[biztech-discussion] Re: biztech-discussion Digest V1 #25
- From: <margh@xxxxxxx>
- To: <biztech-discussion@xxxxxxxxxxxxx>
- Date: Mon, 24 May 2004 11:50:26 -0400
Hello All.
So far I have not seen any indication that people (not just you)
understand the magnitude of the problems nor the long term implications
of the "cheap labor conservative" agenda. I've just started a blog
which includes an attempt to educate on the local level.
http://www.nj.com/weblogs/burlco/
However, the long term implications are horrendous, including the
erosion of the U.S. tax base (which the political clowns might
understand), erosion of U.S. competitiveness in the world market (which
the corporate weenies might understand), and a complete undermining of
the U.S. educational system (which human rights activists ought to
understand).
I am appending the latest newsletter from ZaZona.com. Rob Sanchez has
been activist in the H-1B/L-1/offshoring political "game" for many
years; and even though I don't like doomsday predictions in general, I
have to concede that he's got his facts straight.
White papers are a terrific exercise, but better sooner than later we
are going to have to make the issues public in an in-your-face, up-
close-and-personal style to activate some sense of outrage in the
general public. That is not going to happen without the cooperation of
the media.
The more prominent members of the media are yanking the "racist"
string, accusing any of us who are concerned about not only our jobs,
but our children's future, of discriminating against brown people. They
are not bothering to investigate the offshoring phenomenon as a
manipulative attempt to bolster the U.S. dollar against the euro, the
same game plan used to justify the war in Iraq and the seizure of the
oil fields by Halliburton et al. The low-cost techie in Mumbai is on
the same slippery slope that we are, thanks to the Administration's
fiscal strategy (maybe a bigger economic "bubble" than the dot-com).
So write white papers to get the facts all up front, but any of us with
personal experiences of the cost and media contacts need to get in
front of the public. Unfortunately, some of you may have had the same
experience I've had in the past couple of years -- I get paid well to
clean up the messes caused by cheap labor, and I am bored into
unspeakable insensitivity by the "dumbing down" effect cheap labor has
had on the U.S. job market.
And don't count on Kerry to do anything different if he gets into
office. He hasn't a clue!
Margherite Williams
---------------------------------------
---------------<<<>>>---------------
JOB DESTRUCTION NEWSLETTER
by Rob Sanchez
May 23, 2004 - No. 1019
---------------<<<>>>---------------
Shortage Shouters at the Hospitals
.----------.
/ .-. .-. \
/ | | | | \
\ `-' `-' _/
/\ .--. / |
\ | / / / /
/ | `--' /\ \
/`-------' \ \ (by Jym Dyer)
According to Rob Paral, an immigration attorney, there is a drastic
shortage of medical workers in the United States. That should sound
familiar if you read my last newsletter on the shortage of engineers
and scientists. It's no coincidence that all of this shortage shouting
is coming out at the same time. The cheap labor lobby has made it very
clear for months that they were going to use a media blitz to promote
the importation of foreign labor. Their strategy is becoming very
obvious -- they are fixating the public and the media on outsourcing
while they lobby Congress for more visas. This is a classic strategy of
misdirection to distract American workers.
There are some stats that illustrate just how pervasive the impact of
the importation of medical workers is. Keep in mind that this
immigration attorney probably considers "immigrants" as those medical
workers that came to the U.S. with visas such as green cards, H-1B, and
O-1.
* 1.1 million immigrants account for 13 percent of health care
providers in the United States.
* The foreign born account for 25.2 percent of all physicians; 17
percent of nursing, psychiatric and home health aides, 15.8 percent of
clinical laboratory technicians; 14.8 percent of pharmacists; and 11.5
percent of registered nurses.
Visas used by Physicians:
The admission of physicians occurs primarily through use
of the J-1 and H-1B visa categories.
Visas used by Nurses:
U.S. hospitals and other institutions in desperate need of
nursing personnel can hire foreign-trained nurses as temporary
workers with H-1B visas.
This is some interesting history on nursing visas:
In 1989, the Nursing Relief Act created a pilot program of
H-1A temporary worker visas for foreign-trained nurses.
By 1995, the last year in which employers could petition for
H-1A nurses, some 6,512 had been admitted to the United States.
But Congress allowed the H-1A program to expire and there has
been no comparable replacement program specifically designed to
facilitate the entry of nurses. In 1999, a new nonimmigrant
visa category known as H-1C was created for nurses, but these
visas are only available to nurses sponsored by hospitals in
health professional shortage areas. In addition, only 500 visas
can be issued each fiscal year and there are additional caps on
individual states.
The pressure to allow more H-1B nurses into the U.S. is driven by the
difficulty of getting H-1C visas.
NOTE 18 Given that only a handful of hospitals have received
permission from HHS to apply for H-1C workers, the H-1C
classification is not a viable option for most employers seeking
to recruit foreign nurses. Moreover, the program is scheduled
to end on June 13, 2005.
As in high-tech, there is controversy whether flooding the labor
markets with foreign doctors and nurses depress wages. Predictably this
lawyer said no.
Some observers of the role that immigrant doctors and nurses
play in delivering health care question whether these workers
lower the wages and salaries of U.S. health workers by increasing
the overall supply of workers. However, interviews with health
care workers and their employers, as well as consideration of the
regional and occupational nature of health worker shortages,
suggest that such concerns are largely unfounded.
Solutions for resolving this desperate shortage of medical workers
revolves around importing more of them. These solutions would be
expected from a immigration attorneys.
* The ongoing need for physicians and nurses necessitates the continued
and enhanced use of immigration policy to help fill the gaps.
* Increase J-1 waivers for doctors.
* The Conrad visa program that allows 30 H-1B visas for doctors per
state should be expanded.
* The H-1A visa for nurses should be re-established.
NOTE: This article doesn't reproduce well in ASCII format so you are
better off going to the web page. There are many graphs that are worth
looking at. Much of the article is merely self-serving propaganda, but
there is also a wealth of statistical research that would be of
interest to those who are considering medical careers.
I encourage activists to send me links more articles about shortage of
workers in other professions. I prefer articles that focus on visas as
the solution to these alleged shortages.
------------------------------------
http://www.ilw.com/lawyers/articles/2004,0505-Paral.shtm
Health Worker Shortages And The Potential Of Immigration Policy
by Rob Paral for the Immigration Policy Center
Executive Summary
Foreign-born and foreign-trained professionals play an important role
in the delivery of health care in the United States. This report
examines the important role of immigrant doctors and nurses - many of
whom have received their training abroad - in the U.S. health industry,
using new Census Bureau data as well as information from numerous
interviews with health industry experts. The findings of the report
include:
1.1 million immigrants account for 13 percent of health care providers
in the United States.
The foreign born account for 25.2 percent of all physicians; 17 percent
of nursing, psychiatric and home health aides, 15.8 percent of clinical
laboratory technicians; 14.8 percent of pharmacists; and 11.5 percent
of registered nurses.
During the 1990s, immigrant employment grew by 114 percent in home
health care, 72 percent in nursing care facilities, and 32 percent in
hospitals.
35 million Americans live in areas with too few doctors to adequately
serve their medical needs. Overall, the lack of doctors affects more
than 1,600 geographic areas in the United States. Nearly 16,000 doctors
would be needed to alleviate this shortage.
Foreign-born professionals play a crucial role in filling severe
shortages within the two largest health care occupations: physicians
and nurses.
The most significant federal program sponsoring foreign-trained doctors
to work in underserved areas - managed by the U.S. Department of
Agriculture - was abandoned in February 2002. The program established
in its place - managed by the U.S. Department of Health and Human
Services - has sponsored few doctors and has become increasingly
restrictive.
In 2001, about 1,050 immigrant doctors with temporary J-1 exchange
visitor visas were permitted to stay in the United States in exchange
for their commitment to treat patients exclusively in underserved
areas.
Despite a national shortage of 126,000 nurses, federal policies
designed to permit entry of foreign-trained nurses have become
increasingly restrictionist since the mid 1990s.
In 1990, most nurses were made ineligible for H-1B temporary worker
visas, even while an exemption was made for fashion models. In 1995,
the federal government ended the H-1A program under which employers had
sponsored 6,512 foreign-trained nurses as temporary workers since 1989.
Credential evaluation, tests of English and nursing skills, and other
requirements result in waits of up to one year for nurses who have a
U.S. employer willing to sponsor them for legal residence. The long
wait makes it difficult for hospitals and other health providers to
efficiently fill staffing shortages.
Largely as a result of more stringent requirements, the average number
of nurses granted legal residence in the United States each year fell
to about 4,800 in the late 1990s, compared to nearly 8,600 at the
beginning of the decade.
Introduction
Health care reform is one of the most pressing social and political
issues of our time. Despite major advancements in medical technology,
the number of Americans who have access to medical care continues to
decline. Together with factors such as widespread lack of health
insurance, persistent poverty and low profit margins at medical
institutions, the lack of access to health care is exacerbated by
significant shortages of doctors and nurses. These shortfalls in health
care professionals are found in both rural and inner city areas, where
primary care physicians are often in short supply, and in hospitals and
medical centers nationwide that are unable to locate and hire
sufficient numbers of nurses.
Immigration policy is a tool available to the United States to address
the shortage of health care workers. While programs are available to
bring talented foreign-trained medical professionals into the country,
the number of such persons actually admitted is low compared to the
overall need for doctors and nurses in many health care settings.
Indeed, immigration policy regarding doctors and nurses has become more
restrictive in recent years, even while shortfalls of these workers
have become critical in many communities.
One such community is Grantsville, West Virginia, where the local
hospital put a padlock and chain around its emergency room doors and
closed for 100 days due to a lack of physicians. The area has trouble
recruiting physicians in part because of its rural isolation: the
closest shopping mall is an hour and twenty minute drive.
The Minnie Hamilton Health Care Center took over operations for the
closed Grantsville hospital in 1995. The Center has been largely
unsuccessful in its attempt to hire U.S.-trained doctors, having
attracted only one physician through the National Health Service Corps
in nine years. What makes doctors available to the Hamilton Center and
to the Grantsville area are foreign-trained physicians who have entered
the United States on J-1 "exchange visitor" visas. A waiver program
permits these doctors to stay in the country if they agree to practice
in medically underserved areas like rural Appalachia. Currently, these
foreign-trained physicians represent six of the nine physicians at the
Hamilton Center.
Hundreds of miles away, in the historic African American neighborhood
of Bronzeville on the South Side of Chicago, Mercy Hospital cannot find
enough registered nurses to fill its full-time staff because of an
acute shortage of nurses affecting the entire nation. The shortage of
nurses has forced the hospital to use expensive and temporary contract
nurses. Mercy?s nursing shortage has staffing levels "right on the
edge," according to Catherine Walsh, Vice President for Patient Care
Services at the hospital. Walsh says that Mercy "could use 50 nurses
tomorrow" if they could only find them.
For Mercy Hospital, one of the few bright spots in the nursing
situation is the ability to locate and hire highly skilled
foreign-trained nurses. Mary Ann Padilla is one such nurse. A native of
the Philippines, where she received her bachelor?s degree and nursing
education, Ms. Padilla entered the United States in the early 1990s
under an H-1A temporary worker visa designed especially for nurses. The
H-1A program once brought thousands of needed nurses to the United
States, but Congress allowed the program to expire in the mid-1990s
despite a nationwide shortage of nurses currently estimated at 126,000.
Grantsville, West Virginia and Chicago, Illinois are just two of the
places where thousands of foreign-born professionals are serving basic
health care needs in the United States. Frequently delivering care to
underserved populations and often filling positions for which
native-born professionals cannot be found, immigrant doctors, nurses
and other specialists play a critical role in filling gaps in the
American health care system; gaps that prevent neighborhoods, from poor
communities in inner cities to middle-income communities in large
swaths of rural America, from having access to adequate medical care.
Despite the importance of these workers, the procedures and programs
under which the United States permits the temporary and permanent
immigration of health care professionals are highly complex, involving
constantly evolving laws and multiple federal and state agencies. These
procedures and programs are at once both centrally authorized but
locally implemented. Statistics and data on the immigrants involved are
hard to come by and in some instances have never been compiled, even by
the federal agencies that play key roles in running the programs.
The Role of Immigrants in U.S. Health Care Foreign-born
Professionals are indispensable in thousands of doctors? offices,
hospitals, nursing homes and other places where health care is
delivered every day to millions of Americans. As in the U.S. economy in
general, immigrants in the health care industry play a significant role
at both the high-skilled and low-skilled ends of the occupational
spectrum. Foreign-born professionals play a particularly crucial role
in filling severe shortages within the two largest health care
occupations: physicians and nurses.
The 2000 census counted 1.7 million immigrants in the health care
industry, accounting for about 11.7 percent of all workers, including
non-medical personnel such as administrators or janitors who work in a
health care setting but are not themselves delivering health care
directly. Among health care delivery occupations, such as doctors,
nurses and physical therapists, some 1.1 million immigrants comprise
about 13.0 percent of all workers. NOTE 1
Immigrants in the Health Care Workforce: 2000
Number of Immigrant Workers
Immigrant Percent of Workforce
All U.S. Workers (Including non-health)
16,073,543
12.4%
Health Care -- All Workers
1,695,372
11.7%
Health Care -- Health Care Providers
1,101,792
13.0%
Within specific health care occupations, the representation of
immigrants varies widely. For instance, among optometrists (8.3 percent
of whom are foreign born), dental hygienists (4.6 percent) and
speech-language pathologists (3 percent), the number of immigrants in
the workforce is below the national average of 12.4 percent. However,
there are higher than average numbers of immigrants working as
physicians (25.2 percent); nursing, psychiatric and home health aides
(17 percent); clinical laboratory technicians (15.8 percent); and
pharmacists (14.8 percent). NOTE 2
Percentage of Immigrants in Medical Occupations: 2000
Dentists
14.4%
Dietitians & Nutritionists
10.7%
Optometrists
8.3%
Pharmacists
14.8%
Physicians
25.2%
Physician Assistants
11.2%
Podiatrists
8.0%
Registered Nurses
11.5%
Occupational Therapists
7.4%
Physical Therapists
7.4%
Respiratory Therapists
9.9%
Speech-Language Pathologists
3.0%
Therapists, all other
8.1%
Health Diagnosing & Treating Practitioners, all others
11.0%
Clinical Laboratory Technologists & Technicians
15.8%
Dental Hygienists
4.6%
Licensed Practical & Vocational Nurses
8.8%
Medical Records & Health Information Technicians
8.7%
Other Heath Care Practitioners & Technical Occupations
7.9%
Nursing, Psychiatric, & Home Health Aides
17.0%
Dental Assistants
11.7%
Medical Assistants and other Health Care Support Occupations
9.3%
All Medical Professions
13.0%
All Occupations (not exclusively medical)
12.4%
Note: boldface type denotes categories with higher-than-average numbers
of immigrants.
However, whether the number of immigrant workers in the health care
industry is currently below or above the national average tells only
part of the story. Foreign-born workers have also had a profound impact
on the growth of the health care workforce. The American medical
industry grew by 1.7 million workers during the 1990s, with nearly 25
percent of this growth attributable to the entry of immigrants into the
labor force. While this is relatively low when compared to the more
than 72 percent of net employment growth attributable to immigrants
entering the U.S. labor force as a whole during the 1990s, their
presence in the medical industry played a critical role in increasing
the availability of health care in this country.
Immigrant health workers have been particularly important in home
health care, hospitals, and nursing care facilities. In home health
care, immigrant workers more than doubled in number during the 1990s,
increasing by 114 percent, while the native born workforce grew by only
31 percent. In hospitals, immigrant employment grew by about one third,
32 percent, while native-born employment was essentially flat, growing
by less than 1 percent. The number of immigrants working in nursing
care facilities jumped by 72 percent, while the number of native-born
workers grew by only 3 percent. At the same time, native-born
employment in physicians? offices and outpatient care centers nearly
doubled, increasing by 91 percent, while immigrant employment grew by
only 14 percent.
Growth of the Health Care Workforce in Selected Health Care Sectors:
1990-2000
Industry Employment Growth
Native Born Growth
Foreign Born Growth
Pct. Of Growth Due to Foreign Born
Health Care Industry
25%
21%
62%
25%
Offices of Physicians/outpatient care centers
80%
91%
14%
14%
Home Health Care Services/Other Health Care Services
40%
31%
114%
30%
Hospitals
4%
0%
32%
97%
Nursing Care Facilities
8%
3%
72%
70%
Health Care Practitioner Shortages
Medical care in the United States is envied throughout the world for
its extraordinary sophistication and quality, but the reality is that
high-quality health care is unavailable to millions of U.S. residents.
The lack of access to health care is caused by many factors, including
poverty, lack of health insurance, and high costs for medical services.
But other key factors are a growing national shortage of doctors and an
already critical national shortage of nurses.
The increasing shortage of physicians is already being felt in many
geographic areas. According to the U.S. Department of Health and Human
Services, roughly 34.9 million Americans live in areas designated as
health professional shortage areas. NOTE 3 These are urban and suburban
neighborhoods and rural areas where there is less than one primary care
physician for every 2,000 persons. In addition to shortages of medical
doctors, some 28.5 million Americans reside in areas where there is a
shortage of dentists and 44.4 million persons live in areas that lack
sufficient mental health professionals.
Relieving the shortages of medical personnel would necessitate placing
an additional 16,000 doctors in areas of need, as well as 8,500
dentists and 4,000 mental health professionals. One-third of all areas
with shortages of primary care givers are located in metropolitan
areas, while two-thirds are located in rural areas. Half the
underserved population nationally lives in metropolitan areas and half
in rural areas. Overall, the lack of doctors affects more than 1,600
geographic areas in the United States.
While the federal government reports an existing need for 16,000 more
doctors, other estimates suggest that the United States will be short
50,000 physicians by 2010, with the gap growing to 200,000 by 2020.
NOTE 4 These shortages are due in part to a lack of graduate medical
education infrastructure, and it has been argued that alleviating just
one-third of the coming shortfall in doctors would require the opening
of an additional 25 medical schools. NOTE 5
National Health Professional Shortages: September 2003
Underserved Population
Practitioners Needed
Primary Medical
34,948,853
15,898
Dental
28,508,452
8,526
Mental Health
44,412,800
4,404
Source: National Center for Health Workforce Analysis, HRSA
While the shortage of physicians looms large in the future and is
currently impacting certain regions, the United States has already been
hit hard by dramatic shortages of nurses across the country. The
nation?s hospitals currently need an additional 126,000 nurses, and
90 percent of long-term care organizations are short on nurses. NOTE 6
At Mercy Hospital in Chicago, the shortage of nurses is so severe that
the hospital participates in a program designed to help foreign-trained
nurses who are already in the United States (usually through family
reunification visas) to obtain the English skills and refresher
training needed to pass the Illinois nurse licensure process. At Oakton
Pavillion, a nursing home in DesPlaines, Illinois, administrator Jay
Luchowicz explains that 26 of his staff of 45 nurses are foreign
trained because he cannot locate enough native-born nurses. The
shortage of nurses is leading many institutions to rely on contract
nurses; individuals who work not for the health care institution but
for a labor contractor. At Mercy Hospital , these nurses are about 20
percent of all nurses, and the hospital is forced to pay a premium for
them, with contract nurses costing $50 to $55 per hour compared to $30
per hour for a full-time, on-staff nurse. As Luchowicz puts it,
ruefully considering the almost 100 percent premium he pays for
contract nurses, "How would you like to spend your money?" The salaries
Luchowicz pays for nurses - from $60,000 for an on-staff employee to
the equivalent of more than $100,000 for a contract employee -
underscore that the nursing shortage is not a result of low salaries.
Rather, there simply aren?t enough nurses available.
The Role of Immigration in Relieving Health Worker Shortages
The admission of immigrants into the United States based upon their
ability to provide needed labor and skills is an essential part of the
immigration system. Employment-based immigrants represent almost 10
percent of all immigrants admitted each year. American immigration
policy has experienced a slight shift in favor of these immigrants,
even while family reunification remains the cornerstone of our
admissions policies. NOTE 7
In addition to those seeking a permanent immigration status, U.S.
immigration laws include provisions for non-immigrant visas that are
available for persons coming to the United States on a temporary basis.
The admission of physicians occurs primarily through use of the J-1 and
H-1B visa categories. Physicians who enter the United States as
"exchange visitors" with temporary J-1 visas can receive permission to
remain in the country as employment-based immigrants if they commit to
practicing in areas with health care shortages. These physicians thus
represent Congress' overt effort to place foreign-trained doctors into
areas with acute health care needs.
J-1 Physicians
Exchange visitors with a J-1 visa are defined as persons with a
residence in a foreign country who come temporarily to the United
States to teach, conduct research or receive training. NOTE 8
Categories of J-1 visas include teachers, students, scholars and
physicians. For physicians, the J-1 visa allows graduates of foreign
medical schools to pursue continued training for a maximum of seven
years in an institution in the United States. The presence of J-1 visa
holders in the residency programsof many hospitals is due in part to
the insufficient number of graduates from American medical schools,
which leads residency programs to utilize J-1 temporary immigrants to
remain fully staffed.
The training program of a J-1 visa holder must be accredited by the
Accreditation Council for Graduate Medical Education (ACGME) and each
physician must be sponsored by the Educational Commission for Foreign
Medical Graduates (ECFMG). In order to receive ECFMG sponsorship,
foreign-born physicians must pass the U.S. Medical Licensing Exam, just
like native-born doctors, and a Test of English as a Foreign Language
(TOEFL). After completing their training, physicians with J-1 visas are
usually required to return to their home country for at least two years
prior to applying for permission to work in the United States or being
granted permanent residence. A J-1 physician may request a waiver of
the two-year return rule if returning home would result in persecution
to the physician or cause exceptional hardship to the physician's
U.S.-citizen or permanent-resident spouse or child, or if an interested
U.S. government agency recommends that it is in the public interest for
the physician to remain here to practice medicine.
Federal Agencies Are Requesting Fewer J-1 Waivers at a Time of Growing
Need
Federal law permits interested federal government agencies to recommend
a waiver of the requirement that a J-1 physician return home for two
years. These include agencies such as the Department of Health and
Human Services (HHS), Department of Veterans Affairs (VA), and
lesser-known entities such as the Appalachian Regional Commission (ARC)
and Delta Regional Authority (DRA).
Prior to February 2002, the U.S. Department of Agriculture (USDA)
processed J-1 waiver recommendations for physicians practicing
primarily in rural areas. NOTE 9 This program brought more than 3,000
physicians into underserved rural areas since the mid-1990s. NOTE 10 In
the months following the terrorist attacks of September 11, 2001,
however, the USDA terminated its involvement in the program. As a
result, there was no national program to bring primary care physicians
to underserved areas for approximately 18 months, until July 2003, when
HHS established a program to allow J-1 physicians to practice in
"health professional shortage areas" (HPSAs). NOTE 11
Soon after getting its program off the ground, however, HHS suspended
it for several months, after which the program was re-opened with
substantially tightened eligibility rules. The agency announced that
future applications would only be accepted from areas with a high HPSA
score of at least 14, and waivers would only be granted to doctors
serving in community health centers and rural health clinics. This
leaves out for-profit hospitals even if they are the only medical
center in an area. The new HHS rules for J-1 waivers will further limit
a program that had already been minimally functional. In the state of
Texas , for example, 231 counties qualified for HHS waiver processing
under the agency?s old rules. The new guidelines, however, restrict
the program to 46 counties, and only about two dozen of those have
qualifying health clinics. NOTE 12
States Are Increasingly Responsible for J-1 Waiver Applications In
1994, state governments gained permission to recommend waivers of the
two-year return rule for physicians who practice in medically
underserved areas. NOTE 13 At that time, the so-called Conrad 20
program (named after Senator Kent Conrad of North Dakota, who sponsored
the legislation) allowed each state to recommend up to 20 waivers. The
limit was later raised to 30 per state. Under the Conrad program, a
state department of health or other entity designated by a governor
identifies a physician willing to serve in an area of need. Usually, an
employer wishing to hire a physician approaches the state to report the
physician?s interest in working in an underserved area, and
commitment to work in such an area for at least three years. The state
agency files a petition on behalf of the doctor with the U.S.
Department of State Visa Waiver Office, stating that the employment of
the physician is in the public interest. The State Department then
makes a recommendation to U.S. Citizenship and Immigration Services
(USCIS). State agencies play a critical role in enforcing the rules of
the Conrad program by requiring employers to certify that Conrad
doctors are actually practicing in the areas they commit to serving.
Numbers and Types of J-1 Waivers
Based on interviews with personnel from numerous federal agencies, NOTE
14 an estimated 1,050 waivers of J-1 visas were granted to physicians
destined to practice in underserved areas in 2001. NOTE 15 The majority
of federal agency recommendations likely originated from the USDA.
Estimated J-1 Physician Waivers Processed by State Department, FY2001
Total Federal and State
1,050
Federal Agency
525
USDA*
375
Appalachian Regional Commission
60
Delta Regional Authority**
0
Other Federal Agencies***
90
State Governments
525
*Annualized estimate based on approximately 3,000 USDA waiver
recommendations submitted in 1994-2001 period, per USDA.
** Delta Regional Authority was constituted in 2001 and began
operations in 2002.
*** Represents a residual estimate.
While the number of J-1 waiver recommendations from federal agencies
outnumbered those ori gina ting from state agencies for several years
prior to 2001, this trend is changing. In 2002, state governments for
the first time recommended more J-1 waivers than the federal
government. This is due in part to the demise of the USDA program and
the corresponding decline in federal waiver recommendations for
physicians in underserved areas.
The Texas Primary Care Office, which has been conducting a survey of
states with regard to their use of Conrad waivers, has found a steady
increase in the percentage of state recommendations for
sub-specialists. Whereas in 2000 only about 14 percent of state waiver
requests were reportedly for sub-specialists, this share of waiver
requests grew steadily to about 33 percent by 2003.
The increasing rate at which states are recommending sub-specialists
testifies to their perception that the need for medical care in
underserved areas extends past primary care. Data from the Texas
Primary Care Office surveys show that roughly a fifth of all J-1
physician waiver requests processed in 2001 were for non-primary care
physicians via the Conrad program. NOTE 16
In its surveys, the Texas Primary Care Office also asked states whether
they used all 30 Conrad slots allotted to them and, if so, how many
more slots they would recommend to the State Department.
Recommendations ranged from 5 to 50 additional slots (the latter in the
case of Texas), with 15 states reporting that they would recommend in
excess of 30 additional slots. Interest in additional Conrad slots was
expressed not merely by the largest states in the country, like
California, New York and Texas, but also Arkansas, Iowa, Kentucky, New
Mexico and others. NOTE 17 In other words, for many states the 30
physicians available annually via the Conrad program are insufficient.
The Conrad program presents an interesting mix of federal and state
responsibilities that in some ways parallels the overall process of
legal immigration. That is, the overall number of Conrad physicians is
set by Washington, but the initiation of requests and the burden of
policy implementation fall to a great extent on local entities, in this
case the states. Successfully managing and implementing Conrad waivers
requires states to certify that doctors are serving the populations and
geographic areas they are required to serve. Yet no federal funds are
provided to states to conduct these activities, which can be time
consuming. States have therefore used a variety of methods to fund
their compliance programs. Texas, for example, charges a $2,000
application fee for Conrad waivers, while Michigan charges only an
initial $50 fee and then levies additional fees at other stages of the
program. In Texas, the $2,000-per-application fee generates sufficient
revenue to fund a full-time state employee. Texas also sets aside
Conrad funds in a special account within the state treasury. This
avoids the common situation in state government where fee revenue is
placed in a general fund and then "disappears," leaving agencies to
fight each year for appropriations even if their services are
generating sufficient revenue in the first place.
Immigration Policies and Nurses
Given the serious shortage of qualified nurses in the United States,
one might expect policymakers to design programs that facilitate the
entry of nurses into underserved areas. Indeed, nurses trained abroad
are able to enter the country in a variety of ways, yet the overall
numbers admitted are low and fail to meet the nation?s nursing needs.
Furthermore, the methods by which qualified nursing personnel can enter
the United States actually have been limited in recent years, further
exacerbating shortages.
In 1989, the Nursing Relief Act created a pilot program of H-1A
temporary worker visas for foreign-trained nurses. By 1995, the last
year in which employers could petition for H-1A nurses, some 6,512 had
been admitted to the United States. But Congress allowed the H-1A
program to expire and there has been no comparable replacement program
specifically designed to facilitate the entry of nurses. In 1999, a new
nonimmigrant visa category known as H-1C was created for nurses, but
these visas are only available to nurses sponsored by hospitals in
health professional shortage areas. In addition, only 500 visas can be
issued each fiscal year and there are additional caps on individual
states. NOTE 18 Given that only a handful of hospitals have received
permission from HHS to apply for H-1C workers, the H-1C classification
is not a viable option for most employers seeking to recruit foreign
nurses. Moreover, the program is scheduled to end on June 13, 2005.
The bottleneck restricting the availability of temporary visas for
nurses was also tightened by the Immigration Act of 1990, which added
the requirement that applicants in nearly all occupations eligible for
H-1B visas needed a four-year college degree. While an exception was
made for fashion models, nurses became largely ineligible for H-1B
visas as a result of the legislation. Nursing certification does not
require a bachelor?s degree in 49 of the 50 states, so relatively few
nursing positions can be filled via the H-1B visa. NOTE 19
A look at the delays and complications affecting the entry of qualified
foreign-trained nurses reveals an immigration system that has been
limited in its ability to provide adequate numbers of nurses to the
health care industry. Section 343 of the Illegal Immigration Reform and
Immigrant Responsibility Act of 1996 (IIRIRA) requires that the
credentials of certain foreign health care professionals be certified
and evaluated prior to those individuals being able to work in the
United States. This process includes a review of the health care
worker?s education and licensure, a test of his or her English
ability and, for nurses, a predictive examination. Currently, this
review process is available only through the Commission on Graduates of
Foreign Nursing Schools (CGFNS). NOTE 20
Requiring foreign-trained nurses to prove that they have the requisite
skills to perform their job is important. However, the process of
fulfilling these requirements under U.S. immigration law is
duplicative, slow and expensive. Since foreign nurses must possess
either a nursing license in the state of intended employment or have
passed a test administered by the CGFNS, the additional certification
and evaluation requirements imposed by IIRIRA duplicate requirements
already imposed by state licensing authorities. Moreover, the exam of
nursing skills is available only in the United States and its
territories. Thus applicants have to travel to this country or
locations like Guam to take the nursing test, an arrangement that
constrains participation in the process. Prior to 1996, nurses had to
pass an English test, but the standards were raised by IIRIRA.
Typically, nurses take this test in a large room listening to an audio
tape of two Americans having a conversation. The atmosphere of the test
can be chaotic, and there is reportedly a failure rate of over 50
percent. The high failure rate in combination with the $200 fee
required of test takers discourages potential applicants.
Completion of the testing and certification requirements can take an
entire year, and therein lies the problem with using this immigration
route to satisfy nursing shortages. Hospitals and nursing homes need to
fill nursing slots immediately, and a year-long process of hiring is
obviously an inefficient and unattractive mechanism for obtaining
personnel. U.S. hospitals and other institutions in desperate need of
nursing personnel can hire foreign-trained nurses as temporary workers
with H-1B visas. In fact, if the employer or applicant pays $1,000,
their case can be expedited and receive a decision in 15 days.
Unfortunately, the great majority of unfilled nursing positions in the
United States do not meet the requirements of the H-1B visa, which is
reserved almost exclusively for occupations that require a four-year
college degree.
Data from USCIS illustrate the combined effect of the disappearance of
the H-1A program and the new requirements imposed on foreign-trained
nurses by IIRIRA. During 1991-1996, a period which ends with the
passage of IIRIRA, the average annual number of nurses admitted to the
United States as legal immigrants was 8,564. By the latter half of the
decade, however, that number had fallen to just 4,815. Furthermore, the
1997-2000 average includes about 2,100 former H-1A nurses who adjusted
to permanent residence. The absence of this program means that
declining numbers of these adjustments can be expected in ensuing
years, tending to further lower the numbers of nurses getting permanent
residence.
>Some Considerations on the Economic Impact of Foreign-Trained Medical
Professionals
The ongoing debate over the role of immigration in American society has
many facets, but one of the most contentious is the economic impact of
immigrant workers on the native-born workforce. Some observers of the
role that immigrant doctors and nurses play in delivering health care
question whether these workers lower the wages and salaries of U.S.
health workers by increasing the overall supply of workers.
However, interviews with health care workers and their employers, as
well as consideration of the regional and occupational nature of health
worker shortages, suggest that such concerns are largely unfounded. For
instance, immigrant doctors adjusting from J-1 exchange visitor status
are obtaining employment precisely because there are not enough native
workers in the areas where they are hired. The shortage of 126,000
nurses nationally and the high wages that many hospitals are paying to
fill those shortages lay to rest any concern about native-born nurses
being frozen out of positions by the presence of foreign-trained
professionals. We are very far from a situation in which a native-born
nurse would have difficulty in finding a job. The number of native-born
nurses may be limited by too few slots in nursing schools, and by low
high school graduation rates among groups that might be interested in
nursing, which is one of the few well-paid occupations that does not
require a four-year college degree. However, neither of these problems
is attributable to immigration, and neither can be solved soon.
Conclusion
American immigration policies explicitly recognize the critical role
played by immigrant workers. Special categories of immigrant visas are
reserved for foreign-born workers, tens of thousands of whom are
allowed to enter the United States each year on temporary visas. The
need for immigrant professionals is clearly evident in the field of
health care. Immigrant doctors who entered the United States with J-1
exchange visitor visas are currently treating thousands of persons in
underserved areas of the nation where native-born doctors are in short
supply. Some 70,000 foreign-trained nurses received U.S. permanent
residence in the 1990s and helped alleviate a dramatic national
shortfall of nursing professionals, even while in recent years our
nation has restricted the influx of these workers.
The ongoing need for physicians and nurses necessitates the continued
and enhanced use of immigration policy to help fill the gaps. With
regard to J-1 physicians seeking permission to stay in the United
States and practice medicine, the low numbers of J-1 waivers
recommended to date by HHS - and the increased restrictions applied to
the program by that agency - raise concerns about whether the program
will ever process significant numbers of waivers. Recent revisions to
the HHS program restrict its availability to only the neediest
communities, thereby eliminating about 86 percent of previously
qualifying areas.
Given that about a third of state requests for Conrad doctors involve
medical sub-specialists such as surgeons, there is good reason to
permit sub-specialist applications in all federal waiver programs as
well. NOTE 21 An increase in state allotments under the Conrad program
may be advisable as well given that states? increasing use of waivers
for sub-specialists cuts into the number of primary care physicians
they can request. The current limit of 30 doctors per state has few
parallels in immigration policy. H-1B professionals, for example, are
not allotted on a state-by-state basis.
The national shortage of 126,000 or more nurses at a time of declining
admissions of foreign-trained nurses clearly requires a rethinking of
immigration policy. Even a doubling of current admissions (which
averaged about 7,000 per year in the 1990s) would not significantly
alleviate nursing shortages nor create undue competition for graduates
of American nursing schools. Achieving increased arrivals of
foreign-trained nurses would probably require reestablishment of an
H-1A program that allows nurses to enter the United States without the
lengthy wait times of the existing process.
Few would disagree with the argument that our immigration system should
serve to complement the U.S.-born workforce, and that federal
policymakers have a duty to facilitate the entry of native-born workers
into occupations experiencing labor shortages. One way to address the
need for medical professionals would be to provide further incentives
for U.S.-born physicians to work in underserved rural and inner-city
areas. The National Health Service Corp represents one effort in this
direction, but its existence has not obviated the need to permit
immigrants to work in health shortage areas. Scholarships and loan
waivers could raise the numbers of new U.S.-trained nurses, but these
programs would take years to establish. Ultimately, incentives to
increase enrollment in nursing schools would require deep investment in
the K-12 educational system, where students need to acquire skills and
interests that both increase high school graduation rates and prepare
them for technical careers. The shortages of physicians and nurses,
however, are not problems that can await a solution years or decades in
the future, given the immediate implications that lack of adequate
health care has for American families, workers and the economy.
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---------------------------------------
> Date: Sun, 23 May 2004 15:00:00 -0700
> From: Al Weinrub <Allen.Weinrub@xxxxxxx>
> Subject: [biztech-discussion] Thoughts on Moving Forward
>
> Dear Folks,
>
> For the last couple weeks there has been a pretty lively discussion
> about which offshoring issues the NWU might tackle and how to go
about
> doing that.
Other related posts:
