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Dr. Arjun is a kidney specialist from India who operates multiple dialysis units in Mississippi. Some of these units are located in rural areas as far as 50 miles away from his home in Jackson, Mississippi.¹ While Dr. Arjun received offers from bigger cities, he chose to serve in a rural area since his ultimate goal was to practice in a place where his services were most needed. Mississippi has some of the highest rates of poverty and obesity in the country and thus has a high incidence of kidney disease, especially among people of color. Once Dr. Arjun received an opportunity to interact with patients and witness the need in the region, he decided to settle there. He feels deeply proud of the service he is providing, and his patients—most of whom are African American—are equally grateful. They often tell him that they hope he never leaves the area, a concern that is all too real for rural residents who have long struggled to find stable, accessible, and quality health care.

Of the numerous issues facing rural communities—from grocery store closures to school closures and consolidations²—lack of adequate health care services perhaps most tangibly affects the lives of residents. Notably, the worsening shortage of physicians in rural communities has made it exceedingly difficult for residents to find care. As of January 2019, rural and partially rural areas in the United States accounted for 66 percent of the total primary care Health Professional Shortage Areas (HPSAs)—a designation for health care provider shortages—whereas nonrural areas had only 34 percent of all designations.³ A geographic area is designated as an HPSA if, among other issues, it has fewer providers relative to its population, it serves a higher percentage of people who live below 100 percent of the federal poverty level, and it takes a long time for residents to get to the nearest source of care.⁴ To remove these designations, rural and partially rural areas would need 6,607 more primary care physicians. Rural residents are also facing increasing numbers of hospital closures, as well as issues such as limited transportation, lack of health care coverage or insufficient insurance coverage, and poor health literacy.⁵

All these challenges translate to diminished access to quality health care for rural residents. Often, these residents do not visit their doctors to get preventive care. And even if they do visit a physician, the wait to get an appointment with a doctor may be long, they may be unable to find the specialists they need, or the doctors that are available may be stretched thin or overworked. There are numerous stories that illustrate the plight of rural residents and their struggle to get adequate care. For example, in Webster County, Georgia, there are no doctors available; one pregnant woman’s first trip to the doctor was for her delivery. Another resident and her son walked about 8 miles back from an appointment in Columbus before a motorist offered a ride, and others simply avoided visiting the doctor altogether.⁶ Unfortunately, these health care access challenges are likely to get worse in the coming decades because many rural communities have aging populations whose health care needs and use of services will be different—and greater—than those of other age groups.⁷ For this reason, it is more important than ever to address this crisis now.

Nationally, physicians who are foreign trained or international medical graduates (IMGs)—most of whom are non-U.S. citizens⁸—make up almost one-quarter of active physicians.⁹ In some specialties, such as geriatric medicine and nephrology, IMGs make up approximately 50 percent of active physicians.¹⁰ Many foreign-trained physicians who are neither U.S. citizens nor permanent residents—referred to as “immigrant doctors” in this report—have long been providing essential health care services in these rural communities, adding to available care options.¹¹

This report highlights physician shortages in rural communities, explores some of the main pathways through which immigrant doctors end up practicing there, and provides broad federal and state policy recommendations to better incorporate immigrant doctors into the effort to tackle the rural health care crisis. Through interviews with immigrant doctors practicing in rural communities, this report shines a light on the barriers they face, in terms of both immigration and licensing.

As the report outlines, immigrant doctors must go through multiple hurdles before they can serve an area. These challenges range from complex and restrictive immigration laws to national and state medical licensing processes and their stringent requirements. And rural communities, which are struggling to attract any doctors—regardless of where they were born or trained—face additional challenges in recruiting and retaining immigrant doctors. Federal laws do allow these underserved communities to benefit from immigrant doctors, but the current path for immigrant doctors to practice anywhere is paved with a patchwork of federal immigration policies and mismatched state licensing regulations that do not truly work in anyone’s best interests—neither those of the physicians nor those of the underserved rural communities. Below are some major drawbacks of the system in place today:

• Many immigrant doctors use J-1 exchange visas to complete their residencies in the United States, with the expectation that they will return to their home countries and spend at least an aggregate of two years before they can apply for certain visas. However, if they want to stay in the United States and practice, they need to apply for a waiver of this requirement, called the Conrad 30 program, which is only available if they commit to practice in a federally designated Health Professional Shortage Area, Medically Underserved Area, or Medically Underserved Population for at least three years.¹² While this waiver program helps both rural communities and immigrant doctors, it needs to be reauthorized every two years by Congress and only gives states 30 waivers, regardless of their size or need.
• Immigrant doctors can also apply for H-1B visas to work in the United States. H-1Bs are dual-intent visas that make immigrant professionals eligible to apply for permanent legal residence, known as a green card, if their employer agrees to file it for them. This visa is extremely difficult to get since it has an annual cap and is often oversubscribed.
• The wait times to get a green card, using any of the employment-based categories, are ridiculously long for applicants from certain large countries, such as India and China. Due to per-country limits placed on green cards and a limit on the total number available each year, there are massive backlogs, and certain applicants may have to wait for decades before one becomes available.
• Each state has its own set of laws and policies to license physicians for state practice. As a result, immigrant doctors must navigate the complicated process of getting their state license on top of making sure they maintain their immigration status. This means that they have to overcome numerous barriers in order to meet their full potential.

There are, however, ways to improve and streamline policies and processes to ensure that communities that are significantly underserved by physicians can recruit immigrant doctors to ease some of the health care inequities and improve health care access. These include legislative fixes to the J-1 visa program, reforms to the H-1B visa category, modifications to the per-country limit, and state-level efforts to remove medical licensing barriers. Through a strategic and multipronged approach at different levels of government, the United States would be able to harness the talents of immigrant doctors to help minimize physician shortages in rural communities.

Due to challenges on multiple fronts, the demand for better health care services is high in rural communities. For one, residents in rural areas are older; their median age is 51, compared with 45 for residents in nonrural areas.¹³ In addition, the Centers for Disease Control and Prevention reports that higher percentages of rural residents die from preventable causes than do urban residents, which could be the result of various factors, ranging from high rates of cigarette smoking, high blood pressure, and poverty to lack of health insurance and limited access to health care.¹⁴ Furthermore, while the opioid epidemic has hit nationwide, there are slightly higher rates of recorded drug overdose deaths in nonmetropolitan areas than in metropolitan areas; compared with other areas, nonmetropolitan areas also had higher rates of natural and semisynthetic opioid-related drug overdose death rates.¹⁵

Set against this backdrop of increasing demand for quality health care, the United States is going through a worsening physician shortage. The 2019 Association of American Medical Colleges (AAMC) report projects that by 2032, the United States will have shortages of from 46,900 to 121,900 physicians overall and from 21,100 to 55,200 primary care physicians, as well as a shortage in nonprimary care specialists.¹⁶ Currently, about 14,472 more primary care physicians are needed to offset the undersupply in designated shortage areas. One of the main reasons for this projected physician shortage is the expected shift in demographics, as the growing population of older adults will demand more health care services. The same AAMC study projects that by 2032, there will be approximately 50 percent growth in the population of those ages 65 and older, compared with only 3.5 percent growth for those ages 18 or younger.¹⁷

On the supply side, even though medical schools have been training more doctors since 2002, a 1997 Medicare cap on funding for graduate medical education resulted in an undersupply of residency training slots available for prospective physicians, “creating a bottleneck.”¹⁸ Data show that in the past four decades, more medical graduates have applied for residencies than there have been slots available.¹⁹

This physician shortage is felt even more acutely in rural communities. In these areas, there are only 13.1 physicians and surgeons per every 10,000 residents, compared with 31.2 physicians in urban areas.²⁰ While physician-to-population ratio is an imperfect method of measuring access to care, in the absence of more granular data, it can help show whether there are enough doctors working in an area to adequately serve residents. A 2018 survey from The Medicus Firm of more than 2,000 medical professionals shows that physicians overwhelmingly prefer urban areas to rural areas, likely due to greater career opportunities.²¹ Only 8 percent of those surveyed said that they are currently practicing in a small town or rural community.²² Moreover, only 6 percent of those surveyed reported wanting to live and work in these communities, compared with more than 60 percent saying they would prefer to practice in a metropolitan or suburban area. To make matters worse, rural areas have been increasingly plagued by hospital closures; the North Carolina Rural Health Research Program estimates that more than 100 rural hospitals have closed since 2010.²³ Many of these closures were due to financial distress driven in large part by a declining rural population.²⁴

Combined, these challenges exacerbate the woes of rural residents, further decreasing their access to quality and timely health care services. In 2017, NPR detailed one powerful example in which a resident in a rural Arizona town changed her primary care doctor four times because her doctors were no longer practicing there.²⁵ She was forced to travel more than 60 miles round trip to another town just to see a doctor. It is hard for rural hospitals to recruit doctors because salaries in urban hospitals are more competitive. Moreover, shifting immigration policies have made it harder to recruit immigrant doctors; there are even instances where immigrant doctors who are already serving rural areas are forced to move away in pursuit of positions that would allow them better opportunities to receive a permanent residency, regardless of whether they want to stay.

International medical graduates who are neither U.S. citizens²⁸ nor legal permanent residents have two main options to train or practice in the United States:

• The J-1 visa, under the Exchange Visitor Program, is a temporary nonimmigrant visa category that allows immigrant professionals to gain knowledge and skills that will be valuable in their home countries.²⁹ Immigrant doctors generally use J-1 visas to complete their graduate medical education in the United States.
• The H-1B visa is a temporary visa that allows employers to recruit foreign workers in specialty occupations.³⁰

Of the total 130,545 resident physicians in the United States in 2017, nearly 30 percent, or 37,220, were not U.S. born.³¹ Moreover, about half of those who were not U.S. born were not naturalized or did not have permanent residency and were therefore on some type of visa. (see Table 1)

Additionally, many immigrant doctors use a National Interest Waiver (NIW), which allows physicians and other highly skilled professionals to petition for employment-based permanent residence provided they can prove that it is in the national interest to allow them to work permanently in the United States.³² Among other requirements, physicians under an NIW must practice full time for at least five years in an area federally designated to have a shortage of health care professionals or at a health care facility under the U.S. Department of Veterans Affairs.³³

J-1 visa

Immigrant doctors who wish to train in the United States under J-1 visas must be sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG), which is authorized by the U.S. Department of State to sponsor medical graduates for clinical trainings and research.³⁴ Other requirements for eligibility include passing the first and second levels of the U.S. Medical Licensing Examination (USMLE), having an offer from an accredited medical or training program, and holding an ECFMG certificate.³⁵ The visa can be renewed for a maximum of seven years to allow the medical graduate to complete clinical training. J-1 visa holders are eligible to have their spouse, as well as their unmarried children under age 21, classified as dependents under J-2 visa.³⁶ According to data collected by the Department of State, among the 2,738 J-1 visas granted to physicians in 2018, Canadians made up 25 percent of the total, Indians made up 18 percent, and Pakistanis made up 9 percent.³⁷

To secure the required medical residency in the United States, IMGs must compete with U.S. medical graduates for a limited number of available slots. It is not guaranteed that they will be matched with a residency; in fact, immigrant doctors are matched at a lower rate than those who graduated from U.S. medical schools. Data on residency matches show that while 93.9 percent of those who graduated from U.S. medical colleges were matched in 2019, only 58.6 percent of foreign-trained non-U.S. citizens were matched.³⁸ This means that there were about 2,841 non-U.S. citizens IMGs who passed exams but were unable to secure a residency slot and thus unable to fulfill licensing requirements. There are various reasons why medical graduates who passed the same standard USMLE have different matching rates. A Minnesota task force found that residency programs often prefer recent graduates; however, many immigrant doctors have already spent years completing residencies in their home countries following graduate school and therefore do not fit that bill. Residency programs may also prefer graduates with clinical experience in the United States, which is almost impossible for someone who studied and trained abroad to have.³⁹

After physicians complete their residencies under a J-1 visa, Section 212(e) of the Immigration and Nationality Act requires both them and their J-2 dependents to return to their home country for an aggregate of at least two years before they are eligible to adjust their status to certain other visa categories, such as H-1B.⁴⁰ But Section 220 of the Immigration and Nationality Technical Corrections Act allows interested government agencies (IGAs) to request a waiver of this two-year home residence requirement as long as certain conditions are met. One of the main conditions is that IMGs commit to serve full time in a Health Professional Shortage Area, Medically Underserved Area (MUA), or Medically Underserved Population (MUP) for at least three years.⁴¹ Operating under this law, the U.S. Department of Agriculture became the largest agency to sponsor primary care physicians from abroad, sponsoring approximately 3,000 waivers until its program abruptly ended in 2002.⁴² Several federal government agencies have acted as IGAs, including the U.S. Department of Health and Human Services, the Appalachian Regional Commission, and the Delta Regional Authority.⁴³

At the state level, the Conrad 30 Waiver Program, established in 1994, allows states to sponsor a limited number of waivers to J-1 physicians wishing to practice in a certain state. The program is administered through a designated state public health department, with each state offering up to 30 waivers per year.⁴⁴ The J-1 visa waiver application, submitted by the employer and the applicant, must be approved by the U.S. Department of State.⁴⁵ Ultimately, U.S. Citizenship and Immigration Services (USCIS) reserves the right to grant the waiver and approves the request for the physician to receive an H-1B visa under the waiver, which paves the path for the physician to apply for a green card through the employment-based (EB) category. However, there are serious backlogs in green card availability, especially for individuals from large countries such as India and China.

H-1B visa

Another visa category that immigrant doctors may use for residencies and to work in the United States is the H-1B visa for specialty occupations. Unlike J-1 visas, H-1Bs are dual-intent visas that allow their holders to apply for permanent residence without requiring them to go back to their home country first.⁴⁶ The dependents of H-1B holders—spouses and unmarried children under age 21—are eligible to receive visas under H-4 nonimmigrant classification.⁴⁷ Although H-1Bs are attractive, they are harder to acquire because they are so highly sought after among professionals and have an annual cap, as well as other requirements. The demand has been so high that from 2014 to 2018, the annual cap for H-1B visas was reached within the first five business days that they were made available.⁴⁸ In cases where the annual cap is met, which has become the norm, USCIS conducts a random lottery to decide on which petitions to process.⁴⁹ Many residencies may be exempt from this annual cap because they meet one of the following criteria: “institution of higher education or its affiliated or related nonprofit entities or a nonprofit research organization, or a government research organization.”⁵⁰ But once those H-1B doctors finish their residencies and have to transfer to an employer, who may be nonexempt from the cap, they have to go through the H-1B lottery. Moreover, in contrast to J-1 visas, which are sponsored by the ECFMG, physicians seeking H-1Bs must find a sponsoring institution willing to apply on their behalf. The applicant must also clear all three required levels of the USMLE to apply for an H-1B, compared with just two exams for J-1 visas. Additionally, before an H-1B is approved, applicants must meet state licensing requirements, which vary significantly by state for residents and fellows.⁵¹ It is particularly challenging for immigrant doctors to meet all these requirements when they are at the beginning stages of their residencies. Furthermore, an H-1B is only a three-year visa that can be extended once to a maximum of six years. This limit may not give doctors enough time to finish their residencies and fellowships and start to practice.⁵²

Under the H-1B visa category, individuals are eligible to apply for a green card if their employer is willing to petition for them, but there are major hurdles for those of certain nationalities. Each independent country, regardless of its population size, cannot be issued more than 7 percent of the total yearly green cards available worldwide for family- and employment-based categories.⁵³ In 2017, approximately 140,000 green cards were issued to applicants and their dependents in the United States in the employment-based categories.⁵⁴