J-1 physician visa waivers
J-1 visa waivers allow foreign national physicians to remain in the U.S. and practice in a designated Health Professional Shortage Area (HPSA) immediately following their medical training, rather than returning to their home country for two years and then applying for a traditional immigrant visa1, 2. To be eligible for a waiver, physicians must be sponsored by a state public health department or its equivalent. Waivers have a three-year service commitment and are provided by the federal government as part of the Conrad 30 waiver program, which allows each state to recruit up to 30 physicians per year3, 4, 5. Historically, the program focused on placing primary care physicians in rural areas, though it now also supports the placement of specialists in non-rural, underserved areas5.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased availability of physicians in underserved areas
What does the research say about effectiveness?
There is insufficient evidence to determine whether J-1 visa waivers increase the availability of physicians in rural and other underserved areas over the long-term. Available evidence suggests that waivers may increase providers in the short-term; however, long-term retention appears less likely6, 7, 8, 9, 10. Additional evidence is needed to confirm effects, along with research on methods to recruit and retain additional physicians in underserved areas11 and to discover which patient populations are being served2.
Primary care physicians with J-1 visa waivers may treat patients with lower incomes, greater medical need, and in more rural areas compared to other primary care physicians8. Studies in Wisconsin, Washington, and Nebraska suggest that physicians with J-1 visa waivers provide quality care, but typically remain in their placement area only two years beyond the required commitment9, 10, 12. Physicians with J-1 visa waivers are often among the only health care providers in rural and underserved areas; long work hours and frequent on-call schedules may lead to stress and low retention9, 10. Challenges presented by shifting U.S. immigration policies and visa backlogs may further increase stress, make it more difficult for providers to remain in the U.S., and may further discourage physicians from remaining in their placement area beyond the required three years11. A Maryland-based study suggests physicians with waivers may be less likely to remain in Health Professional Shortage Areas (HPSAs) long-term than those in a loan repayment program8.
While the number of physicians using J-1 visa waivers has increased overtime, fewer participants are primary care physicians and participants are less likely to locate in rural areas1, potentially due to modifications to the Conrad 30 program that allow specialists to receive waivers and practice in urban and suburban areas1.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by intervention design.
Offering J-1 visa waivers to foreign national physicians trained in the U.S. has the potential to decrease disparities in access to care by requiring providers to care for patients in Health Professional Shortage Areas (HPSAs), medically underserved areas, or for medically underserved populations, which are frequently in rural and low income urban areas. Available evidence suggests physicians with J-1 visa waivers are often among the only health care providers in rural and underserved areas9, 10, and when working in primary care they may treat patients with lower incomes, greater medical need, and in more rural areas compared to other primary care physicians8.
Overall, rural populations in the U.S. have higher rates of chronic health conditions, experience more poverty, and have significantly higher mortality rates than urban areas. Lack of access to primary care physicians is one component contributing to higher mortality rates16. Today, approximately 20% of the U.S. population resides in rural areas, but only 10% of physicians provide care there17. Additionally, half of rural physicians are over 55, and a third are scheduled to retire by 203318, creating a substantial and ongoing need to train and retain rural providers.
What is the relevant historical background?
In the 1920s, public health officials warned that fewer physicians were practicing in rural areas; many new doctors were drawn to urban areas post-graduation due to higher salaries, larger patient bases and networks of health professionals, along with more modern technology and facilities, such as laboratories19. Increased physician shortages following World War II and the Korean War encouraged the relaxation of immigration laws so that foreign-born physicians could remain in the U.S. following training20; beginning in 1956, government agencies could recommend waivers for physicians with J-1 visas to remain in the U.S. to practice medicine in underserved areas for at least three years “in the public interest”2. Starting in 1994, the Conrad 20 program allowed states to request up to 20 waivers annually; this expanded to 30 waivers per state in 2002, becoming the Conrad 30 program1, 5.
Equity Considerations
- Does the expansion of the J-1 visa waiver program to include specialists in non-rural areas help or harm the recruitment and retention of primary care physicians into rural areas? How can the program be adjusted to address the needs of both urban and rural underserved areas?
- How might physicians receiving J-1 visa waivers benefit from formal or informal networks of support during their placement in a rural or underserved area?
- What additional strategies can be implemented to make rural areas more attractive and retain providers?
Implementation Examples
Employment of international medical graduates under J-1 visa waivers varies widely among states13. Nationally, waiver use increased from 550 in 2001 to 1,162 in 2020, an increase of 111%1. In 2022, approximately 3,300 foreign-born medical students or residents in the J-1 visa program were eligible for waivers upon completion of their residency. Alaska was the only state without eligible students or residents, while New York State and Pennsylvania had the greatest numbers eligible, with 663 and 263 respectively14.
Federal agencies recommending J-1 visa waivers include the Department of Health and Human Services, the Delta Regional Authority in the Mississippi River Delta Region, the Department of Defense, and the Department of Veterans Affairs Veterans Health Administration2. In turn, these providers are part of the 26.7% of the U.S. physician workforce made up of international medical graduates15.
Implementation Resources
‡ Resources with a focus on equity.
RHIhub-J1 Visa waiver - Rural Health Information Hub (RHIhub). Rural J-1 visa waiver.
US DS-J1 visa - U.S. Department of State (U.S. DS). J-1 visa facts and figures: View data by state.
US CIS-Conrad 30 - U.S. Citizenship and Immigration Services (U.S. CIS). Working in the United States, students and exchange visitors: Conrad 30 Waiver Program.
VDH-Conrad 30 - Virginia Department of Health (VDH). Conrad 30 waiver program 2017-2019 guidelines. Office of Health Equity, Virginia Department of Health; 2017.
DRA-Delta Doctors‡ - Delta Regional Authority (DRA). Delta Doctors.
Footnotes
* Journal subscription may be required for access.
1 Ramesh 2023 - Ramesh T, Brotherton SE, Wozniak GD, Yu H. Evaluation of the Conrad 30 Waiver program’s success in attracting international medical graduates to underserved areas. JAMA Health Forum. 2023;4(7):e232021.
2 Quigley 2022a - Quigley L. Incentive programs for physicians to practice in underserved areas: A nationwide snapshot. Journal of Ambulatory Care Management. 2022;45(2):105-113.
3 US CIS-Conrad 30 - U.S. Citizenship and Immigration Services (U.S. CIS). Working in the United States, students and exchange visitors: Conrad 30 Waiver Program.
4 WI DHS-Conrad 30 - Wisconsin Department of Health Services (WI DHS). Wisconsin Conrad 30 Waiver Program.
5 Patterson 2015 - Patterson DG, Keppel G, Skillman SM, et al. Recruitment of non-U.S. citizen physicians to rural and underserved areas through Conrad State 30 J-1 visa waiver programs. Final Report #148. Seattle, WA: WWAMI Rural Health Research Center, University of Washington, 2015.
6 Goodfellow 2016 - Goodfellow A, Ulloa JG, Dowling PT, et al. Predictors of primary care physician practice location in underserved urban and rural areas in the United States: A systematic literature review. Academic Medicine. 2016;91(9):1313-1321.
7 Wilson 2009 - Wilson NW, Couper ID, De Vries E, et al. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and Remote Health. 2009;9(2):1060.
8 Quigley 2022 - Quigley L. Whom do incentive program physicians serve? New measures for assessing program reach. Journal of Ambulatory Care Management. 2022;45(4):266-278.
9 Opoku 2015 - Opoku ST, Apenteng BA, Lin G, et al. A comparison of the J-1 visa waiver and loan repayment programs in the recruitment and retention of physicians in rural Nebraska. The Journal of Rural Health. 2015;31(3):300-309.
10 Kahn 2010 - Kahn TR, Hagopian A, Johnson K. Retention of J-1 visa waiver program physicians in Washington state’s health professional shortage areas. Academic Medicine. 2010;85(4):614-621.
11 Malayala 2021 - Malayala SV, Vasireddy D, Atluri P, Alur RS. Primary care shortage in medically underserved and health provider shortage areas: Lessons from Delaware, USA. Journal of Primary Care and Community Health. 2021;12:1-9.
12 Crouse 2006 - Crouse BJ, Munson RL. The effect of the physician J-1 visa waiver on rural Wisconsin. Wisconsin Medical Journal. 2006;105(7):16-20.
13 Thompson 2009 - Thompson MJ, Hagopian A, Fordyce M, Hart LG. Do international medical graduates (IMGs) “fill the gap” in rural primary care in the United States? A national study. Journal of Rural Health. 2009;25(2):124-134.
14 US DS-J1 visa - U.S. Department of State (U.S. DS). J-1 visa facts and figures: View data by state.
15 AAMC-State physician workforce - Association of American Medical Colleges (AAMC). State physician workforce data report.
16 Zabel 2023 - Zabel T, Tobey M. Rural internal medicine residencies: Models, facilitators, barriers, and equity considerations. Journal of General Internal Medicine. 2023;38:2607-2612.
17 Arredondo 2023 - Arredondo K, Touchett HN, Khan S, Vincenti M, Watts BV. Current programs and incentives to overcome rural physician shortages in the United States: A narrative review. Journal of General Internal Medicine. 2023;38:916-922.
18 STAT-Empinado 2023 - Empinado H. Treating rural America: The last doctor in town. STAT: Reporting from the frontiers of health and medicine. 2023.
19 Moehling 2020 - Moehling CM, Niemesh GT, Thomasson MA, Treber J. Medical education reforms and the origins of the rural physician shortage. Cliometrica. 2020;14:181-225.
20 Butter 1977 - Butter I, Sweet RG. Licensure of foreign medical graduates: An historical perspective. The Milbank Memorial Fund Quarterly. Health and Society. 1977;55(2):315-340.
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