Rural health advocates are questioning the future of equal access to healthcare in the nation's heartland after what appears to be a final decision by the U.S. Department of Agriculture to stop sponsoring waivers for foreign physicians practicing in medically underserved communities.
Reversing a previous decision, USDA officials said earlier this month that the agency now plans to complete processing 86 pending applications from rural doctors in 21 states. Then it will withdraw from the sponsorship program entirely in its role as an "interested government agency."
"We are accepting no new applications," said Alisa Harrison, a spokeswoman for the department. "We are going to serve as a temporary IGA for the 86 applicants, and at that point, we don't anticipate us getting back into the business."
Rural health providers had hoped the USDA might preserve the program after learning that lawmakers received an April 16 letter in which USDA Deputy Secretary James Moseley told Sen. Pat Roberts (R-Kan.) that the USDA would continue to temporarily approve waivers.
"I think this was a prudent way of doing this as opposed to ceasing the program altogether and creating a tremendous access-to-healthcare problem in rural America," said Alan Morgan, vice president of government affairs and policy at the National Rural Health Association.
After receiving clearance by the U.S. Justice and State departments, USDA officials said the pending candidates' credentials will be verified further by HHS, which also will confirm the facilities at which physicians are working and conduct "periodic monitoring to assure that the service is being provided as proposed," Moseley said in the letter to Roberts.
"HHS can bring resources to the table that USDA certainly does not have the in-house expertise to handle, like checking to make sure these physicians are actually practicing, billing Medicare and are doing what they're supposed to be doing," Morgan said.
The news of the interagency partnership formed to process outstanding applications was welcome relief for rural providers and policymakers left in limbo after the USDA announced in late February that it would abandon its 8-year-old practice of sponsoring waivers (March 25, p. 18). A USDA review at the time determined the agency didn't have the resources to conduct effective background checks in light of new concerns about terrorism. The USDA has brought more than 3,000 foreign physicians to underserved rural communities through the program.
Given that the department has elected to process only the remaining applications, its role is only a partial victory for rural providers, said Carl Shusterman, an attorney who serves as chairman of the American Immigration Lawyers Association's Committee on Health Professionals.
"They haven't committed themselves to doing much, and it sounds like they've been dragged kicking and screaming back into this," he said. "I'm not sure that the attorneys like myself who work with the physicians are going to have the USDA as our first choice. They're so reluctant that we might as well go with the state programs if we can."
Another government program, which Shusterman called more user-friendly, allows each state health department to sponsor 20 foreign-born physicians per year for visa waivers and has historically served as a complement to the USDA program in states such as Iowa, Kansas and Nebraska that have provider shortages. In existence since 1994, the "Conrad 20" program will expire next year unless reviewed by Congress.
With the USDA's decision to stop sponsoring waivers, states will increasingly look to their health departments to fill the gap in granting waivers, Shusterman said. Yet many rural providers argue that the number of sponsorships per state is inadequate to meet demand in many states.
Rural health advocates are, therefore, counting on Congress to pass a bill that would double the size of the Conrad 20 program and allow each state to sponsor up to 40 foreign physicians. Introduced in the Senate in July 2001, before Sept. 11 and concerns of terrorism topped the legislative agenda, the bipartisan "Rural and Urban Healthcare Act of 2001" also would allow states that use all 40 of their sponsorships to apply for unused slots.
Shusterman said the result would allow up to 1,000 more physicians each year to serve in rural America.
"It would go a long way toward addressing the needs of the hardest-hit states," he said. No committee hearings have been scheduled to consider the bill, he said.
Officials from the USDA said although the agency is abandoning the waiver program, it will continue to work with the White House to address long-term solutions.
"The administration remains committed to ensuring that, to the maximum extent possible, physicians are available to provide service to medically underserved areas," Moseley wrote in the letter sent to lawmakers. "For that reason, the White House has formed an interagency task force to review the visa program for foreign physicians."
Harrison said that while the task force was set up to specifically look at the visa program, other options to increase access in rural areas undoubtedly would be addressed by the administration.
"There are a variety of programs that are ongoing and the task force will work on what needs to be done in order to make sure that these underserved areas are served," she said.
"This is a health access issue," Morgan said. "The overwhelming support for the (waiver) program and what it has meant for rural America was the key to getting this decision by the USDA looked at again."