To improve access to physicians in medically underserved areas.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, I thank the distinguished chairman. This might be the last time the Subcommittee on Immigration is on the floor, possibly, in the 108th Congress; and I want to thank the full Committee on the Judiciary staff, and I want to particularly offer my appreciation to the Democratic staff of the Committee on the Judiciary for their very fine work during this Congress and their efforts toward bipartisanship, and thank Nolan Rappaport on the Subcommittee on Immigration for his work on this legislation and others dealing with immigration concerns.

Let me share with my colleagues from an Associated Press article dated August 24: ``Before doctors like Mircea Rachita from Romania arrived in town, patients in this small town had to wait months for doctors' appointments. Now, underserved communities are finding good doctors easy to come by due to a visa waiver program which creates incentives for foreign-born physicians to work in communities American doctors may shun.''

Clearly there is room and need for a bill to improve access to physicians in medically underserved areas, and S. 2302 is the embodiment of that bill, along with a similar House bill.

The purpose of this bill is to make it possible for foreign doctors to provide medical services in geographic areas which have been designated by the Secretary of Health and Human Services as having a shortage of health care professionals. S. 2302 is almost identical to H.R. 4453, which I cosponsored with my colleague, the chairman of the subcommittee, the gentleman from Indiana (Mr. Hostettler).

H.R. 4453 passed the House on October 6 on the Suspension Calendar. The Senate bill has an additional provision which ensures that specialists sponsored by Federal and State agencies are placed in areas that have a shortage in that specialty. The additional provision requires the sponsoring agency to determine criteria for demonstrating a specialist shortage and to meet that criteria in order to sponsor the specialist, a way of broadening access to health care and recognizing the 44 million uninsured Americans who need access to sometimes public facilities that utilize these foreign doctors.

Aliens who attend medical school in the United States on J exchange program visas are required to leave the country afterward and reside abroad for 2 years before they can receive their visas to work here as physicians.

In 1994, Congress created a new temporary waiver of this 2-year foreign residence requirement which allowed States as well as Federal agencies to sponsor the doctors. It applied to foreign doctors who would commit to practicing medicine for no less than 3 years in a geographic area designated by the Secretary of Health and Human Services as having a shortage of health care professionals.

This program has been successful for 10 years in bringing highly qualified physicians to medically underserved areas. It sunsetted on June 1 of this year and created a chasm between the needs of those who need health care and the regulations of the Federal government. We now have brought those pieces together.

The first physician recommended for a waiver in Texas was Dr. Maria Camacho, a pediatric intensivist. Her services to the residents of Harlingen in Cameron County provide a level of health care to children that was previously unavailable in that county.

Dr. K.M. Moorthi is a nephrologist who was recommended for a waiver to serve at a facility in Pecos, Texas, in Reeves County. He works at a dialysis center. Patients requiring dialysis three times per week in that part of Texas used to have to travel more than 70 miles each way for the treatment. Now it is available in this county.

The bill will provide a 2-year extension for this waiver program. We started out with 1 year. I asked for 5 years. We compromised on 2 years. We have made progress.

It will also establish a pilot flexibility program which will allow a State agency to place a doctor at a location that has not been designated as underserved if the doctor, nevertheless, will serve patients from an underserved area. That is a very effective compromise to ensure that the patients, no matter where they are, get served whether they are in an underserved area or those patients that reflect that community.

The exception is limited to five doctors in each State. It targets rural underserved areas that typically get specialty medical care from a major medical facility that is not itself located within an underserved area.

Finally, the doctors who receive a waiver to come here with H-1B visas will not count toward the H-1B cap.

I urge my colleagues to consider this legislation as a very positive step for good health care in America and support it enthusiastically.

Mr. Speaker, I reserve the balance of my time.

Mr. Speaker, I yield such time as he may consume to the gentleman from Michigan (Mr. Conyers).

Mr. Speaker, I yield 3 minutes to the gentleman from North Dakota (Mr. Pomeroy), who I think understands the need for health care in rural America.

Mr. Speaker, how much time remains?

Mr. Speaker, I yield myself such time as I may consume.

In conclusion, I am very glad that the point that was made by the distinguished ranking member and the gentleman from North Dakota (Mr. Pomeroy) is that this is both a medical

bill, a health care bill, and it is an immigration bill. And is it not interesting that we can find an opportunity for bipartisanship around two very key issues.

I think it is also important to reemphasize the fact that we promote and encourage the education and training of individuals here in America in the medical professions, nurses, nurse practitioners, physicians, physician assistants and others that are the cornerstone of our health care system. But we know our hospital systems are overburdened. We know there are many, many people that are underserved. This bill serves a very valuable purpose.

Might I reemphasize the fact that we will give opportunities to hospitals that are located or designated as not an underserved area? It reaches out to serve the underserved, which is something we try to encourage our teaching hospitals to do, who typically are not in areas that can be considered that, so that the individuals get high-quality service. They will be able to utilize this legislation.

Mr. Speaker, in my concluding remarks, I think it is important to note that we do have before us an immigration bill. I was hoping before the conclusion of the 108th Congress we might be in a better position to really attack the question of comprehensive immigration reform. Many of us have had initiatives that have languished for a very long time. I cite for this body the Comprehensive Immigration Fairness Reform Act that really looked at immigration in a very comprehensive manner.

Probably over the next couple of months we will hear a raging debate on immigration, those for it, those against it. The debate on immigration can be a very tense and conflicted debate. It raises some of the most unpleasant aspects of many of those who are pro and con, in many instances, not being able to find common ground. I would encourage my colleagues to look at this forthrightly and understand that we can no longer turn the lights out and close the curtains on this very important issue.

We can no longer have a temporary guest program, albeit how well- intentioned this administration may be, the Flat Earth Theory that allows people to come in for 3 years and then suggest to them that they must then leave the country in order to, if you will, remain in a position to possibly have another job again. The guest worker program proposed by President Vincente Fox and this administration will not work. You will not get 8 million illegal immigrants in this country to accept that philosophy. Nor will you get to a point where you would like to be, a secure America, because we are not focusing on securing our borders. We are focusing on what I think is misdirected in a temporary guest worker program.

Comprehensive reform allows us to allow individuals to earn access to legalization, to document those who are here, and be able to be safe from terrorists by distinguishing those who have come here for economic opportunity as opposed to those who have come to do us harm. Why can we not understand that in a bipartisan way?

Now, let me say also, if we are going to do anything in the last hours of this session, make sure that we do something that helps legal immigrants who are here who for years who have been trying to reunite their families. We have passed out of the House in a bipartisan manner 245-I which would allow legal immigrants to reunite with mothers and fathers, husbands and wives or children. That would be a fair approach, and the Senate needs to help us, the other body, if I might say, needs to help us in that. Any discussion about H-1Bs clearly should be a discussion in recognizing that we must protect American jobs. We must protect American jobs in order to have an open and adequate discussion on immigration.

In conclusion, let me say this, Mr. Speaker, I would hope that our good friends who are dealing in the conference on issues of immigration reform would not pursue these in the 9/11 intelligence bill. Allow us to have a full, comprehensive debate and a full, comprehensive bipartisan approach to immigration reform that will last and will be invested in America and will make America work and comply with our principles of democracy and empowerment and equality.

Putting poison pills on an intelligence bill that deals with fixing the intelligence system is no way to go forward on a vital question of how we bring America together and answer the questions of those who say, what do you do about those illegal immigrants? Are you just going to affirm them for doing the illegal wrong thing? No, we are not. We are going to give them the opportunity to earn access to legalization while they are already here paying taxes, children in school, building houses and contributing to this economy.

Let us wake up America and stop the divisive debate on immigration and stand up for what we believe in.

This country was founded on immigration. How many of us can forget the early pinnings of this Nation; the turn of the century and the 1900s and immigrants coming from Europe? This is the very same.

Protect the borders, respond to those in Arizona and California and Texas who are concerned about the constant flow of illegal immigrants and the large deaths in the deserts. We do that by securing the borders, working with our friends in South and Central America, providing economic opportunity there, and working on a real immigration reform bill.

It saddens me that we come to the close of the 108th Congress when we could have sat down, looked each other in the eye, sat around the table and done the right thing.

I can only say that I applaud the J-1 visa legislation, a good sign of working together. It will help people in America, and I hope it will help us improve our health care system, but we can also heal a broken immigration system by doing the very same thing, looking each other in the eye and sitting around and putting the doctors to work, the political doctors to work, of good mind and good faith and make this country what it is, a country that believes in the Statue of Liberty's words: Bring us your poor and oppressed.

I thank the distinguished Speaker, and I ask my colleagues to support this legislation, and I hope the charge is that we will face immigration the way it should be, in a fair, equitable and balanced way.

Mr. Speaker, I yield back the balance of my time.

Mr. Speaker, I rise today to join my fellow colleagues in support of S. 2302, also known as H.R. 4156. I first would like to thank Senator Conrad and Congressman Jerry Moran for sponsoring this important piece of legislation. I would also like to thank the committees jurisdiction for their quick actions in allowing this bill to come to the floor.

Mr. Speaker, over the tenure of my congressional career I have come to the floor repeatedly to demand that Congress act to address the needs of the medically underserved and to ensure that we do everything possible to eliminate arbitrary barriers which give rise to healthcare disparities.

As there is a vast amount of research on the subject of rural physician recruitment and retention, this bill is by no means a comprehensive policy. Rather, the purpose is to be a temporary stop gap measure to allay the crisis of rural health and healthcare providers.

Mr. Speaker, more than 51 million Americans live in areas classified by the U.S. Office of Management and Budget (OMB) as nonmetropolitan. They comprise one-fifth of the U.S. population. Rural populations are found to be older, poorer, sicker, less educated and to have a perception of worse health status than their urban counterparts.

They also have higher infant mortality and injury-related mortality rates, fewer hospital beds and physicians per capita, and are much less likely than urban residents to have private or public health insurance. Moreover, while the number of individuals living below the poverty line is disproportionately high in rural areas, the number receiving Medicaid benefits is disproportionately low.

In a study of the utilization rates of 28 categories of medical services, found that, with the exception of major surgical procedures, urban residents received between 20 percent and 30 percent more of each type of service than did rural residents.

With at least 20 percent of the population living in rural areas, less than 11 percent of the Nation's physicians are practicing in nonmetropolitan areas. Today, more than 2,500 physicians were needed in nonmetropolitan areas to remove all nonmetropolitan health professional shortage area (HPSA) designations for primary care. More than twice that number are needed to achieve a 2,000-1 ratio in those HPSAs. This is the current situation and does not factor in the aging physician population serving rural areas, nor does it factor in the statistical designation dealing with counties as the main reference point.

As a medical doctor, I understand that nonmetropolitan physicians derive a larger share of their gross practice revenue from Medicare and Medicaid patients than metropolitan physicians. These public programs pay physicians at lower rates than private insurers. There is a decreased ability in nonmetropolitan areas to perform economically enhancing procedures (hospitals with decreasing obstetrical and surgical units, etc.), which further decreases relative reimbursement rates. Thus, nonmetropolitan physicians, on average, work more and earn less than their metropolitan counterparts.

Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs) in designated HPSAs and medically underserved areas (MUAs), and differential Medicare payments to qualifying rural areas have helped to enhance reimbursement. But currently, the mandate that States pay RHCs and FQHCs their reasonable costs under Medicaid is being phased out. Medicare managed care program reimbursement to RHCs has threatened to be lower than the current reimbursement. Both of these payment changes will put providers in jeopardy.

Mr. Speaker, I along with my Congressional Black Caucus counterparts have consistently pushed the Congress for more equitable fee reimbursement and to fully fund Title VII and Title VIII health profession training program. We have also called for the strengthening, expansion, and reauthorization of these programs in our minority health bill H.R. 3459, the Healthcare Equality and Accountability Act, which I look forward to moving on the 109th Congress.

S. 2302/H.R. 4156 acknowledges that international medical graduates, through State initiated J-1 visa programs, have initially met some unmet needs of rural areas. But Mr. Speaker, I would like to highlight a recent study published by the Council on Graduate Medical Education that stated that although international medical graduates have made an important contribution to the provision of medical care in some rural areas, training these graduates is an inefficient way to expand physician supply in rural areas. Although many inner city hospitals are dependent on international medical graduates for providing care to underserved urban populations, more direct avenues exist for meeting the needs of these hospitals. The funds would be better targeted to programs that increase the flow of U.S. health professional graduates to underserved rural areas.

Therefore, Mr. Speaker while I strongly support the underlying bill, I again call on Congress to move legislation in the 109th that will do the following.

Increase ORHP funding for research related to physician recruitment, retention and networking should be supported and enhanced.

Reevaluate how designation of HPSAs and MUAs are given so the designated areas accurately reflect underserved status.

Increasing the Title VII funding for AHECs and health education training centers should be supported and enhanced.

Encourage and mandate that medical schools confront their obligation to target admissions and training to underserved populations, both rural and urban, in the primary care professions.

Encourage medical school environments to encourage individuals into primary care and encourage early and long-term rural exposure to positive rural physician role models, and such educational programs should be adequately funded.

Increase scholarship programs to place medical students with mentoring physicians in rural or remote practices during an elective or vacation period should be encouraged.

Support medical schools' and residencies' efforts to integrate community orientation and a team approach to health care. To achieve the full benefit of this effort, there needs to be further infrastructure building of rural allied health teams and rural communities' commitment to meeting the challenges of a changing health care system.

Encourage family practice residencies to offer rural electives, rural emphasis and rural training tracks.

Direct the Bureau of Health Professions (BHP) funding for residencies that are building rural-based programs and funding for those programs that have a history of producing

rural physicians should become a staple rather than be at the mercy of national budget politics. An aggressive plan to increase funding should be sought.

Increase support by the BHP to primary care residencies to be continued and enhanced.

Decrease professional isolation by supporting teleinformatics and outreach education programs of states and by the use of nonphysician providers.

Increase retention through more appropriately rural-trained candidates.

Identify care needs at the community level. Use state and federal funds to assist rural hospitals where access to care would be threatened by hospital closure and physicians would be further deprived of opportunities to utilize their professional skills.

Develop and use innovative delivery systems that emphasize coordination and cooperation among providers, institutions and communities.

Develop programs allowing rural clinicians to undertake periodic rotations through academic hospital services (with locum tenens backup) in order to learn or update procedures.

Provide for those areas that do not qualify for RHC or FQHC status but still are faced with the disproportionate numbers of Medicare and Medicaid patients, there should be enhanced Medicare and Medicaid payments to rural providers.

Evaluate the enhanced reimbursement available through RHC and Community Health Center designations needs to be adequately maintained to retain providers and avoid decertification as the area's needs are met. If the same level of Medicare and Medicaid and uninsured patients persists and the area is decertified because of an adequate supply of physicians, a cycle will develop leading to economic unfeasibility, provider dissatisfaction and lower retention rates.

Mandate the States to pay RHCs and FQHCs reasonable costs under the State's Medicaid program.

Ensure that Medicare managed care reimbursement must equal or exceed the RHC and FQHC Medicare reimbursement.

Increase the supply of primary care providers in rural areas by lessening speciality and geographic differentials in physician income.

Establish relocation grants, especially for remote areas, to defray the costs of moving and setting up a practice.

Mr. Speaker, in the 109th Congress I will introduce a bill that codifies these recommendations among others and will hopefully begin the process of ensuring that we provide healthcare for all Americans within or close to current expenditures.

Mr. Speaker, I move to suspend the rules and pass the Senate bill (S. 2302) to improve access to physicians in medically underserved areas.

Mr. Speaker, I ask unanimous consent that all Members may have 5 legislative days within which to revise and extend their remarks and include extraneous material on S. 2302, the bill currently under consideration.

Mr. Speaker, I yield myself such time as I may consume.

Mr. Speaker, I rise in support of S. 2302. This legislation will extend the program under which alien doctors can avoid having to return home for 2 years by agreeing to practice in medically underserved areas here in America.

Aliens who participate in medical residencies in the United States on a ``J'' visa program visa must generally leave the United States after the completion of their residencies to reside abroad for 2 years. The intent behind the policy is to encourage American-trained foreign doctors to return home to improve health conditions that advance the medical profession in their native countries.

In 1994, Congress created a waiver of the 2-year foreign residence requirement. State departments of public health may request a waiver for foreign doctors who commit to practicing medicine for no less than 3 years in geographic areas designated by the Secretary of Health and Human Services as having a shortage of health care professionals. The number of foreign doctors who can receive the waiver is limited to 30 per State each year. The waiver has proven to be an important means of ensuring quality medical care in areas of the United States with physician shortages.

S. 2302 is substantially similar to H.R. 4453, a bill introduced by the gentleman from Kansas (Mr. Moran) that this body passed by voice vote on October 6. It will extend the waiver program to June 2006. It will also allow each State to place five of the doctors it sponsors each year in areas not designated by HHS as physician shortage areas. The bill continues the practice of allowing foreign doctors receiving waivers to receive H-1B visas regardless of the annual H-1B visa quota. Finally, the bill clarifies that doctors receiving waivers can practice specialty medicine. However, when a doctor works in a specialty, there must exist a shortage of health care professionals able to provide services in that specialty to the patients he or she will serve.

I urge my colleagues to support this bill.

Mr. Speaker, this time I will insert into the Record an exchange of jurisdictional letters between the chairman of the Committee on Energy and Commerce, the gentleman from Texas (Mr. Barton), and myself.

U.S. House of Representatives,

Committee on Energy and Commerce,

Washington, DC, November 16, 2004.

Hon. F. James Sensenbrenner, Jr.,

Chairman, Committee on the Judiciary, U.S. House of

Representatives, Rayburn House Office Building,

Washington, DC.

Dear Chairman Sensenbrenner: This week the House is

scheduled to consider S. 2302 under suspension of the rules.

S. 2302, as passed by the Senate, contains language, which

provides for exemptions to section 214(l)(1)(D) of the

Immigration and Nationality Act, involving the Secretary of

Health and Human Services. As you know, Rule X of the Rules

of the House of Representatives gives the Committee on Energy

and Commerce jurisdiction over public health.

I recognize your desire to bring this legislation before

the House in an expeditious manner. Accordingly, I will not

exercise my Committee's right to a referral. By agreeing to

waive its consideration of the bill, however, the Energy and

Commerce Committee does not waive its jurisdiction over S.

2302. In addition, the Energy and Commerce Committee reserves

its right to seek conferees on any provisions of the bill

that are within its jurisdiction during any House-Senate

conference that may be convened on this legislation. I ask

for your commitment to support any request by the Energy and

Commerce Committee for conferees on S. 2302 or similar

legislation.

I request that you include this letter and your response in

the Record during consideration of the bill. Thank you for

your attention to these matters.

Sincerely,

Joe Barton,

Chairman.

Mr. Speaker, I yield such time as he may consume to the gentleman from Kansas (Mr. Moran), the author of the House counterpart to this bill.

Mr. Speaker, I yield myself the balance of the time.

Mr. Speaker, lest anyone be confused as a result of the previous speaker that this is a wide-ranging, overall immigration bill that deals with amnesty and guest workers and all of those very contentious issues, let me lay that impression to rest. This bill does not do that, and I fear that the previous speaker's statement ends up hurting the support for this bill that is broad and bipartisan.

All this bill does is allow a foreign national who is a graduate of an American medical school and who has completed his residency in an American hospital to practice in a medically-underserved area, somewhere in the United States, and the request would have to be made by a State Department of Public Health and limited to no more than 50 doctors per State.

Now, this is not what the gentlewoman from Texas is talking about. We will deal with that in due course, but let us make sure that this bill is not confused with the other more broad and contentious bills.

This bill has to pass because it extends a program that expired in June of this year, and if we vote this legislation down, then we are not going to have those doctors in the medically-underserved areas.

We should keep the discussion and bills like this confined to what is in the bill, rather than a wide-ranging overall debate on immigration policy.

Mr. Speaker, I yield back the balance of my time.

Mr. Speaker, on that I demand the yeas and nays.

Mr. Speaker, I thank the gentlewoman for yielding me time.

I am pleased to associate myself with the ranking member on the Committee on the Judiciary, the gentleman from Michigan (Mr. Conyers), as well as my former co-chairman with the Rural Health Care Coalition, the gentleman from western Kansas (Mr. Moran).

Truly, we have a growing problem relative to the delivery of rural health care, and that is we do not have enough professionals to deliver the care required. As we look at the pipeline, those coming along compared to those nearing the end of their practice years, we realize that we are working ourselves into a pretty serious problem here and that is especially so when you consider the aging of the population. So I agree with the gentleman from Michigan (Mr. Conyers). We need to look at this systemically, why this is happening, and address it. But in the near term, we need to take the step that offers a Band-Aid solution but an important Band-Aid at that, and that is the legislation before us.

North Dakota receives about a dozen doctors a year through this important visa waiver provision. Twenty-six cities in the State I represent have participated in this program. We would have a situation where failure to authorize this would create immediate problems in six or seven small towns. They would face the departure of critical medical personnel under the loss of this visa waiver.

With the passage of it, conversely, we will have opportunities to continue to build capacity. I have one city that has been going through an incredibly expensive proposition of hiring an anesthesiologist on a Locum Tenens basis. This is a temporary hire coming in from other parts of the country, and it costs a fortune. We hope to move through a resident hire through the application of this visa waiver provision.

So, bottom line, while this is an immigration bill, it is all about making sure health care services for peoples' needs in rural areas and underserved communities are available, and I urge its adoption.

I yield to the gentleman from Michigan.

I thank the gentleman very much.

Senator Conrad has done very good work on this, as has the gentleman from Kansas (Mr. Moran) in the House and others. I am very pleased, as the gentleman mentioned earlier, a bipartisan moment on health care. This is a good bill. Let us pass it.

Mr. Speaker, I rise today in support of S. 2302, which would reauthorize the ``Conrad 30 J-1 Visa Waiver Program.'' Reauthorization of this important program will help districts that experience shortages with respect to health care professionals, such as Guam, by allowing certain U.S.-trained foreign doctors to remain in the United States to practice medicine in these underserved areas.

Like many rural and insular areas, Guam experiences great difficulty attracting and retaining qualified health professionals. The cost of providing health care is higher in Guam

than in many areas on the mainland, and incidents of chronic disease are above national averages. The Conrad 30 J-1 visa Waiver Program is an important tool that allows poor, rural and insular areas to meet the health care needs of their communities by permitting International Medical Graduates to maintain their work visas in the United States if they agree to remain in areas defined by the Department of Health and Human Services as Health Professional Shortage Areas or Medically Underserved Areas or Populations. Normally, these foreign physicians would have to return to their respective home countries for 2 years before they could return to the United States to again practice medicine.

While I believe priority should always be given to American doctors and health professionals for local hiring, it is clear that there are simply not enough health care professionals to meet demand in underserved areas such as Guam. Without the services of skilled foreign physicians from countries such as the Philippines, it would be difficult for Guam's public health care system to meet the medical needs of our community. S. 2302 reauthorizes a program that has been successful in addressing the issues of recruitment and retention of qualified health professionals in these areas, and I urge my colleagues to support its passage.