[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]


                    IS THERE A DOCTOR IN THE HOUSE?
                  THE ROLE OF IMMIGRANT PHYSICIANS IN
                       THE U.S. HEALTHCARE SYSTEM

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON IMMIGRATION AND CITIZENSHIP

                                 OF THE

                       COMMITTEE ON THE JUDICIARY

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       TUESDAY, FEBRUARY 15, 2022

                               __________

                           Serial No. 117-55

                               __________

         Printed for the use of the Committee on the Judiciary
         
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               Available via: http://judiciary.house.gov
               
                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-614 PDF                 WASHINGTON : 2022                     
          
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                       COMMITTEE ON THE JUDICIARY

                    JERROLD NADLER, New York, Chair
                MADELEINE DEAN, Pennsylvania, Vice-Chair

ZOE LOFGREN, California              JIM JORDAN, Ohio, Ranking Member
SHEILA JACKSON LEE, Texas            STEVE CHABOT, Ohio
STEVE COHEN, Tennessee               LOUIE GOHMERT, Texas
HENRY C. ``HANK'' JOHNSON, Jr.,      DARRELL ISSA, California
    Georgia                          KEN BUCK, Colorado
THEODORE E. DEUTCH, Florida          MATT GAETZ, Florida
KAREN BASS, California               MIKE JOHNSON, Louisiana
HAKEEM S. JEFFRIES, New York         ANDY BIGGS, Arizona
DAVID N. CICILLINE, Rhode Island     TOM McCLINTOCK, California
ERIC SWALWELL, California            W. GREG STEUBE, Florida
TED LIEU, California                 TOM TIFFANY, Wisconsin
JAMIE RASKIN, Maryland               THOMAS MASSIE, Kentucky
PRAMILA JAYAPAL, Washington          CHIP ROY, Texas
VAL BUTLER DEMINGS, Florida          DAN BISHOP, North Carolina
J. LUIS CORREA, California           MICHELLE FISCHBACH, Minnesota
MARY GAY SCANLON, Pennsylvania       VICTORIA SPARTZ, Indiana
SYLVIA R. GARCIA, Texas              SCOTT FITZGERALD, Wisconsin
JOE NEGUSE, Colorado                 CLIFF BENTZ, Oregon
LUCY McBATH, Georgia                 BURGESS OWENS, Utah
GREG STANTON, Arizona
VERONICA ESCOBAR, Texas
MONDAIRE JONES, New York
DEBORAH ROSS, North Carolina
CORI BUSH, Missouri

          AMY RUTKIN, Majority Staff Director & Chief of Staff
               CHRISTOPHER HIXON, Minority Staff Director
                                 
                               ------                                

              SUBCOMMITTEE ON IMMIGRATION AND CITIZENSHIP

                     ZOE LOFGREN, California, Chair
                    JOE NEGUSE, Colorado, Vice-Chair

PRAMILA JAYAPAL, Washington          TOM McCLINTOCK, California, 
J. LUIS CORREA, California               Ranking Member
SYLVIA R. GARCIA, Texas              KEN BUCK, Colorado
VERONICA ESCOBAR, Texas              ANDY BIGGS, Arizona
SHEILA JACKSON LEE, Texas            TOM TIFFANY, Wisconsin
MARY GAY SCANLON, Pennsylvania       CHIP ROY, Texas
                                     VICTORIA SPARTZ, Indiana

                JOSHUA BREISBLATT, Deputy Chief Counsel
                    ANDREA LOVING, Minority Counsel
                            
                            
                            C O N T E N T S

                              ----------                              

                       Tuesday, February 15, 2022

                                                                   Page

                           OPENING STATEMENTS

The Honorable Zoe Lofgren, Chair of the Subcommittee on 
  Immigration and Citizenship from the State of California.......     1
The Honorable Mary Gay Scanlon, a Member of the Subcommittee on 
  Immigration and Citizenship from the State of Pennsylvania.....     2
The Honorable Tom McClintock, Ranking Member of the Subcommittee 
  on Immigration and Citizenship from the State of California....     3
The Honorable Jerrold Nadler, Chair of the Committee on the 
  Judiciary from the State of New York...........................     5

                               WITNESSES

Dr. David J. Skorton, President and CEO, Association of American 
  Medical Colleges
  Oral Testimony.................................................     7
  Prepared Testimony.............................................    10
Dr. Raghuveer Kura, Interventional Nephrologist, Poplar Bluff 
  Regional Medical Center
  Oral Testimony.................................................    16
  Prepared Testimony.............................................    18
Kristen A. Harris, Principal, Harris Immigration Law
  Oral Testimony.................................................    22
  Prepared Testimony.............................................    24
Kevin Lynn, Co-Founder, Doctors Without Jobs
  Oral Testimony.................................................    49
  Prepared Testimony.............................................    51

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Articles submitted by the Honorable Andy Biggs, a Member of the 
  Subcommittee on Immigration and Citizenship from the State of 
  Arizona for the record
  An article entitled ``Termination of unvaccinated health care 
    workers backfires as Biden pledges help amid COVID surge,'' 
    Fox News.....................................................    84
  An article entitled ``Health officials let COVID-infected staff 
    stay on the job,'' ABC News..................................    90
Materials submitted by the Honorable Mary Gay Scanlon, a Member 
  of the Subcommittee on Immigration and Citizenship from the 
  State of Pennsylvania for the record
  A letter from Ian D. Wagreich, Chair, International Medical 
    Graduate Taskforce to the Department of Health and Human 
    Services.....................................................   106
  Statement from the American Medical Association................   109
  Statement from the Educational Commission for Foreign Medical 
    Graduates (ECFMG | Faimer)...................................   120
  Statement from Jeffrey A. Singer, Senior Fellow, Department of 
    Health Policy Studies, Cato Institute........................   122

                                APPENDIX

Materials submitted by the Honorable Zoe Lofgren, Chair of the 
  Subcommittee on Immigration and Citizenship from the State of 
  California for the record
  Statement from the American Academy of Family Physicians (AAFP)   128
  Statement from the American Academy of Neurology (AAN).........   131
  Statement from the Healthcare Leadership Council (HLC).........   133
  Statement from Upwardly Global.................................   135
  Statement from the American College of Physicians (ACP)........   137
  Statement from the Physicians for American Healthcare Access...   141
  Statement from the Association of American Medical Colleges 
    (AAMC).......................................................   142
  Statement from the Honorable Brad Schneider, a Member of 
    Congress from the State of Illinois..........................   146
  Statement from Progressives for Immigration Reform and Doctors 
    without Jobs.................................................   148
Statement submitted by the Honorable Sheila Jackson Lee, a Member 
  of the Subcommittee on Immigration and Citizenship from the 
  State of Texas for the record..................................   152

 
                    IS THERE A DOCTOR IN THE HOUSE?
                  THE ROLE OF IMMIGRANT PHYSICIANS IN
                       THE U.S. HEALTHCARE SYSTEM

                       Tuesday, February 15, 2022

                        House of Representatives

              Subcommittee on Immigration and Citizenship

                       Committee on the Judiciary

                             Washington, DC

    The Subcommittee met, pursuant to call, at 2:00 p.m., via 
Zoom, Hon. Zoe Lofgren [Chair of the Subcommittee] presiding.
    Present: Representatives Lofgren, Nadler, Jayapal, Correa, 
Garcia, Jackson Lee, Scanlon, McClintock, Buck, Biggs, Tiffany, 
and Spartz.
    Staff Present: John Doty, Senior Advisor and Deputy Staff 
Director; David Greengrass, Senior Counsel; Moh Sharma, 
Director of Member Services and Outreach & Policy Advisor; 
Cierra Fontenot, Chief Clerk; Merrick Nelson, Digital Director; 
Joshua Breisblatt, Deputy Chief Counsel; Anthony Valdez, 
Professional Staff Member/Legislative Aide; Julie Rheinstrom, 
Counsel; Andrea Loving, Minority Chief Counsel for Immigration; 
Kyle Smithwick, Minority Counsel; Andrea Woodard, Minority 
Professional Staff Member; and Kiley Bidelman, Minority Clerk.
    Ms. Lofgren. The Subcommittee on Immigration and 
Citizenship will come to order, a quorum being present.
    Without objection, the Chair is authorized to declare a 
recess of the Subcommittee at any time. I want to welcome 
everyone to this afternoon's hearing: Is There a Doctor in the 
House? The Role of Immigrant Physicians in the U.S. Healthcare 
System.
    I'd like to remind the Members that we've established an 
email address and distribution list dedicated to circulating 
exhibits, motions, or other written materials that Members 
might want to offer as part of our hearing today. If the 
Members would like to submit materials, please send them to the 
email address that has been previously distributed to your 
office, and we will circulate the materials to the Members and 
staff as quickly as we possibly can.
    I also ask all Members to please mute your microphones when 
you're not speaking. This will help prevent feedback and other 
technical issues. You can unmute yourself anytime you seek 
recognition.
    This hearing will explore the essential role of immigrant 
physicians in the provision of general and specialized 
healthcare in the United States. Access to high-quality 
healthcare has long been an issue of great importance 
throughout the United States and, unfortunately, for many, 
access to healthcare has been lacking due to a scarcity of 
physicians in their area.
    Our immigration system has long contemplated a need for 
physicians. Throughout the pandemic, immigrants in healthcare 
fields have served on the front lines and have been a driving 
force behind the research that led to the development of 
vaccines and cutting-edge COVID-19 treatments. Unfortunately, 
our antiquated immigration system discourages these needed 
physicians from coming to and remaining in the United States, 
which exacerbates a serious level of physician shortages.
    This hearing will allow the Subcommittee to hear from 
Witnesses who will discuss the current and future demand for 
physicians, the current process for foreign physicians to 
complete medical residencies and remain permanently in the 
United States, as well as the need for reforms to our 
immigration laws as they pertain to physician immigration.
    Now, I've Chaired the Immigration Subcommittee in this 
Congress and in prior years, and one of the things I'm 
committed to doing is making sure that less Senior Members of 
the Committee also have an opportunity to sit in the Chair, 
have the opportunity to shape a hearing, and have the 
experience of presiding.
    With that in mind and, without objection, my colleague, 
Representative Mary Gay Scanlon, will preside over this 
hearing, give her public statement, and recognize our esteemed 
Ranking Member, Mr. McClintock.
    So, I now recognize Ms. Scanlon for her opening statement 
and ask her to take the virtual Chair.
    Ms. Scanlon.
    Ms. Scanlon. Thank you, Chair Lofgren. I thank you 
virtually as I take the virtual Chair. So, thank you for the 
opportunity to Chair today's hearing to discuss the importance 
of immigrant physicians in our healthcare system.
    The United States is currently facing a shortage of 
physicians. According to the U.S. Department of Health and 
Human Services, more than 86 million people live in areas with 
an insufficient number of primary care physicians. The 
coronavirus pandemic has exacerbated existing shortages as 
physicians across the country have been under extreme strain, 
causing some of them to leave their jobs. Sadly, some of our 
most dedicated frontline physicians have lost their lives in 
the fight against this pandemic.
    Immigrant physicians have been on the forefront of this 
fight, putting themselves in harm's way, even when for some of 
them their death would leave family members without status and 
at risk for deportation.
    Foreign nationals make up about 25 percent of the 
population of those obtaining graduate medical education in the 
United States. The Educational Commission for Foreign Medical 
Graduates, the Philadelphia organization that certifies and 
sponsors foreign physicians who undergo medical training in the 
United States, reports that over 70 percent of the physicians 
they sponsor for training are pursuing graduate medical 
education in a primary care specialty. We cannot continue to 
attract foreign physicians to this country with an immigration 
system that doesn't take their dedication into consideration.
    Now, our current immigration system makes it difficult for 
immigrant physicians to work in the United States. For example, 
while our immigration laws seek to encourage immigrant 
physicians to work in rural and medically underserved areas, 
the pathways to legal status and work authorization in such 
areas are insufficient.
    The Conrad 30 program, which helps place immigrant 
physicians in underserved areas, only allocates a maximum of 30 
slots in each State. My home State of Pennsylvania, which has 
the fourth highest number of immigrant physician exchange 
visitor trainees in the United States, in part because we have 
such a robust medical training system in the region, nearly 
always has more than 30 applicants for its Conrad slots.
    Additionally, the pathways to green cards for immigrant 
physicians involve decades-long backlogs for individuals from 
countries like India and China. These long waits discourage 
physicians from remaining in our country when they know they 
can travel elsewhere and obtain permanent residency in a matter 
of months.
    The lack of physicians is exacerbated by the fact that our 
population is aging. As more and more people in our country 
reach retirement age, we will need additional doctors to meet 
our Nation's healthcare needs. Presently, 34 percent of the 
demand for physicians comes from patients 65 and up, what is 
projected to only increase in the coming years. Meanwhile, over 
two of every five physicians in the United States will be 65 or 
older within the next 10 years. So, those retirements are also 
creating additional pressure.
    It's imperative that we work to fix this problem now, to 
ensure that Americans have access to the medical care they 
need. Immigrants play an important role in alleviating the 
physician shortage. It's especially important that we address 
the problems immigrant physicians face as they 
disproportionately fill jobs in general medicine and 
gerontology, which face staffing shortages, and underserved 
areas that badly need medical care.
    I'm looking forward to discussing the significant 
contribution of immigrant physicians to our healthcare system 
and the proposals to improve our immigration system to better 
utilize their talents. This is a bipartisan problem that 
requires bipartisan solutions, and I'm committed to working 
with my friends and colleagues across the aisle to find those 
solutions.
    So, I wish to thank all our Witnesses for appearing today, 
and I'm looking forward to hearing your perspectives.
    So, it is now my pleasure to recognize the Ranking Member 
of the Subcommittee, the gentleman from California, Mr. 
McClintock, for his opening statement. We're so glad to see you 
here today.
    Mr. McClintock. Thank you, Madam Chair. Thank you for your 
kind words.
    In the time that the Democrats controlled the Executive 
Branch, roughly 2 million illegal immigrants have been 
apprehended by Customs and Border Protection and, of these, 
roughly a million have been admitted into our country. That 
doesn't include the hundreds of thousands of got-aways who've 
evaded apprehension while the Border Patrol has been inundated 
by migrants responding to the unmistakable open borders 
invitation that this Administration issued on day one.
    It is quite clear this policy is deliberate. As Secretary 
Mayorkas bragged last month, and I quote: ``We have 
fundamentally changed immigration enforcement in the interior. 
For the first time ever, our policy explicitly states that a 
noncitizen's unlawful presence in the United States will not, 
by itself, be a basis for the initiation of enforcement 
action.'' Now, let me repeat that so it sinks in. Quote: ``A 
noncitizen's unlawful presence in the United States will not, 
by itself, be a basis for enforcement action.''
    Fellow Americans, if our immigration laws are not going to 
be enforced, we have no immigration laws. If we have no 
immigration laws, we effectively have no border. if we have no 
border, in very short order we will have no country, just this 
vast international territory between Canada and Mexico.
    No civilization has ever survived a mass migration on this 
scale that the Democrats have been actively encouraging, 
aiding, and abetting since they took power. History warns us 
that countries that either cannot or will not secure their 
borders simply aren't around very long.
    Now, in this deliberately created border chaos, individuals 
on the terrorist watch list are entering our country. 
Previously deported aliens who have committed murder and other 
crimes continue to enter our country.
    Now, this is the Immigration Subcommittee of the House 
Judiciary Committee. Republicans have begged the majority to 
address this crisis since they created it. Instead, the 
Subcommittee has had five hearings, including this one. In four 
of the five, the Democrats have focused on bringing additional 
foreign nationals into the United States.
    They have yet to explain how American workers are helped by 
flooding the market with cheap foreign labor, or how our 
schools are made better by flooding classrooms with non-
English-speaking students, or how our streets are made safer by 
refusing to deport criminal illegal aliens as the law requires. 
They have yet to explain how our hospitals are made more 
accessible by packing emergency rooms with illegal aliens 
demanding care.
    Instead, their solution is to import still more foreign 
doctors to treat the exploding foreign population. Enough.
    As we will hear, there are thousands of U.S. citizens who 
have earned their medical degrees, at enormous cost, some 
carrying over $100,000 in debt to do so, but they cannot be 
placed in residency programs that make it possible for them to 
practice medicine.
    Furthermore, foreign nationals are already admitted to 
practice medicine in this country through a large number of 
visa programs. They qualify for J visas: 353,000 were issued in 
2019. How many physicians were included? We don't know. They 
qualify for H-1B visas: 188,000 were issued in 2019. How many 
physicians among them? Unknown. They qualify for O visas, 
18,000 were granted in 2019. How many physicians were included? 
Again, unknown. They qualify for TN visas: 21,000 were issued. 
How many physicians? Unknown.
    Yet, as we will hear, the physician shortage in the United 
States is largely of our making. We have the doctors. We just 
don't match them with the residency programs they need to enter 
practice. Now, don't you think that just maybe we ought to put 
American physicians first? Don't you think just maybe we should 
take control of our borders before we encourage more foreign 
nationals to cross it? Don't you think just maybe we ought to 
enforce our immigration laws before our jails, our schools, our 
prisons, and our hospitals are completely overwhelmed?
    The American people are awakening to the damage that's 
being done by the left's open border policies. The proceedings 
today are just another attempt by the left toward meaningless 
borders. The American people know what that means to their 
families, their prosperity, their communities, their safety, 
their schools, and their healthcare.
    Now, when we put Americans first, we enjoyed the lowest 
unemployment rate in 50 years, the lowest poverty rate in 60 
years, and the fastest wage growth in 40 years. I believe the 
American people are going to want those days back very soon, 
and that includes securing our borders. They're going to have 
the chance to set things right very soon, in about 266 days, I 
believe.
    I yield back.
    Ms. Scanlon. Thank you for that, Mr. McClintock.
    I will now recognize the Chair of the Judiciary Committee, 
the gentleman from New York, Mr. Nadler, for his opening 
statement.
    Chair Nadler. Thank you, Madam Chair.
    Our country has long relied on foreign-educated physicians 
to supplement the domestic physician workforce. Today's hearing 
invites us to explore the role that immigrant physicians play 
in the provision of healthcare in the United States, including 
essential services they provide to Americans in rural and 
medically underserved areas.
    I also appreciate the opportunity to examine how our broken 
immigration system has made it difficult for such physicians to 
remain in our communities and continue to provide critical care 
to those in need.
    Today, approximately 200,000 foreign medical graduates work 
as physicians in the United States. Immigrants account for more 
than 50 percent of physicians practicing geriatric medicine, 
approximately 40 percent of those practicing critical care and 
internal medicine, and nearly one-quarter of those practicing 
general medicine.
    Even before the COVID-19 crisis, experts were projecting 
that our country would experience a significant shortage of 
physicians in the near future. Due to the aging population and 
other factors, the American Association of Medical Colleges 
estimated a shortage of nearly 140,000 physicians by 2033.
    The COVID-19 outbreak has brought this problem into sharper 
focus. The pandemic has taken an enormous mental and physical 
toll on physicians in the United States, exacerbating existing 
shortages and making these projections even more dire.
    In response, Governors throughout the country, including in 
my home State of New York, implemented emergency measures, such 
as relaxing licensing requirements, to increase the pool of 
available physicians. Yet, many States still struggle to meet 
the demand for care.
    Unfortunately, our outdated immigration system only adds to 
the problem. Although foreign-educated physicians can come to 
the United States to complete their medical training, their 
temporary visa options are limited. Without a visa 
classification that is designed specifically for them, foreign 
physicians are forced to deal with the challenges of the flawed 
system that was designed decades ago.
    After completing their training, if they want to stay here 
permanently and continue to treat patients in their 
communities, they must overcome additional obstacles. For 
example, the Conrad 30 program, which is intended to facilitate 
the placement of immigrant physicians in underserved areas by 
shortening the visa application process, only allows 30 such 
physicians in each State to benefit from this program. If a 
physician is fortunate enough to be allocated--to be allotted 
one of those visas, many must then wait for years and often 
decades for an immigrant visa to become available.
    Over the years, various bills have been introduced that 
would improve the physician immigration system. Some would 
exempt certain physicians from the numerical limits on 
immigrant visas. Others would remove or ease the current 
barriers while streamlining and improving processing. We should 
explore these and other options.
    We have an obligation to ensure that all Americans have 
ready access to quality medical care today and in the future. 
To do that, we must ensure that our immigration system 
facilitates rather than blocks the admission of the best 
doctors from around the world.
    I want to thank Chair Lofgren and Ms. Scanlon for holding 
this valuable hearing. I thank all of today's Witnesses for 
participating in this important discussion. I yield back the 
balance of my time.
    Ms. Scanlon. Thank you, Mr. Nadler.
    It is now my pleasure to introduce our Witnesses for 
today's hearing.
    Dr. David Skorton is the President and CEO of the 
Association for American Medical Colleges, which is a nonprofit 
institution that represents the Nation's medical schools. So, 
these are American medical schools, teaching hospitals, health 
systems, and academic societies.
    Prior to becoming the President and CEO of the Association 
of American Medical Colleges in 2019, Dr. Skorton served as the 
13th secretary of the Smithsonian Institution and as the 
President of two universities: Cornell University and the 
University of Iowa. Dr. Skorton received both his BA and his 
M.D. from Northwestern University.
    We also welcome Dr. Raghuveer Kura. He's an interventional 
nephrologist at the Poplar Bluff Regional Medical Center. 
Following his medical education at the Armed Forces Medical 
College in Pune, India, Dr. Kura came to the United States in 
2003 to undergo graduate medical education in internal medicine 
and nephrology at Penn State Milton S. Hershey Medical Center 
and College of Medicine.
    Dr. Kura is the only nephrologist serving the small town of 
Poplar Bluff, Missouri. In 2021, Dr. Kura received his green 
card under the EB-1 category as a, quote, ``alien of 
extraordinary ability,'' end quote. Despite the freedom of 
movement his green card affords, Dr. Kura has chosen to remain 
in Poplar Bluff, a medically underserved area, to treat his 
patients.
    We also welcome Kristen Harris, principal of Harris 
Immigration Law, LLC. Having practiced immigration law 
exclusively for the past 17 years, Ms. Harris advises 
healthcare entities across the United States regarding 
immigration, including sponsorship of physicians, researchers, 
allied healthcare professionals, and technical professionals, 
as well as E-Verify and I-9 compliance.
    Additionally, Ms. Harris works with the American Medical 
Association, the American Association of Medical Colleges, and 
the Educational Commission for Foreign Medical Graduates, which 
is based in Philadelphia, on physician immigration issues. Ms. 
Harris received her bachelor's degree from Yale University and 
her JD from the University of Michigan Law School.
    We are also joined by Kevin Lynn. Mr. Lynn is the co-
founder of Doctors Without Jobs and the Executive Director of 
Progressives for Immigration Reform. Previously, Mr. Lynn 
served in a variety of roles in the private sector, including 
as a director at Ryan, LLC, and as a senior manager at Ernst 
and Young. Mr. Lynn has served in a volunteer capacity at 
several organizations, including Respect Farmland, Democracy 
for America, and the 1992 Ross Perot campaign. Mr. Lynn was a 
captain in the United States Army and received an associate of 
arts degree from Kemper Military College.
    So, we welcome all of our distinguished Witnesses and thank 
them for participating in today's hearing.
    I'll begin by swearing in our Witnesses. I'd ask that you 
each make sure your audio is on and that we can see your face 
and your raised right hand while we administer the oath.
    I think, Dr. Kura, you need to unmute as well.
    Do you each swear or affirm under penalty of perjury that 
the testimony you're about to give is true and correct, to the 
best of your knowledge, information, and belief, so help you 
God?
    Dr. Skorton. I do.
    Dr. Kura. I do.
    Ms. Harris. I do.
    Mr. Lynn. I do.
    Ms. Scanlon. Thank you so much.
    Let the record show that the Witnesses answered in the 
affirmative.
    Please note that each of your written statements will be 
entered into the record in its entirety. We'll just ask 
everyone, Witnesses and Members of Congress, to keep their mute 
button on when they're not speaking so that we can try to 
minimize chaos.
    Witnesses, I'd ask that you summarize your testimony in 5 
minutes. To help you keep track and stay within the time, there 
is a timer on your screen which you'll see.
    So, Dr. Skorton, if you could lead us off, I'd appreciate 
it.

               STATEMENT OF DR. DAVID J. SKORTON

    Dr. Skorton. Thank you, Chair Nadler, the Honorable 
Scanlon, Chair Lofgren, Ranking Member McClintock, and the 
Members of the Subcommittee.
    Immigration is the bedrock of the United States. It is 
because of our diversity of backgrounds, cultures, and ideas 
that we have thrived, not in spite of it. I have been fortunate 
to work in education, government, and healthcare, and have seen 
firsthand the value immigrants bring to this country across the 
board, even in my immigrant father's family-owned shoe store.
    Approximately 23 percent of physicians practicing in the 
U.S. identify as foreign born. These physicians help improve 
access to care, particularly for patients in rural and other 
underserved areas, but many face significant challenges to 
enter and remain in the U.S. Physician diversity has been 
widely recognized as key to excellence in medicine and quality 
care. Physicians from other countries have a unique cultural 
perspective which can affect patients' health and their 
healthcare experiences.
    The importance of physicians from other countries was seen 
acutely during the pandemic but is amplified each year as a 
result of growing nationwide health workforce shortages. The 
AAMC projects the overall physician shortage will grow to a 
total of up to 124,000 physicians by 2034. Simply put, we need 
more doctors from everywhere.
    Academic medicine has responded by increasing enrollment by 
35 percent over the last two decades, including opening 30 new 
medical schools and 6 more have applied to be considered for 
accreditation. However, increasing medical school enrollment 
without commensurate increases in graduate medical education 
residency positions has no effect on the size of the workforce, 
because medical residency training is required for licensure 
and medical practice.
    The AAMC recommends a multipronged approach that includes 
increasing the number of Medicare-supported residency 
positions, as well as improving the immigration processes for 
physicians and for teaching hospitals.
    Residency program directors seek the best candidates, 
regardless of citizenship status or national origin, through a 
highly competitive selection process, and some students may be 
unable to find a residency position in the U.S. Last year, 55 
percent of non-U.S. graduates of international medical schools 
matched to a residency program. Comparatively, 93 percent of 
U.S. seniors matched to a residency program, and 99 percent of 
U.S. medical school graduates enter residency or full-time 
practice within 6 years. I can confidently say that physicians 
from other countries are not displacing graduates of U.S. 
medical schools.
    For non-U.S. physicians who are fortunate to make it 
through rigorous medical education, examinations, screening, 
and obtain a residency position, the 3 months between the match 
and program start dates is a critical immigration window. The 
AAMC humbly offers to work with the Subcommittee on ways to 
help ensure the physician immigration process is predictable, 
expedient, efficient and better aligned with the continuum of 
medical education, training, and State licensure.
    In addition, the AAMC supports the Conrad 30 program that 
has recruited 15,000 physicians to rural and underserved 
communities over the last 15 years by waiving the J-1 visa home 
country return requirement. The AAMC endorses the bipartisan 
Conrad State 30 and Physician Access Reauthorization Act, 
which, among other improvements, would allow the program to 
expand beyond 30 slots per State if certain nationwide 
thresholds are met.
    We are glad that Congress has recognized the vital role of 
the National Health Service Corps by steadily increasing 
funding and believe the number of Conrad 30 waivers should 
likewise be increased for the first time in two decades.
    The AAMC also urges Congress to pass a permanent pathway to 
citizenship for individuals with DACA status, such as the 
bipartisan Dream Act of 2021 or the House-passed American Dream 
and Promise Act of 2021. The 34,000 current healthcare 
providers with DACA status encompass a diverse, multiethnic 
population, who are often bilingual and more likely to practice 
in underserved communities.
    Finally, the AAMC supports reducing green card backlogs and 
prioritizing healthcare workers through the bipartisan 
Healthcare Workforce Resilience Act.
    Thank you again for the opportunity to testify regarding 
the critical importance of physician immigration to the U.S. 
healthcare system.
    [The statement of Dr. Skorton follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Scanlon. Thank you, Dr. Skorton, and thank you for your 
well-timed presentation.
    Dr. Kura, you're up next. You have 5 minutes.

                STATEMENT OF DR. RAGHUVEER KURA

    Dr. Kura. Chair Nadler, Chair Lofgren, Chair Scanlon, 
Ranking Member McClintock, and the Honorable Members of the 
Committee, it is an honor to speak with you today on this 
urgent public health issue. Thank you for the opportunity to 
offer my perspective on an issue I understand firsthand as an 
immigrant physician serving in rural and underserved areas.
    The United States is in the midst of a healthcare workforce 
crisis. We are facing an ever-growing shortage of doctors, 
exacerbated by the COVID-19 pandemic. The reality is this 
healthcare worker shortage existed before the pandemic and will 
continue to harm communities, particularly rural and 
underserved communities, absent congressional action.
    I came to the United States in 2001, completed my residency 
in internal medicine, a fellowship in nephrology at Penn State 
University on a J-1 visa. As a condition of my visa, after 
completing my residency, I either had to return to India for 2 
years before applying for a new visa or apply for a Conrad 30 
program, which waived the 2-year home residency requirement if 
I would practice in a designated underserved area for a minimum 
of 3 years.
    Upon arriving in Missouri, I learned of patients traveling 
80 miles to see the nearest nephrologist. In fact, I was the 
only nephrologist in the area 24/7 for the past 11 years to 
serve the community I now call home.
    Despite the visa restrictions, serving in southeast 
Missouri for the last 11 years has been an incredibly 
fulfilling mission. I supported building a new dialysis unit in 
2015, which now has about 90 patients receiving dialysis every 
other day, along with 18 staff members. Currently, I'm the 
director of one inpatient and three outpatient dialysis units 
across southeast Missouri.
    I am proud to support my patients, their families, my 
staff, and the local economy in southeast Missouri, but these 
visa restrictions have greatly impacted many physicians like me 
and the communities we serve. For many international 
physicians, the pathway to permanent residency will take 
decades, limiting our career mobility and jeopardizing the 
immigrant status of our children.
    Doctors on the temporary H-1B visa may only work for their 
visa sponsors and are not allowed to start their own practices, 
work outside the specific practice area, or even volunteer. 
These restrictions are not hidden from international physicians 
like me, but they inevitably impact our patients with sometimes 
life-and-death consequences.
    The COVID-19 pandemic complicated these issues when highly 
skilled physicians could not lend support to hospitals in need 
due to their visa restrictions. Legislation to confront this 
challenge is pending before Congress and could help save 
American lives.
    I would like to share how these issues personally affected 
me, my family, and my patients. The H-1B visa mandates every 
physician to apply for a renewal every 3 years, leaving the 
country for a stamp on their passport to freely move across the 
border.
    In 2019, I chose to go to Canada, as it was closer and 
would allow me to quickly return to my patients, who must have 
a supervising physician on site to receive their care. 
Unfortunately, my renewal was delayed due to an unfortunate 
administrative processing issue, even though I had been in the 
country for 16 years and was preapproved for the green card.
    The added stress of finding a physician to cover for me 
while dealing with the complicated immigration process took a 
toll on me and my family. The uncertainty was so stressful that 
I began applying for jobs in Canada and received offers of 
employment, but I did not want to leave my patients. So, I 
reached out to my representative for help and was able to come 
back to my patients in a timely fashion.
    Given this overwhelming need, Congress should take a closer 
look at the bipartisan legislation for further incentivizing 
physicians like me to serve in underserved areas. The Conrad 30 
reauthorization would strengthen the incentives for 
international physicians to complete their residencies in the 
United States and practice in underserved areas, maximizing the 
return on investment that Congress makes in graduate medical 
education. This legislation would also provide greater clarity 
to physicians who fulfill their visa obligations, strengthening 
the incentives to serve in rural and underserved areas.
    In 2020, after applying for EB-1 extraordinary ability 
visa, I was fortunate enough to get my green card. I am 
grateful that my family no longer has to deal with the 
uncertainty of my H-1B status, but there are many physicians 
like me who are not so lucky.
    Thank you again for the opportunity to speak with you 
today. I look forward to answering your questions.
    [The statement of Dr. Kura follows:]
    
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    Ms. Scanlon. Thank you, Dr. Kura.
    Ms. Harris, you're now recognized for 5 minutes.

                 STATEMENT OF KRISTEN A. HARRIS

    Ms. Harris. Thank you.
    Good afternoon, Chair Lofgren, Chair Scanlon, Ranking 
Member McClintock, and the Members of the Subcommittee. Thank 
you for the opportunity to speak with you today about the need 
for improvements to our Nation's physician immigration system.
    My name is Kristen Harris, and I am an immigration attorney 
that has represented hundreds of hospitals, healthcare systems, 
physician practice groups, clinics, and foreign national 
physicians for more than 17 years. The opinions I am expressing 
today derive from years of physician immigration practice.
    At no time have Americans been in greater need of high-
quality, U.S.-trained foreign national physicians. Dr. Kura and 
his dedication to his patients exemplifies how critical these 
physicians are to addressing our healthcare access issues.
    Unfortunately, our current system is suboptimal, at best, 
in its ability to attract and retain the most talented 
physicians in the world to treat and care for Americans. We 
have outdated laws on our books that include barriers to 
retaining U.S.-trained foreign national physicians.
    Today, I bring you concrete examples of missed 
opportunities caused by our current physician immigration 
system. In each case, we have a willing employer, a U.S.-
trained physician, and Americans in need of a doctor.
    One, we need to improve and expand the Conrad 30 program. 
Under this program, doctors in J status who will otherwise have 
to leave the U.S. at the end of their training can stay here if 
they treat patients in a medically underserved area for 3 
years. Each State is allotted only 30 waivers per year, a limit 
that was last raised in 2002.
    The program has successfully brought thousands of U.S.-
trained physicians to medically underserved communities, but it 
can do more if it is expanded and improved. States like Texas, 
Indiana, California, Pennsylvania, and many more regularly max 
out of their 30 slots early in the year.
    For example, our firm represents an independent safety net 
hospital in one of the poorest cities in Massachusetts. The 
hospital sponsored an Indian-born, U.S.-trained primary care 
physician for a Conrad waiver. It timely filed the application. 
The physician was fully eligible, but the State program had 
maxed out for the year and the physician was not among the 
lucky 30 that year. By the time the recommendations were 
announced, he was out of options and moved to Canada with his 
family to practice there. This happens time and again. By 
expanding the number of waivers available to each State, 
Congress can solve this problem.
    Two, we need to improve the J waiver options for Federal 
agencies, such as the VA and HHS, to carry out important 
programs, such as treating veterans and the medically 
underserved. The statute provides for greater opportunities 
than is administered by the agencies at present. For example, 
my firm represents nephrology practices, including a practice 
that continues to find U.S.-trained J-1 physicians who are 
ready, willing, and able to start treating dialysis patients 
but for their need for a J waiver. They haven't been able to do 
that.
    Any one such nephrologist can cover 13 practice sites 
stretched across a five-county area, including outpatient 
dialysis clinics and rural areas in Indiana so remote and so 
underserved that the Department of Labor does not have 
sufficient wage data for doctors. Unique patient visits from 
one physician can exceed 200 patients in a month, yet this 
practice cannot apply to the HHS program to keep these 
physicians in the U.S. because they have received subspecialty 
training. This must change.
    Three, we need to change the H-1B category for U.S.-trained 
physicians. Many physicians applied for the H-1B visa after 
completing their training, but there is an H-1B cap or limit 
which can serve as a barrier to physician immigration. For 
example, our firm represents a family-owned medical practice in 
Texas. For months, they have searched for a U.S.-trained and 
licensed primary care physician to start patient care 
yesterday. They found the perfect candidate, who's bilingual 
and ready to relocate from Peru to Texas. Unfortunately, before 
the doctor can start working here, she must first participate 
in the random H cap lottery held in March. Statistically, the 
odds are against her getting selected at all. Even if the 
doctor does win the lottery and her H is approved, her visa 
won't allow her to start treating Texans until October, at the 
earliest. This is at least 8 months of lost care and coverage. 
This must change. Congress should exempt physicians from the H 
cap limit to address our Nation's immediate healthcare needs.
    Fourth and finally, the employment-based green card system 
needs to be fixed to keep our U.S.-trained doctors in the 
country on a permanent basis. Doctors born in India can wait 
for over a decade before they're permitted to even file their 
final step for a green card, due to current per-country limits, 
even when their services to the medically underserved have been 
deemed to be in the national interest by USCIS. This is wrong. 
These physicians fill an immediate need for Americans and, 
therefore, should be permitted to file a green card 
immediately, just as with immediate relatives of U.S. citizens.
    Healthcare access is a bipartisan constituent issue that 
requires bipartisan solutions. The solutions presented today 
are well within congressional reach, and our Nation will 
benefit from Congress working together to improve healthcare 
access for all Americans by making it easier for us to retain 
our U.S.-trained physician workforce.
    Thank you again for the opportunity to testify and thank 
you for your attention to this critical issue.
    [The statement of Ms. Harris follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Scanlon. Thank you very much.
    Mr. Lynn, you are now recognized for 5 minutes.
    I think we need you to unmute.
    I think we're still having a technical problem. It looks 
like you unmuted.
    Not hearing anything yet.
    No. I can see that you're talking, but it's not coming 
through.
    Can our tech folks help us here?
    Okay. Let's suspend the hearing for a minute while we work 
on the technical issue, and we will be back in a minute. Our 
tech folks are working on it. So, the Committee will suspend.
    [Pause.]
    Ms. Scanlon. We'll resume. You are recognized for 5 
minutes.
    Mr. Lynn. Thank you very much.
    Ms. Scanlon. Sure.

                    STATEMENT OF KEVIN LYNN

    Mr. Lynn. Chair Lofgren, Chair Scanlon, Ranking Member 
McClintock, and the distinguished Members of the Subcommittee, 
thank you for allowing me the opportunity to discuss the 
consequences of immigrant physicians in the U.S. healthcare 
system.
    The United States is facing a doctor shortage; however, it 
is a shortage of our own making. In recent years, thousands of 
American medical doctors have been denied the right to practice 
medicine. This is one of the most unreported stories and one of 
the most ignored situations by our elected officials and 
medical community, leadership in America, including our medical 
schools, and the various governing bodies who represent 
physicians.
    In 2018, Progressives for Immigration Reform started the 
Doctors Without Jobs project to build awareness of the number 
of U.S. citizen doctors graduated from medical schools who were 
not matching to residency positions each year while foreign-
trained physicians were. This encouraged more doctors to 
advocate for themselves and push back against graduate medical 
education profiteers.
    The match is the mechanism by which medical school 
graduates move into medical residencies at teaching hospitals. 
It is a process managed by the National Resident Matching 
Program. Please understand that without a medical residency, a 
doctor cannot practice medicine, and a residency may require 3-
7 years to complete, depending on the specialty.
    Each year, over 7,000 U.S. citizens and lawful permanent 
resident medical graduate physicians, which include seniors and 
prior year graduates, do not match for a medical residency, all 
of whom are qualified, ready, and willing doctors who have been 
sidelined and are waiting to serve their communities now, a 
situation we worked to draw attention to at the start of the 
pandemic so that they might be deployed. Our call went 
unanswered.
    There is much more to this story that should concern the 
subcommittee. In 2021, over 4,000 noncitizen foreign-trained 
physicians received residencies in the U.S. This is an enormous 
increase from 10 years prior where 2,700 foreign-trained 
physicians received residencies.
    Between 2011 and 2021, more than 40,000 non-U.S. citizen, 
foreign-trained physicians were given U.S. taxpayer-funded 
residencies. Each residency costs taxpayers 150,000 a year. So, 
we are subsidizing foreign doctors. Many foreign-trained 
physicians arrive in the U.S. for residency training via the J-
1 visa, a cultural exchange visa. In addition, foreign-trained 
physicians arrive via the H-1B visa program to work directly in 
hospitals.
    In 2020, over 3,500 labor condition applications were filed 
for 4,252 workers for the occupation of medical doctor. Of 
those, over 3,000 were approved. In addition, over 5,000 
applications to extend from prior years were also approved.
    Every country prioritizes its citizens. Canada, the last 
holdout, has changed its policy to prioritize Canadian citizens 
and permanent legal residents a couple years ago. Failure to 
prioritize Americans is emblematic of our medical establishment 
preferring to import foreign healthcare workers instead of 
making necessary investments that would broaden medical 
education and improve our healthcare delivery infrastructure.
    This doesn't just cause problems here at home. A 2020 
Migration Policy Institute article titled ``Global Demand for 
Medical Professionals Drives Indians Abroad Despite Acute 
Domestic Healthcare Worker Shortages,'' describes the brain 
drain and the harm it does to India's healthcare system. The 
same can be said for countries in sub-Saharan Africa, where 
healthcare professionals are also lured to the U.S., U.K., and 
Canada.
    A poor country's loss is a rich country's gain. The 
estimated financial benefit to the United States from luring 
physicians from sub-Saharan Africa is believed to be in and 
around $846 million. The sending countries lose about $2.1 
billion from the investments made in their doctors who leave.
    According to survey data, in 2020, roughly 70 percent of 
doctors in the U.S. were born here, about 20 percent were 
naturalized, and 7 percent are noncitizens. These percentages 
have remained fairly consistent over the past 10 years.
    Every area of American endeavor has been impacted by 
relentless importation of foreign workers, starting with lower 
paying work, seasonal hospitality workers, and then on to 
manufacturing, to technology workers, and now to doctors, who 
have spent at least 8 years and hundreds of thousands of 
dollars to practice the healing arts, a very specialized 
profession, only to be sidelined and saddled with debt they are 
unlikely to be able to pay off if they can't practice medicine.
    The demand and enthusiasm to enter the medical profession 
is there. Applications to medical schools are at an all-time 
high, as are enrollments in the Nation's nursing programs. We 
have thousands of physicians in line waiting for residency 
training. We need more residency positions, and we must 
prioritize U.S. citizens and lawful permanent residents.
    Thank you for your time.
    [The statement of Mr. Lynn follows:]
    
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    Ms. Scanlon. Thank you, Mr. Lynn.
    Thank you for your testimony. We'll now proceed under the 
5-minute Rule with questions, and I'll begin by recognizing 
myself.
    Dr. Skorton, let me start with you. As you described in 
your testimony, the AAMC has done a great deal of research on 
the physician shortage. According to that research, what are 
the main drivers of physician shortage in the United States?
    Dr. Skorton. Thank you, Chair Scanlon. There are really 
five factors.
    First, one is the happy fact that our country is growing.
    Second, the fact that our country is aging. With age, as 
was mentioned in opening remarks from the Members of the 
Subcommittee, will come the necessity of greater need for 
healthcare.
    Third, the healthcare workforce is aging. I'm an example of 
that. I'm proudly in the over-65 crowd. At a certain point, 
like every other kind of worker, the medical worker in the over 
65 will decide to retire. Because of the big hump of humanity 
in the boomers, we're seeing more retirement.
    Fourth, as I mentioned in my opening remarks, and I'll 
reiterate very briefly, just the fact that we've increased the 
number of first-year medical students by over a third is not 
enough to make a difference because of the need for graduate 
medical education slots. We're still not getting the job done, 
something about which we all, I believe, agree.
    Finally, a special more recent phenomenon, and that is the 
stress of COVID-19 on the country, of course, has been dramatic 
and terrible. It has also been dramatic and terrible on the 
healthcare workforce. We have lost people to COVID. We have 
lost people to behavioral health problems, even suicide, 
related to the stresses of COVID, as best exemplified by Dr. 
Lorna Breen in New York, at New York-Presbyterian Allen 
Hospital.
    Then this has led to some physicians deciding that they 
wanted to retire earlier than planned, or if not retire, to 
perhaps reduce their hours.
    So, those five factors are the ones that we believe are 
leading to this continuing shortage. Let me just take a quick 
prerogative, since I have the floor, to say that we need 
doctors in all disciplines. Certainly, primary care and 
behavioral health, but also every specialty that you can 
imagine. We need them in urban areas. We need them in rural 
areas. We need them in well-served areas. We need them in 
underserved areas.
    Thank you.
    Ms. Scanlon. Thank you, Dr. Skorton.
    Dr. Kura, we appreciate the excellence and dedication that 
you and your non-USA-born colleagues bring with your attendance 
at U.S. medical colleges and research institutions and your 
treatment of folks in our communities.
    You noted in your testimony that you're the only 
nephrologist in the area that you serve. Has your employer 
attempted to recruit other nephrologists to that area, and, if 
so, why weren't those efforts successful?
    Dr. Kura. Thank you, Congresswoman Scanlon. Yes. When I 
first came to Poplar Bluff, it was back in 2010, I never 
thought I would be staying here for more than 3 years. Once I 
start hearing stories from the patients and the amount of 
stress they have to go through that made me decide that I have 
to [inaudible] 2012, I reached out to my nearest dialysis folks 
and said, I want to build a dialysis unit for people, because 
they're not able to get adequate footing here. So, that helped 
me start a new dialysis unit and was done by 2015. The dialysis 
unit at that point had only about 15-20 patients. Now, it has 
90 patients, and the volume is increasing.
    Yes, we do need more nephrologists. We have an 
advertisement out there for the past 10 years to get 
nephrologists or to hire nephrologists. I need a partner. I 
cannot be working like this for the next 10 years. I was 35 
when I started this and I'm 46 now.
    There is always a shortage of physicians and staff here, 
but people do not want to come here due to its geographical 
location. There is not a lot to offer other than healthcare 
here. People want to fly out. The best thing they say--the 
first thing they say, how far is St. Louis from here? It's 
about 2.5 hours. So, that deters them from coming to rural 
areas as such.
    I want to grow this place. I want to help people here. I 
have established my roots. I have established relationships 
with my patients. I mean, they know my family. Unfortunately, I 
am not able to get help. We need a legislative Act to get more 
help.
    Thank you.
    Ms. Scanlon. Thank you.
    Ms. Harris, can you very briefly add what would be the 
number one thing you think Congress should do to help ease this 
issue? I know your extended testimony is in the record.
    Ms. Harris. Okay. Thank you. I think one of the biggest 
fixes, honestly, would be to exempt physicians--there are a 
number of ways to do this--from the per-country limits. That 
would be huge.
    Ms. Scanlon. Thank you. I see my time has expired.
    I believe, Representative McClintock, you're recognized for 
5 minutes.
    Mr. McClintock. Well, thank you very much.
    Mr. Lynn, do we have data on how many American healthcare 
workers have been fired from their jobs because they declined 
mandated vaccinations? I have seen one report putting the 
number at over 10,000.
    Mr. Lynn, you're muted.
    Mr. Lynn. Thank you, Ranking Member McClintock. I have not 
been studying data on fired physicians, but I know, anecdotally 
speaking, in California, where I lived for 20 years, as well as 
here in Pennsylvania, and where I have relatives in New York, I 
have many family Members who are in the healthcare industry, 
and they're being literally threatened with either take the jab 
or quit.
    Mr. McClintock. Well, I would think 10,000 fired because, 
in their own medical judgment, they should not be taking the 
vaccine, that's a significant number. Now, we're told the 
growing population needs more doctors, and that makes sense as 
far as it goes, but much of the population growth has been 
because of an unprecedented increase in foreign nationals 
entering the country, both legally and illegally. Seems to me 
this is putting us in a feedback loop where the more foreign 
nationals enter the United States, the more foreign doctors 
we're told we need to import. Is this a sustainable strategy?
    Mr. Lynn. No. The strategy itself is unsustainable, because 
ultimately you cannot have infinite growth on a planet with 
finite resources. Roughly 80 percent of all population growth 
in the United States is attributable to immigrants and the 
children of immigrants. I myself am the child of an immigrant.
    So, we have to understand that there is a push factor as 
well as a pull factor in this. Yes, a rising population is 
certainly a factor. We have also been seeing a move to States, 
such as the Carolinas, to the Southwest, to States like 
Georgia, of populations over the past three decades.
    Because we froze the number of residencies in 1997, we have 
not been able to, one, build teaching--or expand medical 
education programs in these areas and expand teaching hospitals 
in these areas.
    Mr. McClintock. So, we basically made it more difficult for 
us to produce doctors among Americans, correct?
    Mr. Lynn. Absolutely. That is absolutely the case. The 
costs are just so prohibitive as well. Despite that, there's 
huge demand.
    Mr. McClintock. Can you share with us a couple of stories 
of medical school graduates in Doctors Without Jobs who've not 
been able to get jobs as physicians in the U.S.?
    Mr. Lynn. Oh, absolutely. The co-founder of Doctors Without 
Jobs, Dr. Doug Medina, was never able to match. I know of at 
least several that I can tell you point-blank where some have 
talk about suicide. Well, imagine you're straddled with over 
$400,000 in debt and your income is--you're getting income from 
Uber as well as working a job that might be paying $15 an hour 
working on a dock, which is someone that I know is doing that, 
and you have over $400,000 in student loans and the interest is 
accumulating.
    Mr. McClintock. These are physicians who have received 
their medical degree, so it's not a question of competence.
    Mr. Lynn. Absolutely. All of them have received either a 
medical degree here in the United States or in a foreign degree 
program.
    Mr. McClintock. Has the rate of unmatched physicians 
increased or decreased in recent years?
    Mr. Lynn. It actually increased. Last year, it was 1,431 
U.S.-trained physicians; and total, it was over 7,000. So, we 
actually saw an increase in the unmatched numbers from U.S. 
medical schools and a small decrease in U.S. citizens, lawful 
permanent residents who studied abroad.
    Mr. McClintock. Now, let's be clear on this point. If 
you're not matched--if you receive your medical degree, you are 
a medical doctor, but you cannot match with a residency 
program, you can't practice medicine. Do I have that right?
    Mr. Lynn. That's absolutely correct, sir.
    Mr. McClintock. That is a situation that is affecting over 
10,000 U.S. doctors at this moment?
    Mr. Lynn. Absolutely. All of them could have been deployed 
during COVID. There were opportunities to do that, particularly 
July 1, 2020, when foreign-trained physicians needed to be at 
their residency positions.
    Mr. McClintock. Okay. So, we've refused to match over 
10,000 Americans who have their medical degrees. We fired 
10,000 healthcare workers because, in their professional 
medical judgment, they should not be receiving a vaccine. 
That's 20,000 right there. Yet, we're told the only answer is 
import more foreign nationals. Does that pretty much sum up 
this hearing so far?
    Mr. Lynn. It does sum it up. There's just this bias to not 
really address the infrastructure problems, the hard problems 
that require investment in Americans and American institutions. 
As always, the panacea is to import foreign workers, again, 
whether it's--
    Ms. Scanlon. The gentleman's time has expired.
    With that, I would recognize Mr. Nadler for 5 minutes.
    Chair Nadler. Thank you, Madam Chair.
    Dr. Skorton, AAMC has conducted a great deal of research on 
the provision of healthcare in the United States. Can you 
discuss how living in a medically underserved area impacts a 
person's health? Does this include a decrease in the likelihood 
that they'll seek out regular medical checkups?
    Dr. Skorton. Thank you, Chair Nadler. It's a very, very 
important question. I am glad to have a chance to answer it.
    There are really two big issues here. In any underserved 
area, whether it's in an urban area, a rural area, any 
underserved area, people, by definition, will not have access 
either to preventive services, for example, like cancer 
screening, or to therapeutic services.
    Noncommunicable chronic diseases like the type that Dr. 
Kura deals with, kidney failure, hypertension, diabetes, heart 
disease, these are things that require ongoing medical care, as 
well as cancer screening. One of the big concerns that we have, 
Mr. Chair, in terms of COVID is people stepping away from 
getting cancer screenings during COVID.
    In addition to those things that I mention, behavioral 
health services are at a premium, and we need that very, very 
much in our country for a wide variety of reasons, including 
the epidemic of substance use disorders. So, that's one set of 
things.
    The other set, which is huge, is in addition to these 
healthcare or medical-related items, there are the so-called 
social determinants of health. It turns out that the things 
that affect our health most strongly are these social 
determinants of health, the ability to live in an area where we 
have clean air, clean water, safe streets and so on are very, 
very important. The precursors to social determinants of 
health, racism and poverty, have an enormous effect on people 
and frequently in underserved areas.
    So, there are the medical issues and then there are the 
social determinants of health, and both of these contribute to 
the problems.
    Thank you for the question, sir.
    Chair Nadler. Thank you.
    Dr. Kura, since receiving your green card, you and your 
wife can now live and work anywhere in the United States. Why 
have you chosen to remain in Poplar Bluff, Missouri?
    Dr. Kura. Thank you, Chair Nadler, for the question. As I 
have mentioned, I have come to Poplar Bluff about 10 years ago. 
As time went on and I had my children and my wife is a 
physician, too. She works about 30 miles from here at a place 
called Sikeston. I built the dialysis unit, seeing the need 
that there are patients who need more room. There's growing 
population. There's aging population.
    I started working more, and although I had restrictions to 
do what I could. Being on a visa, I could establish--I could 
get a loan from a bank. I built a dialysis unit. Now, it has 
about 18 staff Members. This dialysis unit has grown. Now, I'm 
the director.
    I consider this as my home now. I have been in India for 
about 25 years, and I have been in the United States for almost 
20 years. This I consider as my home, and this place called 
Poplar Bluff is where I grew. I have my roots. My patients know 
my children. It's difficult for me to just pack my bags and go, 
detach from my patients, who look upon me as their family. I 
cannot just leave this place. I have to proceed with what I 
have at this moment.
    Chair Nadler. Ms. Harris, we heard from Dr. Kura about some 
of the challenges he faced from the difficulties he experienced 
obtaining his visa abroad, the logistical challenges once in 
the United States, and the long wait on the green card backlog. 
Would you say that his--that this experience is a common one 
for physicians coming to the United States, especially from 
countries like India?
    Ms. Harris. Yes. Unfortunately, I can say that he actually 
exemplifies the problems that we see again and again.
    If I could just take a quick moment to say in what ways:

          (1) Is the way he went straight from graduate medical 
        training to a medically underserved area and then stayed there.
          (2) The fact that even though he started there over 10 years 
        ago, and even though he filed what's called a Physician 
        National Interest Waiver Petition, even though he worked there 
        for 5 years in an underserved area, he still didn't get to file 
        his last green card step until he was able to prove he had 
        extraordinary ability in the EB-1 category.

    So, this is a real example of our system being broken and 
not showing the benefits and appreciation and incentives to 
somebody who might not have Dr. Kura's altruism to stay in that 
area. So, it's a real example of how broken our green card 
system is.
    One other thing that's very sad, and often happens to 
physicians and their patients, when they go to get a visa 
abroad, they are planning on coming back. Their patients are 
planning on them coming back on time. So, with a mere week or 
2, or several months to a consulate, which might not seem huge 
from their perspective, when it comes to these physicians and 
their medically underserved patients, it's really, really 
significant when they get held up abroad at the consulate.
    Chair Nadler. Thank you.
    My time has expired. I yield back
    Ms. Scanlon. Thank you very much.
    I see Mr. Buck isn't with us right now. So, I recognize 
Representative Biggs for 5 minutes.
    Mr. Biggs. I thank the Chair.
    This is the fifth hearing that the Immigration Committee, 
this Subcommittee held this Congress. None of hearings have 
focused on the Biden border crisis. None of the memorandums 
that the majority has prepared for the five hearings even 
mention the border crisis, which means that the context of this 
hearing is out of whack a little bit. Based on the materials 
prepared and circulated by the majority, you wouldn't even know 
that there is a border crisis. Perhaps you're in denial.
    Maybe you're in denial that we are experiencing the worst 
border crisis in our history. Maybe you're in denial that the 
policies implemented by President Biden and Secretary Mayorkas 
are making the crisis worse. Maybe you're hoping that if you 
don't acknowledge the crisis, the American people will not 
realize just how big a crisis we have on the southern border.
    If that's the plan, I don't think it will work. Since 
President Biden took office, CBP has encounter more than 2 
million illegal aliens at the southern border, that doesn't 
include the got-aways. During that time, DHS has released 
hundreds of thousands of illegal aliens into our communities by 
some estimates over 800,000, all in violation of the law. 
During that time, Secretary Mayorkas has abused the very 
limited authority that Congress is giving him to Perl aliens 
into the country by Perling at least 70,000 illegal aliens into 
the country. That's not normal. I suspect that the actual 
numbers are probably higher.
    Additionally, we know that CBP is interdicting only a small 
amount of the illegal drugs that cross our border. The estimate 
that I was told by CBP individuals just 2 weeks ago was that 
maybe 5-10 percent, and that includes Fentanyl, which according 
to CDC data, has killed more Americans, aged 18-45, than COVID 
did in the last 2 years.
    What the majority focused on today, not the Biden border 
crisis and not Secretary Mayorkas' failures. Majority won't 
call Secretary Mayorkas to testify before this Committee, which 
has jurisdiction.
    I once again, Madam Chair, I call upon our Committee Chair 
to request a full hearing with Senator--excuse me, Secretary 
Mayor-kas so we can conduct proper oversight. Democrats are 
here today arguing that we need to import more foreign doctors, 
but I have not heard a single one of them criticize President 
Biden's vaccine mandate, which forced hospitals to fire 
doctors.
    In fact, in her opening statement, Representative Scanlon, 
mentioned many numbers of causes, and many reasons why doctors 
and healthcare providers are leaving the field in droves and 
that we don't have enough doctors. She left out one reason, and 
I'll only mention one today: For more than a year, doctors, 
nurses, and other healthcare professionals were on the 
forefront, the front lines of providing care during the COVID 
outbreak.
    Many of them, including--many folks, including some on this 
Subcommittee, praised these professionals and heroes. While we 
face the shortages in the medical field highlighted by the 
Chair and others on the Subcommittee, some of these same 
supporters changed course and demanded that tens of thousands 
of these heroes, who chose not to be vaxxed be terminated from 
their jobs. That doesn't make sense to me. President Biden 
effectively fired all the unvaccinated healthcare workers in 
America.
    So, here's the way to think of it, it is one article 
talking about more than 30,000 healthcare workers out of jobs 
in New York alone because of vax mandates. At the same time, 
what adds to the strangeness of all of it is that you have 
doctors being fired for not receiving a COVID-19 vaccine, but 
hospitals allowing COVID-19 positive healthcare workers to 
continue working. If we need more doctors, then a logical first 
step would be not to fire the doctors we currently have, unless 
they are incompetent.
    Mr. Lynn, thanks for being here today. There has been a 
systematic effort by some to replace American workers with 
foreign workers. Thanks for your work that you're shedding 
light on this area.
    Mr. Lynn. Thank You.
    Mr. Biggs. Is there a reason, Mr. Lynn, that foreign-born 
medical school graduates are getting taxpayer-funded residency 
positions over American doctors?
    Mr. Lynn. I'm gobsmacked by it. It would be one thing--
prior to 1980, there was a situation that existed where we 
weren't filling the residencies available. So, you could see 
where at that point there would be some mechanism to help fill 
that with foreign-trained physicians and we did. However, that 
is not the case today. As I've testified, there are thousands 
of doctors every year who are U.S. citizens, or here--or lawful 
permanent residents that are not getting residency positions. 
They've gone through 8 years of education. It's not like when 
you're in an attorney you're told that, well, you have to pass 
the bar in a specific State. I don't think anyone told them 
that your chances of becoming a doctor after you've graduated 
as a doctor were 50/50 or one in 10. I think that would be a 
little fairer if they would begin on informing them of the 
current day risk. No, I don't see a need at this point to 
continue with the number of foreign-trained physicians. We have 
the doctors right here in the U.S.
    Mr. Biggs. Mr. Lynn, my time has expired.
    Madam Chair, I have two articles I'd like to submit to the 
record, one entitled, ``Termination of Unvaccinated Healthcare 
Workers Backfires as Biden Pledges Help Amid COVID Surge.'' 
Another entitled, ``Health Officials Let COVID Infected Staff 
Stay on the Job.'' I'll provide those copies to the Committee.
    Ms. Scanlon. Without objection. Thank you.
    Mr. Biggs. Thank you.
    [The information follows:]

   
                        MR. BIGGS FOR THE RECORD

=======================================================================
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Ms. Scanlon. Next--I'm sorry. I would recognize 
Representative Jayapal for 5 minutes.
    Ms. Jayapal. Thank you, Madam Chair.
    The pandemic has taken a tremendous toll on our brave 
healthcare workers. As countries around the world compete for 
medical talent, the United States is at a disadvantage. 
Currently, there are more than 1 million individuals stuck in 
the employment-based visa backlog. About 16,000 of those people 
are physicians. These backlogs make it incredibly difficult to 
attract qualified healthcare workers to come and work here.
    Recently, my home State of Washington passed a law allowing 
internationally trained medical graduates the chance to obtain 
renewable 2-year licenses to work as doctors. This is an 
important step. Congress also has to take action to allow 
immigrant medical professionals the chance to work in their 
chosen field, and to serve our country in this difficult time.
    Dr. Kura, your story resonated very strongly with me. I 
think I may be the only Member of the Judiciary Immigration 
Subcommittee to be on an H1B, to have been on an H1B visa. It 
took me 17 years of an alphabet soup to ultimately get my 
citizenship. I am grateful to you for your service to our 
country as a physician.
    In your testimony you talk about the difficulties that you 
faced, the uncertainty of your immigration status, the 
harassment when coming back into the United States, and more. 
You already have a very demanding job as the only nephrologist 
serving your area for many years. I understand it took you 
almost 20 years just to get your green card. Briefly, can you 
tell me how receiving your green card changed life for you and 
your family? Did it open up new opportunities for you to have 
that green card?
    Dr. Kura. Well, a green card is new to me, after longing 
for that for about 15-11 years of hardship and 9 years of 
residency fellowship prior to that. A total of about 20 years, 
I could finally get it in 2020. It is relatively new.
    Prior to obtaining green card, I could do only so much. I 
tried to work in a place called Sikeston. I tried to establish 
myself in rural areas other than Poplar Bluff. I get a letter 
from USCIS stating I have to show how many hours I would be 
spending, at what time I would be spending in which ER, in 
which ICU, in which hospital. I cannot answer that question. No 
doctor is--it's impossible for any physician to tell which ER 
he's going to be--which patient is going to appear in which 
ICU, where do I have to pull from to get dialysis, or urgently 
take care of a patient.
    I withdrew my application for my extension of H1B, or it is 
called adjunct H1B. The endpoint is not me. The endpoint is the 
healthcare that is getting affected because there's nobody else 
to take care of those patients and the hospitals have to ship 
them 2 hours away to St. Louis or to Memphis. Such is the 
condition of current status.
    Now, after getting my green card, I could establish myself. 
I do not have to prove to my sponsors that I am going there, or 
I am going to a different place to work. I can just apply for 
my credentials. Once I'm credentialed, I can work in those 
hospitals and take care of all the patients.
    Ms. Jayapal. One of things first things you did was to 
start building an urgent care facility, right?
    Dr. Kura. Correct, I am. Now, in my hometown we have only 
one urgent care. We are seeing about 230-250 patients from 9 
a.m.-5 p.m. So, I decided to build one more urgent case. The 
plans are in place. We're going to start digging next month. 
This is going to cost me quite a bit, but I'm willing to do 
that, because this place needs it. The only way I can do this 
is by the ability to have a green card. If I was on an H1B I 
don't think I will be able to do this.
    Ms. Jayapal. Dr. Kura, if you could choose all over again, 
knowing what you know now, would you still choose the United 
States, or would you go somewhere else that's more welcoming 
and allowing of immigrant doctors?
    Dr. Kura. Okay, that's a difficult question to answer, 
because to every person, when they are at the age of 25 or 24, 
when he looks at the United States, the dream place, it is the 
land of opportunity. It's the place where I can shine because 
I'm talented. I closely relate myself to the IT professionals 
who have come here and are now CEOs of big companies. I'm 
pretty sure the United States is proud of them. Likewise, I'm 
in the medical field. Unfortunately, they could get their green 
cards early and be where they are, but I could not get my green 
card until about 2 years ago.
    So, looking back at everything, if I had a crystal ball, 
and if I could see myself today talking to you all, I would not 
probably have chosen the United States. I probably would have 
gone to Canada to prove my mettle, to prove my worth, I would 
have been in a better spot. However, after establishing myself, 
putting my time and effort and energy into this place for such 
a long time, I cannot detach myself. I'm going to rise. I'm 
going to go strong at that point.
    Ms. Jayapal. We are so grateful to you.
    Madam Chair, my time has expired.
    I just want to point out it can take up to 195 years for 
those just entering the green card waiting line to receive 
permanent residency.
    With that, I yield back.
    Ms. Scanlon. Thank you.
    With that, we recognize Representative Buck for 5 minutes.
    Mr. Buck. Thank you, Madam Chair.
    Dr. Skorton, I want to visit with you. You mentioned in 
your testimony that there were five factors that really caused, 
or caused in part, the issues that we have with the doctor 
shortage in this country. I think that you really, perhaps 
because of a liberal bias, perhaps because of other factors, 
you've really understated some of other issues that exist.
    My friend and colleague from California, Mr. McClintock, 
has pointed out the vax mandate and the serious consequences to 
our healthcare system as a result of that. My friend from 
Arizona, Mr. Biggs, has talked about the crisis at the border. 
We not only have people coming into this country that have 
diseases that stress our healthcare system, and frankly cause 
illness and injury to our border security patrol officers, but 
we also have illegal drugs coming into this country across our 
southern border that stresses our healthcare system.
    Fentanyl has been a scourge in this country. Heroin has 
been a scourge in this country. Neither of them is produced in 
this country. They are both imported illegally, mostly across 
the southern border. We also have an overwhelmed immigration 
system that just can't handle the kind of things that we're 
talking about, much less putting on another burden, another 
stress with the necessity of looking at applications from 
doctors overseas.
    So, I think you really should acknowledge that there are 
more than five factors that cause the problems that we're 
dealing with. It's not just an aging population. It is not just 
a growing population. It is really a series of very poor policy 
decisions that have been made by the Biden Administration, in 
particular, had a have caused additional stress to our system.
    I have a question for you, Dr. Skorton. I'm wondering, what 
percentage of doctors that come into this country and or 
medical students that come into this country and who receive a 
taxpayer-subsidized, not completely paid for necessarily, but 
taxpayer-subsidized education and then go to work in areas that 
are hard to recruit doctors for either rural areas, or some of 
the more dangerous urban areas. How many of those doctors stay 
5-10 years and continue to practice in those areas?
    Dr. Skorton. Thank you very much for your question, 
Representative Buck.
    I don't have the answer to that. I will get back to you 
very quickly for the record within a couple of days at the 
most, just so I can answer that question.
    Since I've garnered the floor, I just wanted to say two 
other things very quickly. I think that the Committee and 
Subcommittee deserves to have some reconciliation between the 
numbers I'm giving you and the numbers that Mr. Lynn is giving 
you.
    I want to make this offer to Mr. Lynn, we are both children 
of immigrants. I would like to make the offer to work with the 
Subcommittee staff and Mr. Lynn so we can reconcile very 
different numbers that you're hearing so that we can give you 
something that you can hang your hat on.
    The other thing I must say is that I take extreme umbrage 
for Mr. Lynn characterizing the graduate medical education 
system as profiteering. It's a negative cost center--
    Mr. Lynn. Mr. Skorton, you made 34--
    Mr. Buck. Look, I'm not here to--look, my time. You're both 
wrong. I don't give up the floor so you guys can argue. You can 
do that on your own time.
    Dr. Skorton, another question. Would you find the number 50 
percent, the 50 percent of the taxpayer-subsidized students, 
medical students in this country, get their taxpayer-subsidized 
education and leave the country to go back to their country of 
origin?
    In other words, Americans are paying for doctors in other 
countries to get their medical education and work in those 
other countries. Would that number surprise you?
    Dr. Skorton. Well, I can't tell you whether it would 
surprise me or not. I've never looked at that number. What I 
would have to know, Representative Buck, whether they left 
because they were unable to get permanent residency in the 
country or what the reason was. I am very glad to look into 
that as I told you. I promise you I will get back to the 
Committee quickly for the record.
    Mr. Buck. Okay. I thank you for getting back to me on that 
issue.
    I do have to say that I am really distressed that the 
Committee, this Subcommittee, has not addressed some of the 
underlying causes, and just automatically defaults to a 
position of bringing in foreign nationals to deal with our 
medical shortages in this country. I think we've got to look at 
a much more encompassing and holistic approach.
    With that, I yield back, Madam Chair.
    Ms. Scanlon. Thank you.
    Representative Correa is recognized for 5 minutes.
    Mr. Correa. Thank you, Madam Chair.
    First, I want to thank all our Witnesses for joining us 
here today. It's a very important issue that we have to 
address, which is really the healthcare of our society today as 
we age, as we grow in population.
    I agree with some of my colleagues. We have to look at all 
the options, including adding more slots to educate doctors 
here in America, not only doctors, but nurses. We've been 
importing nurses from all over the world for decades.
    My wife right now, my spouse, is an OB/GYN at Kaiser. I can 
tell you right now, she's going through burnout. She's working 
way too many hours. When they call her in because another one 
of her colleagues can't come in, she just will not say ``No.'' 
She goes in and it's a tough time.
    Thank you to the Witnesses. I have a couple of quick 
questions for Dr. Skorton. First, confirm you said 23 percent 
of physicians in the U.S. are foreign-born. Is that correct?
    Dr. Skorton. Yes, sir. That is approximately right.
    Mr. Correa. Did we have a doctor shortage before COVID-19?
    Dr. Skorton. Yes. We've had a doctor shortage for a long 
time, especially initially in primary care, behavioral health, 
but it is across all the specialties, yes.
    Mr. Correa. Behavioral health, is that issue of substance 
abuse, Fentanyl abuse, drug abuse, and mental health? That's 
what we are talking about, correct?
    Dr. Skorton. Yes, sir. Including substance abuse and mental 
health in general.
    Mr. Correa. Dr. Skorton, very quickly. You mentioned 30,000 
DACA health providers. Are you saying we have 30,000 health 
providers under the DACA program where they could be deported 
at any time should the DACA program be terminated?
    Dr. Skorton. I think the specifics would be that they would 
lose work authorization, Representative.
    Mr. Correa. Okay.
    Dr. Skorton. Thirty-four thousand is the number. They sure 
could use that if DACA were rescinded.
    Mr. Correa. They are productive Members of our society, 
paying taxes, saving lives, as my colleague mentioned, 
frontline workers. Thank you.
    Dr. Skorton. You bet.
    Mr. Correa. Dr. Lynn talked about sidelined doctors' 
residency mismatch. That brings back nightmares. When my wife 
and I got married a long time ago, we were praying, hope to God 
that she would match somewhere in L.A., not Chicago and not 
somewhere else. Thank goodness that she did match. Stayed here, 
we got married, and the story is a happy one ever after.
    Dr. Lynn, and I'm going to ask Dr. Skorton, I want to find 
out, what is this thing about a mismatch, about sidelined 
educated American doctors?
    Dr. Skorton, I'm going to give you the opportunity to 
answer that quickly.
    Dr. Skorton. The only answer that I can give without 
checking the numbers of Mr. Lynn as I've offered to do is tell 
you that we depend on the residency training directors to do a 
very careful job of choosing the people who are most likely to 
benefit from residency training. As I mentioned at the 
beginning, within 6 years of that finishing medical school, 99 
percent are practicing or are in residency slots. We believe 
that it's important to allow the residency directors to do what 
they are doing.
    It's also important for me to mention, Representative, that 
we are very concerned about students who do not match at the 
double AAMC, very concerned, as are those at the medical 
schools. They will work with those who didn't match to look at 
the reasons. Perhaps they matched only against a very, very 
competitive specialty. Perhaps they didn't apply to enough 
programs. Perhaps there was something in their application that 
could be better. The medical schools are devoted to trying to 
help them. Perhaps Dr. Kura or others know about that 
particular status. So, we are also very, very concerned about 
it, sir.
    Mr. Correa. Dr. Skorton, I'd love to take you up on your 
offer to help us reconcile some of those numbers for this 
Subcommittees, because this is important for us as 
policymakers.
    You mentioned increase in freshman slots at medical 
schools, 33 percent? Is that correct?
    Dr. Skorton. Thirty-five percent. Some of it was because of 
enlarging, and 30 new medical schools, and six more on deck 
waiting for accreditation.
    Mr. Correa. I say this to you because it's very expensive 
to educate a doctor. To hear that there's no match here, that 
doctors are sidelined, there's something here that's wrong. I'd 
love to work with you trying to figure this one out. At the end 
of day, 35 percent increase in freshman, I would imagine that's 
still not going to address the doctor shortage moving forward.
    Dr. Skorton. One thing, Representative, is that we can 
increase the number of doctors in medical schools even more. If 
we don't open up that blockage at the graduate medical 
education level, we will not have more doctors taking care of 
patients. So, it's been a great thrill to see the two-decade-
long freeze lifted just in the last year, year-and-a-half. We 
are very much hoping that Congress, in its wisdom, will 
increase funding for Medicare--Medicare-funded GME slots, not 
for the doctors, but for the patients of America, we hope that 
that will happen.
    Mr. Correa. Madam Chair. I'm out of time. I yield. Thank 
you.
    Ms. Scanlon. Thank you very much.
    Representative Tiffany, you're recognized for 5 minutes.
    Mr. Tiffany. Thank you very, much Madam Chair.
    Dr. Kura, it was implied earlier in some questioning that 
you were not welcomed to America. Did the people of Poplar 
Bluff not welcome you?
    Dr. Kura. No. It's never been that. People of Poplar Bluff 
love me and continue to love me. I know they will love me in 
future also. It is the way the system works. I never implied 
that people did not like me.
    Mr. Tiffany. Okay.
    Dr. Kura. I will just expand on that a little bit. When I 
was flying to come into the United States across the port, I 
was questioned as to what the full form of H1B is. I do not 
know the answer to that. I was questioned if I have applied for 
green card, and how many days I would stay, or how many years I 
would stay in this country. Well, I've applied for a green 
card, but I did not get it. Those kinds of questions deter me 
from coming back into the country.
    Mr. Tiffany. Okay. Thank you very much, Dr. Kura. Thank you 
for the work that you do.
    Mr. Lynn, why were residencies frozen? In earlier 
questioning, you mentioned that residencies were frozen. Why 
were they frozen?
    Mr. Lynn. I wish I had an answer for that, and I do not. 
They were frozen in 1997. That just demonstrates that--
    Mr. Tiffany. What's been the impact of that?
    Mr. Lynn. Oh, well, the impact is one, as you've seen, the 
number of residency opportunities based on the number of 
graduates from medical school, it's not being able to pair up. 
This is why we're seeing sidelined physicians.
    Might I state, I'm happy to submit for the record how I 
came up with my numbers, because they take into account, for 
instance, when we did a deep dive into this in 2020, I looked 
at the matched, the unmatched with interviews, the unmatched 
without interviews, which is often not reported, and that's how 
we came up with our numbers.
    Mr. Tiffany. I appreciate that very much.
    Mr. Lynn. Yeah.
    Mr. Tiffany. I sure hope you share that with my office. We 
would really appreciate it.
    I remember when I sat on the Joint Finance Committee in 
Wisconsin that dealt with all things budgets. As a Member of 
that Committee, we saw the restrictions and what really were 
barriers to entry. We created more residencies, including in 
rural parts of the State and those have been filled. So, I 
think there are ways in which we can deal with this, but it's 
important that we, as Americans, that policymakers that we 
create those ways of doing it, including at the State level.
    I have to comment in regard to losing physicians, with 
what's happening with the vaccine mandates, I've seen it 
locally. I represent a largely rural area in northern 
Wisconsin. I have had friends who have lost their primary 
physician as a result of a vaccine mandate. When you think 
about the Mayo Clinic, which is in our region, they lost 700 
employees, now not all doctors, but they lost 700 employees as 
a result of vaccine mandates. When you see things like that 
that are happening, the American public is going to be a little 
bit skeptical about claiming poverty that we can't get enough 
physicians here in America when we're driving them out with 
vaccine mandates.
    I'd add one other thing. We heard about bringing all these 
people in from--bringing doctors in from Africa, India, and 
places like that. We've been hearing so much about equity. Are 
we doing the right thing as Americans, taking doctors from poor 
countries? I pose that is as a rhetorical question. Should we 
really be doing that? If we're just going to just benefit the 
United States of America at the detriment for poor countries? 
For those that are standing on the equity ground right now, how 
do you support that? Just a rhetorical question.
    I would close just by saying this: Why is Secretary 
Mayorkas not here? Why is he not here? The preeminent issue, 
certainly one of the top three issues, if not the most 
important issue facing America right now, is a borderless 
southern border. Yet, we still have not seen Secretary Mayorkas 
here. The cynic in me asks the question: Do you want to bring 
in more doctors because we have for Fentanyl and 
Methamphetamine overdoses than we've ever seen in America? Is 
that why we need to import doctors? Is it because of the 
increased crime, including the sanctuary cities of the 
Democrat-run cities that have been setting records for murder 
rates in America? Is that why we have to import doctors? Or is 
it the human trafficking?
    When we see--I've been to the border three, four times in 
the last 2 years, been to Panama. The number of women that are 
sexually assaulted are incredible. I say to the advocates for 
more immigration that sit on this panel, America has deep 
concerns, Americans have deep concerns about what is going on. 
Some of this better get fixed, otherwise you're not going to 
get what you're asking for today, because Americans want the 
border controlled, and it is not now. When are we going to have 
that hearing from Secretary Mayorkas?
    Ms. Scanlon. The gentleman's time has expired.
    Mr. Tiffany. I yield back.
    Ms. Scanlon. Thank you.
    Representative Garcia is recognized 5 minutes.
    Ms. Garcia. Thank you, Madam Chair. Thank you to all the 
Witnesses and for your patience in going through this hearing. 
It's been a very interesting topic. I know that this hearing 
alone won't just--adds so much more and highlights the very 
many contributions that immigrants have made and will continue 
to make in the United States of America.
    To have to face a shortage of health professionals in this 
country is, at the very least, unfortunate and shameful, 
especially during this pandemic period.
    In my district, studies indicate that Houston has one of 
the lowest rates of healthcare workers among major U.S. metro 
areas. The Houston metro area has 3.35 healthcare workers for 
every 100 residents. That places Houston at number 10 on the 
list of major metro areas with the lowest share of healthcare 
workers per capita, including doctors, nurses, and therapists. 
I can attest to this shortage, because I can tell you that in 
my district alone, we have one small community hospital. We are 
essentially a doctor desert. For the work of the FQHCs and 
other health clinics provided by the County or the city, we 
would not have healthcare in my district.
    As Members of Congress, we have a duty to our constituents 
and the Nation to develop a robust and comprehensive healthcare 
system to meets the needs of all Americans, especially our most 
vulnerable communities. I know that thousands of healthcare 
professionals are knocking at our doors every day, ready, 
willing, and able to provide the essential services that people 
in my community and across America need. So, we need to do 
everything possible to keep those doors open.
    I wanted to start with you, Dr. Skorton. I, too, am very 
interested in reconciling those numbers, because it doesn't 
seem to me to be that easy that maybe 10,000 doctors were fired 
because they didn't want to get a vaccine, and that maybe 
10,000 were matched and that would be enough for the shortage. 
It is not really quite that simple, is it?
    Dr. Skorton. Well, I think a general statement I could 
make, Representative Garcia, is that we need more doctors, more 
American doctors, more doctors from overseas. We need more 
doctors in this country. Has been said by both--several of the 
Witnesses today, we need more residency slots. We need more 
graduate medical education. So, we need to put our shoulder to 
the wheel and makes sure that this happens. It is critically 
important. The reason that it's important is that we need to be 
there for districts like yours and throughout the country, 
urban and rural, we need more doctors.
    Ms. Garcia. Right. The whole residency thing has really 
caught my ear, because it is this match question. I have a 
nascent pediatrician. I remember when she was cited that day 
and got her match, and she went on to do her residency. Who 
decides on the number of residencies? What other factors 
influence that? Surely, they don't sit there and go, Oh, here's 
the pile of the foreign-trained doctors. We're going to do 
those first. They don't pick and choose that way. Do they? Do 
they not use objective criteria to decide who gets matched with 
whom?
    Dr. Skorton. They sure do, Congresswoman. They sure do use 
objective criteria. Those criteria include a whole panoply of 
things. Obviously, the scores on tests, obviously how the 
person has done in medical school, obviously the 
recommendations that they get. Certain specialties are 
extraordinarily competitive and others are less competitive. 
So, it's a wide variety.
    I must give a public tip of the hat to those who run the 
residency training programs throughout the country. It's a 
difficult job to do. As I mentioned before, it's a negative 
cost center. If we were making money on it, then every hospital 
would want to have teaching facilities, but it's not the case. 
Only a minority of hospitals do this because it is complicated, 
it's costly, and it's draining to the system.
    So, it is based on a variety of criteria. Although nothing 
is perfect, I have great, great confidence in the overall 
system. Yet, it is very important that we figure out for those 
who do not match what we can do to help them going forward. As 
I mentioned, this is a high priority for us at the AAMC, 
Congresswoman, and for the medical schools themselves.
    Ms. Garcia. Real quickly, because I didn't have time, Ms. 
Harris, we're really just focused on immigrants who have been 
trained here. They may be foreign-born, but they were trained 
in America. Do you know how many of those may have come to 
America through the southern border?
    Ms. Harris. When you say through the southern border, do 
you mean without authorization?
    Ms. Garcia. I mean just coming through the southern border.
    Ms. Harris. Okay.
    Ms. Garcia. I leave that up to the immigration justice to 
decide whether they are authorized or not. It's not my job.
    Ms. Harris. So, very briefly, nearly all foreign-born 
physicians in the United States doing graduate medical 
education are doing so through a visa, through a visa that got 
stamped in their passport by the U.S. Government. The very 
minor exception, and I can get these numbers to you, I think 
the AAMC may have them as well, would be what we call DACA. So, 
there are some DACA medical students who I believe may have 
matched into GME. That would be the only, only subcategory that 
would not have already been vetted by the U.S. Government 
before they ever arrived for the purpose of graduate medical 
education.
    Ms. Garcia. So, none of these folks are adding to this 
supposed crisis at the southern border?
    Ms. Harris. No, not at all.
    Ms. Scanlon. Thank you, gentlewoman your time has expired.
    Ms. Garcia. I yield back.
    Ms. Scanlon. Thank you.
    Representative Jackson Lee, you are recognized 5 minutes. 
Representative Jackson Lee you're muted. You're recognized 5 
minutes.
    Ms. Jackson Lee. Thank you very much. Thank you for this 
hearing. Thank you to the Witnesses. Dr. Skorton, I'm going to 
focus a lot of my questions on your testimony. Thank you again 
for leading the Nation's doctors.
    Living as well in Houston and interacting with the Texas 
Medical Center, but also the public health system, which is 
Harris Health, portions of which are in my congressional 
district and spending a lot of time on the journey that we took 
with the pandemic have worked. I'm sure you're aware of Dr. 
Peter Hotez and the enormous work that he's been doing. I have 
worked with him extensively throughout a number of infectious 
diseases: Ebola, West Nile, et cetera, that doctors, 
researchers are researchers are crucial. There are individuals 
in the Texas Medical Center that are still attempting to get 
citizenship. They are either legal permanent residents, or they 
have the physician status, and they are not even at that point. 
It does cause a depression, if you will, in the level of 
research and the amount of expertise that we have. So, I happen 
to be one that believes that we can answer the points that have 
been made by our minority Witness. I happen to believe we can 
walk and chew gum at the same time. There is no doubt that 
medicine is international. You actually may want the expertise 
of international research to provide Americans with the very 
best medical care that they can. I think the brain drain of 
training foreign doctors and then losing them is also a 
concern. So, we must find just, like we have to regularize 
immigration, we must find a crucial way to be able to address 
that. So, hopefully, I've laid the groundwork for a number of 
questions.
    One, my empathy for individuals who have bought into social 
media, and not gotten vaccinated, and who are in the medical 
arena is limited at best. You might comment.
    Also, I want to make sure that you give us your best answer 
on how we address the question from the American Medical 
Association's perspective on dealing with doctors, foreign 
doctors--I guess I just missed that exact point, if you'd like.
    Then answer the question about homegrown doctors, in 
particular, the African-American community and the low number 
of doctors, and how we cannot be attacked by supporting the 
reality of importance of doctors who are immigrants, but also 
push this idea of ensuring where there are depressed areas 
without African-American doctors, that we can do that as well. 
That's why I focused on you, Doctor, and I yield to you at this 
time.
    Dr. Skorton. Thank you very much, Congresswoman. Very, very 
important questions. I'll try to be brief.
    First, my colleagues at the Association of American Medical 
Colleges would want me, just for the record, to say that we 
don't represent the AMA, but the Association of American 
Medical Colleges. That is the medical schools teaching 
hospitals in academic societies.
    Ms. Jackson Lee. Thank you for clarifying that. Thank you.
    Dr. Skorton. Thank you for allowing me to.
    Our failure, especially to get African-American men in 
medicine is one of the failures of my generation of leadership. 
The year that I started, my first faculty position, 
Congresswoman, 1979, 1980 up until last year, we didn't change 
the proportion of Black men in medical schools by even .1 
percent. So, we have a lot of work to do. We are beginning to 
see some light at the end of the tunnel.
    As was mentioned, I believe actually by Mr. Lynn, 
applications to medical schools are very high. Last year, we 
saw not only a great increase in applicants from the African 
American and Hispanic community, but increases in matriculants 
from both of those communities. In passing for the record, let 
me just say, however, that in the Native-American and Alaska 
Native communities, although we saw increase in applicants, we 
actually saw a decrease in matriculants.
    Second, I would say that there are some other good ideas, 
especially thinking about the pathways to a medical career. I 
personally, having been in higher education for a long time, 
think that we need to start earlier in the educational pathway, 
perhaps as early as middle school, in helping people to dream a 
dream of a life in science and medicine.
    Also, I wouldn't want to yield the floor without saying 
what a treasure to the country the Texas Medical Center is in 
every field of medicine and Dr. Hotez as well.
    Thank you.
    Ms. Jackson Lee. Can you quickly answer the question about 
what we need for the immigration, the doctors who are 
immigrants? That's what I asked that as well.
    Dr. Skorton. Sure. There are few things, and you can get 
the most authoritative advice from Kristin Harris. We are very 
lucky to have her as a Witness. I will just tell you that if we 
could have a pathway to citizenship through DACA, and if we 
could do something with the Conrad 30 program to increase the 
number of slots in that program, that would be a pretty good 
start. In my longer submitted testimony, Congresswoman, there 
are a few other areas that we think would also be helpful.
    Ms. Scanlon. Thank you.
    Ms. Jackson Lee. Thank you.
    Ms. Scanlon. The time of the gentlewoman has expired.
    Chair Lofgren is recognized for 5 minutes to close us out.
    Ms. Lofgren. Thank you, Madam Chair. Thanks to all the 
Witnesses.
    Just a couple of thoughts. It's a rare occasion when we 
have Witnesses that have actually testimony that is I'm sure 
offered in good faith and under oath that is factually at odds. 
So, I am looking forward to getting the further information 
from Mr. Lynn and the further analysis by Dr. Skorton so we can 
sort through how this divergent testimony can be reconciled. 
I'll just say that when that happens, we will make it part of 
the official record, obviously. I'm very interested in it.
    One question I guess I have is whether the discrepancy 
relates to the nature whether it's an M.D. or a different type 
of degree. I hope that that can also be addressed when the 
analysis is made.
    Ms. Harris, I heard your testimony as an expert on 
immigration law, talking about adjustments to the Conrad 
program, the per-country cap, DACA and the like. As you may 
know, the House recently passed the America COMPETES Act, 
which, among other things, would exempt immigrants who undergo 
U.S. medical residency and fellowship programs from the 
numerical limits on green cards. Wouldn't that actually be a 
simpler way to just deal with this whole issue?
    Ms. Harris. Absolutely. I make reference in the written 
testimony at greater length. Basically, so long as technical 
corrections are clarified such that all those would be outside 
of the country limit, that would be an elegant solutions, 
absolutely to taking all these physicians outside of the 
country limit. Absolutely.
    Ms. Lofgren. I would just note that to be qualified for a 
green card, you need to actually prove that there is no 
American citizen or legal permanent resident who is able and 
willing to take the job that has been offered to you. So, that 
is the standard. Only in that case are you qualified for that 
visa.
    I'm just interested as well, Dr. Kura, thank you for your 
service to your patients. One of the things I note in the 
immigration field is that people in underserved communities are 
so grateful to the physicians who come in to take care of them.
    I remember, when we were pursuing adjustments to the per-
country cap that I think has become politically more fraught at 
this point unfortunately because of actions taken by the U.S. 
Senate, talking to a physician from India and his wife, who was 
also a physician in a little town in Iowa. They practice 
together. They were the only doctors in that town. They were 
both on H-1B visas. No, he and she was exempt. The problem was, 
they had, looking at a 50-year wait for a visa and their 
children as dependents had grown up in the United States. When 
they reached 21, they were going to have to return to India, 
even though their parents were living in this little town in 
Iowa. They were considering, and I think, in fact, ultimately 
did, leaving their patients for the sake of their children to 
go to Canada where they got the green card equivalent in about 
5 months. Is that a phenomenon that you have seen around the 
country among immigrant physicians, Dr. Kura?
    Dr. Kura. Thank you very much, first, for the question, 
Madam Lofgren. Yes, I do have one dentist who has left the 
country to Canada, and one rheumatologist who has left the 
country for Canada.
    My wife is a rheumatologist in Sikeston, a small place in 
southeast Missouri. She is booked out for 6 months. I mean, the 
earliest she can see a new patient is 6 months down the road. 
Such is the State of affairs.
    Ms. Lofgren. Thank you, Doctor.
    Dr. Kura. I'm sorry.
    Ms. Lofgren. My time is just about to be expired and I know 
the Chair is going to insist on it. I'll just say this, that 
there are a lot of things we need to do. We need to make sure 
that medical education isn't as expensive, crushingly 
expensive. We need to make sure that we have enough slots for 
training. Those aren't within the jurisdiction of this 
Subcommittee. This issue is. I think this has been an important 
hearing.
    I yield back to Ms. Scanlon with thanks.
    Ms. Scanlon. Thank you, Chair.
    Without objection I would like to enter statements from the 
following organizations and individuals into the record. We 
have a letter from the International Medical Graduate Task 
Force to HHS,a statement from the American Medical Association, 
anda statement from the Educational Commission for Foreign 
Medical Graduates. We also have an individual statement fromDr. 
Jeffrey A. Singer, a Senior Fellow with the Department of 
Health Policy Studies at Cato.
    [The information follows:]

                     MS. SCANLON FOR THE RECORD

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    That concludes today's hearing. I'd like to, once again, 
thank our panel of witnesses for participating in this hearing.
    Without objection, all Members will have 5 legislative days 
to submit additional written questions for the Witnesses or 
additional materials for the record.
    Without objection, the hearing is adjourned. Thank you.
    [Whereupon, at 3:50 p.m., the Subcommittee was adjourned.]

    
                                APPENDIX

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    A statement from the Physicians for American Healthcare 
Access (PAHA), which includes nearly 1,000 international 
medical graduates (IMGs) in over 40 states, submitted by the 
Honorable Zoe Lofgren, Chair of the Subcommittee on Immigration 
and Citizenship from the State of California for the record is 
available at:

https://www.dropbox.com/s/54ru48nzgnfutsb/Lofren-PAHA-
907pgs.pdf?dl=0].

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