Remedying the doctor shortage with the J-1 visa waiver

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The U.S. faces a shortage of 124,000 physicians by 2034 according to the latest study by the Association of American Medical Colleges – a projection exacerbated by the COVID-19 pandemic, hospitals seeing increased traffic, aging population, and physicians retiring early.

In turn, healthcare entities are exploring options to address shortages. A foreign-born graduate recently trained in the U.S. can serve as a valuable recruit. As such, the Conrad 30 Waiver Program has become an employment pathway to fill those voids in medically underserved areas.

If a foreign medical student trains in the U.S., they are typically here on a J-1 Visa, and as a condition, the student has a two-year home residency requirement following completion of fellowship. This home residency requirement is a significant deterrent to foreign medical graduates seeking work in the U.S.

The Conrad 30 Program

In 1994, however, in an attempt to address a growing physician shortage in rural and urban areas, the Conrad Program was formed. This Program allowed each State’s Department of Health to sponsor 20 international medical graduates (IMGs) each year for a “J-1 Waiver” of the two-year home residency requirement. The approved applicants are required to serve in federally-designated shortage areas. The Program targets physicians who fulfilled a U.S. residency program, mostly in primary care and general practices. (Conrad basics)

In 2003, Congress reauthorized the Program and increased it to allow 30 waiver spots per state per year. The reauthorization added 10 spots for specialist physicians, resulting in the Conrad 30 Waiver Program. States collectively recruit 800 to 1,000 IMGs annually through Conrad 30, enabling more than 15,000 IMGs to practice in the U.S.

But while it is a valuable pathway for aiding physician shortages – foreign-born physicians account for 26% of U.S. doctors – it’s important to understand the intricate application requirements and how they vary by state. Each state differs in qualifying practice areas and eligible designated specialties. Each state has geographic location requirements, which need to be satisfied before the Conrad 30 Waiver Program is considered a viable path.

If not understood and evaluated properly, the process can be convoluted and lengthy, creating a headache for healthcare executives.

J-1 Waiver Process Explained

In seeking a waiver, healthcare executives must first understand the state’s Conrad 30 requirements and approved practice areas. Each state gets 30 spots, but only 10 of these spots are for specialty physicians.

The physician’s practice needs to be an approved specialty for the employment state’s Conrad 30 program, and states vary on their list of practices and specialties. The specialty may not be on the employment state’s list of designated specialties. Sometimes, the specialty designation can be added, however, the specialty may be difficult to add.

Adding a specialty to a state’s designated list takes time and know-how. This part of the process can create a bottleneck in employing IMGs in specific practices beyond general care.

Next, the physician has to apply for and be granted a Conrad 30 spot. Then, the employer applies to the U.S. Department of State for a recommendation of the physician for a waiver.

If approved, the DOS recommends the physician for a waiver to the United States Citizenship and Immigration Services (USCIS). If the DOS recommends the waiver, USCIS will typically grant it.

Finally, once USCIS grants the J-1 Visa Waiver, the petitioner can apply for an employment Visa to work in the U.S. The most appropriate Visa is typically an H-1B, and Conrad 30 physicians are not subject to the H-1B Visa cap. This means once they receive their waiver, a physician can apply for an H-1B Visa at any point throughout the fiscal year.

In addition to the varying state guidelines, there are several federal requirements that are important to know for IMGs to meet, according to USCIS:

• Admitted to the U.S. under section 101(a)(15)(J) of the INA to receive medical training;
• Obtain sponsorship of a state health department or equivalent;
• Complete the U.S. DOS Form DS-305, J-1 Visa Waiver Review Application;
• Obtain a no objection statement from their home country if they were funded by home government or contractually obligated to return upon completion of exchange training;
• Agree to begin employment within 90 days of receipt of the waiver; and
• Full-time contract to practice 40 hours per week and a minimum of three years at a healthcare facility designated by the U.S. Department of Health and Human Services as a Health Professional Shortage Area, Medically Underserved Area, or Medically Underserved Population, or serving patients who are in a HPSA, MUA, or MUP.

There are 10 flex slots that are allowed for each state with physicians working in locations not designated as being in shortage areas, but the sponsor and healthcare entity must serve the residents of a shortage area and demonstrate the inability to find an American to fill the position.

Forensic pathology added as Louisiana’s largest parish fills physician need

Louisiana has 19 forensic pathologists – equal to one death examiner for every threeparishes in the state, according to a July 2022 article by the New Orleans Advocate. The statistics mirror a nationwide shortage of forensic pathologists exacerbated by the increase of opioid overdoses, deaths from drugs laced with fentanyl, COVID-19 pandemic-related deaths, and from a surge in homicides and suicides. There is a growing need for timely death investigations and autopsies.

We recently worked with the Louisiana Department of Health to get forensic pathology added to the list of J-1 Visa waiver specialties. Louisiana became just the fifth state to recognize forensic pathology as a J-1 waiver specialty. Before Louisiana, forensic pathology was only a waiver qualifying specialty in Washington, Wisconsin (no longer recognized), Maryland (no longer recognized), Montana, and Virginia.

The waiver addition has already filled a need for autopsy review in the largest parish of Louisiana, Jefferson Parish, as Trinidad native Dr. Randall Bissessar joined the Jefferson Parish Coroner’s Office, beginning May 1, 2023.

Following his graduation, Dr. Bissessar had only returned to Trinidad for less than a year. Forensic pathology was not on the list of Louisiana specialties for Conrad 30, further delaying his path to employment in the U.S. Forensic pathologists are very specialized. The Jefferson Parish Coroner’s Office previously had three full-time pathologists, but were down to just one full-time and one part-time, despite the need to assist other parishes in processing their examinations. Now, that critical hire has been made.

Throughout each of the steps involved in the Conrad 30 Program and J-1 Visa Waiver Application processes, knowledge of the requirements is essential to ensure the necessary steps are completed accurately, whether that be adding a specialty to a state’s designated list all the way through the obtainment of an Employment Visa.

Mary Kate Fernandez, an associate in the New Orleans office of Adams and Reese, practices in business immigration, litigation, and labor and employment. She can be reached at mary.fernandez@arlaw.com.