Order Code RS22584
Updated October 1, 2008
Foreign Medical Graduates: A Brief Overview
of the J-1 Visa Waiver Program
Karma Ester
Information Research Specialist
Knowledge Services Group
Summary
The Educational and Cultural Exchange Visitor program has become a gateway for
foreign medical graduates (FMGs) to gain admission to the United States as
nonimmigrants for the purpose of graduate medical education and training. The visa
most of these physicians enter under is the J-1 nonimmigrant visa. Under the J-1 visa
program, participants must return to their home country after completing their education
or training for a period of at least two years before they can apply for another
nonimmigrant visa or legal permanent resident (LPR) status, unless they are granted a
waiver of the requirement.
To qualify for a waiver, a request must be submitted on behalf of the FMG, by an
Interested Government Agency (IGA), or a state Department of Health. In exchange,
the FMG must agree to work in a designated healthcare professional shortage area for
a minimum of three years. The ability of states to request a waiver is known as the
“Conrad State Program,” and was added temporarily to the Immigration and Nationality
Act (INA) in 1994. The “Conrad State Program” has been extended by the past several
Congresses. Most recently, Congress forwarded legislation the President that would
extend the program through 2009. This report will be updated as warranted by
legislative developments.
Background
International medical graduates (IMGs) are foreign nationals or U.S. citizens who
graduate from a medical school outside of the United States. In 2007, the most recent
year for which data are available, there were 902,053 practicing physicians in the United
States, and IMGs accounted for 25.3% (228,665) of these.1 The use of foreign IMGs in
many rural communities of the United States has allowed states to ensure the availability
of medical care to their residents.
1 American Medical Association, International Medical Graduates in the U.S. Workforce, A
Discussion Paper, October 2007.

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This report focuses on those IMGs who are foreign nationals, hereafter referred to
as foreign medical graduates (FMGs). Many FMGs first entered the United States to
receive graduate medical education and training as cultural exchange visitors through the
J-1 cultural exchange program. While there are other ways for FMGs to enter the United
States, including other temporary visa programs as well as permanent immigration
avenues, this report focuses on FMGs entering through the J-1 program.2
Waiver Request Process
As exchange visitors, FMGs can remain in the United States on a J-1 visa until the
completion of their training, typically for a maximum of seven years. After that time,
they are required to return home country for at least two years before they can apply to
change to another nonimmigrant status or legal permanent resident (LPR) status. Under
current law, a J-1 physician can receive a waiver of the two-year home residency
requirement in several ways:
! the waiver is requested by an interested government agency (IGA) or
state department of health;
! the FMG’s return would cause extreme hardship to a U.S. citizen or LPR
spouse or child; or
! the FMG fears persecution in the home country based on race, religion,
or political opinion.
Most J-1 waiver requests are submitted by an IGA and forwarded to the Department
of State (DOS) for a recommendation. If DOS recommends the waiver, it is forwarded
to U.S. Citizenship and Immigration Services (USCIS) in the Department of Homeland
Security (DHS) for final approval.3 Upon final approval by USCIS, the physician’s status
is converted to that of an H-1B professional specialty worker. Prior to 2004, J-1 waiver
recipients were counted against the annual H-1B cap of 65,000.4
Interested Government Agencies (IGAs). An IGA may request a waiver of
the two-year foreign residency requirement for an FMG by showing that his or her
departure would be detrimental to a program or activity of official interest to the agency.
In return for sponsorship, the FMG must submit a statement of “no objection” from the
government of his or her home country, have an offer of full-time employment, and agree
to work in a health professional shortage area or medically underserved area for at least
2 For further information on options available for temporary or permanent admission to the
United States, see CRS Report RS20916, Immigration and Naturalization Fundamentals, by Ruth
E. Wasem.
3 Oversight of the J-1 program has been the responsibility of several agencies over the past 20
years; it is currently the responsibility of the Department of State. While the Department of State
recommends J-1 waiver requests, DHS has the final authority to determine if the exchange visitor
is subject to the home residency requirement and to approve the waiver.
4 In instances where the H-1B cap has been met, the physician’s J visa status was extended, and
the physician was granted H-1B status in the following fiscal year. For further information on
H-1B visas, see CRS Report RL30498, Immigration: Legislative Issues on Nonimmigrant
Professional Specialty (H-1B) Workers, by Ruth E. Wasem.

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three years.5 According to USCIS regulations, the FMG must be in status while
completing the required term and must agree to begin work within 90 days of receipt of
the waiver. If an FMG fails to fulfill the three-year commitment, he or she becomes
subject to the two-year home residency requirement and may not apply for a change to
another nonimmigrant, or LPR status until meeting that requirement. Although any
federal government agency can act as an IGA, the main federal agencies that have been
involved in sponsoring FMGs are the Department of Veterans Affairs (VA), the
Department of Health and Human Services (HHS), the Appalachian Regional
Commission (ARC), and the United States Department of Agriculture (USDA).6 Under
the “Conrad Program” discussed below, state health departments may also act as IGAs.
Department of Health and Human Services (HHS). HHS had begun
accepting waivers to primary care physicians only relatively recently. Historically, HHS
had been very restrictive in its sponsorship of J-1 waiver requests. HHS emphasized that
the exchange visitor program was a way to pass advanced medical knowledge to foreign
countries, and that it should not be used to address medical underservice in the United
States.7 HHS’ position was that medical underservice should be addressed by programs
such as the National Health Service Corps. Prior to December 2002, HHS only
sponsored waivers for physicians or scientists involved in biomedical research of national
or international significance. In December 2002, HHS announced that it would begin
sponsoring J-1 waiver requests for primary care physicians and psychiatrists in order to
increase access to healthcare services for those in underserved areas.8 HHS began
accepting waiver applications on June 12, 2003, but suspended its program shortly after
for reevaluation. On December 10, 2003, HHS released new program guidelines, and
reinstated their program.
Appalachian Regional Commission (ARC). Established by Congress in 1965,
ARC is a joint federal and state entity charged with, among other things, ensuring that all
residents of Appalachia have access to quality, affordable health care. The region
covered by ARC consists of all of West Virginia and parts of Alabama, Georgia,
Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South
Carolina, Tennessee, and Virginia.
ARC will submit a request for a waiver at the request of a state in its jurisdiction.
The waiver must be recommended by the governor of the sponsoring state. In return, the
FMG must agree to provide primary care for at least 40 hours a week for three years at
a health professional shortage area facility. The facility must be a Medicare or Medicaid-
certified hospital or clinic that also accepts medically indigent patients. The facility must
5 For more information on Health Professional Shortage Areas (HPSA), see
[http://bhpr.hrsa.gov/shortage]. This site also provides information on the Proposed Rule
concerning shortage area designations.
6 Other participants in the program have been the Department of Housing and Urban
Development (HUD), which ended its participation in 1996, and the U.S. Coast Guard.
7 See General Accounting Office, Foreign Physicians: Exchange Visitor Program Becoming Major Route
to Practicing in U.S. Underserved Areas, GAO/HEHS-97-26, December 30, 1996.
8 U.S. Department of Health and Human Services, “HHS Exchange Visitor Program, Interim
Final Rule,” Federal Register, vol. 67, no. 244, December 19, 2002, p. 77692.

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also prove that it has made a good faith effort to recruit a U.S. physician in the six months
preceding the waiver application. In addition, the physician must be licensed by the state
in which he or she will be practicing, and must have completed a residency in family
medicine, general pediatrics, obstetrics, general internal medicine, general surgery, or
psychiatry. The physician must sign an agreement stating that he or she will comply with
the terms and conditions of the waiver, and will pay the employer $250,000 if he or she
does not practice in the designated facility for three years.
Delta Regional Authority (DRA). On May 17, 2004, the DRA officially began
accepting applications for its new J-1 visa waiver program. The DRA includes 240
county or parish areas in Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi,
Missouri and Tennessee. The goal of the Authority is to stimulate economic development
and foster partnerships that will have a positive impact on the economy of the eight states
that make up the Authority. Under the DRA’s waiver program, physicians must submit
an application processing fee; agree to practice in DRA designated shortage areas for a
period of at least three years; and agree to pay $250,000 to the sponsoring facility if they
do not fulfill any portion of their commitment, or $6,945 per month for each month they
fail to fulfill their requirement.
Conrad State Programs. In 1994, Senator Kent Conrad sponsored the provision
establishing the J-1 visa waiver program at the state level. The program is commonly
referred to as the “Conrad State Program” program after him.9 Under the original
program, participating states were allowed to sponsor up to 20 waiver applications for
primary care physicians annually. To date, this provision has been extended several
times. In 1996, the program was extended until 2002.10 Once again in 2002, the program
was extended until 2004 and the number of waivers allowed per state was increased to
30.11
In 2004, Congress extended the Conrad program until June 1, 2006, and expanded
the program to allow states to recruit primary care and specialty physicians.12 Other
provisions of the law exempted waiver recipients from the H-1B annual cap, and allowed
the states to place up to five physicians in facilities that serve patients living in designated
shortage areas without regard to the facility’s location. Previously, physicians could only
serve in facilities located in designated shortage areas. In 2007, the program was
extended through June 1, 2008.13
The waiver process for states is the same as other IGAs, however administration of
the program varies by state. FMGs who are sponsored for a J-1 visa waiver by a state
9 Immigration and Nationality Technical Corrections Act of 1994, P.L. 103-416; 108 Stat. 4305,
§220.
10 Illegal Immigration Reform and Immigrant Responsibility Act of 1996, P.L. 104-208, division
C, §622; 110 Stat 3009.
11 21st Century Department of Justice Appropriations Authorization Act, P.L. 107-273; 116 Stat.
1758, §11018.
12 To Improve Access to Physicians in Medically Underserved Areas; P.L. 108-441; 118 Stat.
2630.
13 Physicians for Underserved Areas Act; P.L. 109-477; 120 Stat. 3572.

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agree to practice medicine in designated shortage areas in the sponsoring state for a
period of three to four years. FMGs working in these areas are not only required to meet
the general requirements for medical licensing in the United States, but they are also
required to meet state-specified licensing criteria. According to a 2006 Government
Accountability Office (GAO) report on the J-1 program, states accounted for 90 percent
of waiver requests, and had requested over 3,000 waivers between 2003 and 2005.14
Legislation Introduced in the 110th Congress
Several bills have been introduced in the 110th Congress that would extend or
expand the Conrad Program. During the comprehensive immigration reform debate,
several larger immigration bills (S. 330 and S. 1639) contained provisions that would
make the Conrad program permanent. In addition, the Conrad State 30 Improvement Act
(S. 2672/H.R. 5707) was introduced, and would provide incentives to physicians working
in rural and medically underserved areas by making the program permanent and
increasing the number of specialty slots from 5 to 10. To date, none of the above bills
have passed.
On March 10, 2008, Representative Zoe Lofgren introduced H.R. 5571 to extend
the Conrad program until June 1, 2013. This bill was reported favorably by the House
Subcommittee on Immigration, Citizenship, Refugees, Border Security and International
Law on March 12, 2008, and passed the House on May 21, 2008. On September 27,
2008, the Senate passed H.R. 5571 with an amendment extending the program’s
expiration date to March 6, 2009.
14 See General Accountability Office, Data on Use of J-1 Visa Waivers Needs to Better Address
Physician Shortages, GAO-07-52, November 2006.

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