The Crisis in Primary Care

Addressing healthcare shortages through immigration

The COVID-19 pandemic made clear that the healthcare system in the United States faces significant and longstanding challenges that will undermine our ability to respond to future public health threats. These challenges include an aging population, worker shortages at all levels, and a lack of diversity in the healthcare industry.  In rural areas, these challenges are especially difficult to address. 

In New Hampshire, where my law practice is based, healthcare is the fastest-growing industry and has the most unfilled jobs. Compounding the problem is the number of Nurse Practitioners (NP) and Primary Care Providers (PCPs) reaching retirement age. In a recent report from the Endowment for Health, we learn that 24 percent of the state’s NPs and 27 percent of our PCPs are over 60. New Hampshire is also projected to be 10th among all states with the most severe nursing shortages. 

What’s the Solution? 

One obvious solution to this crisis is to retain foreign nationals who completed medical training within the United States.  This will require that healthcare service providers — both public and private — work with policymakers to improve the immigration process for healthcare professionals. How can expand the programs in place to alleviate the shortage?

A sizeable immigrant workforce is already integral to our nation’s healthcare system. The Healthcare Workforce Coalition reported in 2022 that about 29 percent of our physicians are born in other countries. Similarly, 15 percent of all registered nurses in the United States are foreign-born.

United States Citizenship and Immigration Services (USCIS) has a visa option that enables International Medical School Graduates (IMGs) to come to the United States to complete their training.  Post-training the vast majority of these physicians must return to their home country for at least two years.  However, there are visa programs allowing a very limited number of physicians to remain in the U.S.  Those programs prioritize physician placement in the nation’s most critically underserved regions. 

The J-1 Visa 

The J-1 visa is a non-immigrant “exchange visitor” visa often used by International Medical School Graduates (IMGs) pursuing a medical residency or fellowship training in the United States. The J-1 visa permits holders to remain in the United States until their medical education is complete — usually up to seven years. 

Then, when they’ve finished their education, J-1 visa holders must return to their home country for two years to fulfill “the home residency requirement” before they can work visas to return to return to the United States. 

The J-1 Waiver

The J-1 Waiver eliminates the two-year home residency requirement for eligible applicants, allowing them to stay in the United States and acquire an H-1B visa to practice medicine. Only the federal Citizenship and Immigration Services office can grant the actual J-1 waiver, but any federal agency can recommend that a J-1 waiver be granted. 

For physicians, J-1 waivers are usually recommended through:

The key application requirements to receive a J-1 waiver include:

  • The J-1 visa waiver applicant must have an offer of employment from a healthcare facility in the United States.
  • In most instances, the healthcare facility where the J-1 visa waiver applicant will be working must be in an area designated by the United States Department of Health and Human Services (HHS) as a Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or a Medically Underserved Population (MUP)
  • J-1 visa waiver applicants and their prospective employers must commit to at least three years of employment.

The Conrad 30 Waiver Program

Under the federal Conrad 30 Waiver Program, each state administers its own J-1 waiver program through that state’s Department of Health and Human Services. Each state can recommend up to 30 J-1 waivers yearly — 20 in designated medically underserved areas or health professional shortage areas, and 10 in non-designated areas. While this program is critical, it isn’t enough to counter the rising national physician shortage. 

Since each state is given 30 spots regardless of population density or area, in some parts of the nation these waiver recommendations are much easier to come by than in other parts of the country.

In New Hampshire, the J-1 Visa Waiver program is administered by the Rural Health and Primary Care Section (RHPC) of the NH Department of Health and Human Services. As of February 8, 2023, 14 of 20 designated J-1 visa waiver recommendations remain available. 

New Hampshire is also part of the relatively new program through the Northern Border Regional Commission (NBRC) which enhances economic and community development opportunities in northern Maine, New Hampshire, Vermont, and New York. NBRC is modeled after other commissions — like the Appalachian Regional Commission and the Delta Regional Authority — and collaborates closely with its participating partners to complement each state’s existing Conrad 30 program.

Support for Employers

For health care provider organizations seeking to build their primary care staff with non-citizens— or any organization exploring the global talent pool to facilitate growth — the experienced immigration law attorneys at Orr & Reno can assist you in all aspects of the immigration, visa, and compliance process. 

Emily A. White

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