This visa allows companies or universities in the U.S. to sponsor a highly skilled immigrant with temporary status for up to six years, including physicians hired to complete their medical residency, thereby cutting  into the eligible J-1 applicant pool.

While there is incredible demand for H-1B visas, there is much less demand for Conrad waivers. Approximately 800-1000 J-1 Conrad waivers are issued every yearwell below the 1,500 available spots, a trend that remains unchanged for the better part of a decade. It is becoming  increasingly difficult to find physicians willing to take the jobs for some areas.

Choosing between using a J-1 or an H-1B presents a list of tradeoffs: it’s a lot less of a hassle for a physician to get an H-1B, and there is no home residency requirement or obligatory service. On the other hand, schools are more willing to accept J-1s, and it is easier to get residency for family members on the J-2. Regardless of personal choice, the Conrad program is much better for the state of rural health than the H-1B.

The rural health crisis is something that the U.S. can ameliorate in part by making the Conrad waiver more attractive to foreign doctors; the practical policy question is how to do it efficiently and effectively. Now more than ever this question is time-sensitive, as more and more rural doctors retire and fewer replace them.

Those who finish the program need incentives to stay in rural areas after their service. To inform constructive change, policymakers should listen to requests and recommendations from the state health departments who run their programs. Legislation should support efforts to integrate doctors into their communities better, and retain them once the program is completed. Collecting statistics on the efficiency and efficacy of the program could inform best practices for state administrations across the country.

Federal oversight can lend direction to struggling state health departments whose professional expertise do not generally include recruitment and retention of new American immigrants. Recent Senate efforts to make needed changes to the program were relegated to die in committee, but should be revived and improved to make the program great again.

The fate of America’s rural health system remains precarious. Importing doctors is one practical solution to addressing rural medical needs. The Conrad program, and programs like it, can provide real options for states to fulfill their missions if they’re given the support they require.