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Take Two National Interest Waivers Before Bedtime and Call Me in the Morning: National Interest Waiver Eligibility for Clinical Physicians Hot Topics in Employment - Based Immigration. 1999 I. Introduction This article examines the eligibility of a certain class of physicians - specifically those working in designated medically underserved areas - to qualify for permanent residence under the national interest waiver/job waiver provisions of the Act1 in the aftermath of Matter of New York State Department of Transportation (hereinafter: NYSDOT).2 In a sense, this is an article with a very limited objective. This article does not directly challenge the validity of NYSDOT, particularly in its injection of an exceptional ability standard to national interest wavier adjudications or its emphasis on the labor certification application process. Similarly, this article does not examine in any depth the issue as to whether NYSDOT exceeds the statutory parameters of the national interest waiver provisions. Furthermore, this article does not touch upon a very problematic issue as to whether NYSDOT in its actual application is being utilized by the Immigration and Naturalization Service (INS*) Regional Service Centers as an invitation to issue blanket denials of national interest waivers or whether the case will be regarded as setting forth clearer, more definite standards in the interest of administrative consistency. Rather, this article essentially assumes that NYSDOT has articulated certain new, albeit more rigorous, standards governing national interest waiver adjudications which presupposes that the national interest wavier classification still has both relevance and intrinsic meaning in case adjudication. Furthermore, this article is limited to a specific class of physicians - i.e., primary care physicians practicing in areas which have been designated by the federal government as medically underserved. Particularly at this point in time following the promulgation of NYSDOT as a precedent decision, this type of focus on a specific professional class seems timely and relevant in that it should force both the practitioner and the Service to reexamine the role and contributions of physicians within certain broader national contexts. As of this writing, NYSDOT is being applied in a manner which essentially reverses the Service's previous record of favorably considering national interest waiver cases for primary care physicians working in medically underserved areas. This sudden reversal of policy is simply unwarranted and counterproductive not only to national interests, but runs counter to a clear and consistent pattern of federal government initiatives intended precisely to encourage the relocation of physicians to medically underserved areas. As such, even under the newly articulated NYSDOT standards, physicians working in medically undeserved areas should continue to merit approval as cases of national as opposed to local concern. II. Background Patterns of Adjudication The national interest waiver classification is a rather recent initiative arising from the Immigration Act of 1990 , although the concept of immigration serving the national interest certainly has its antecedents in previous legislative enactments.4 While there may have been little direct legislative history which illuminates the Congressional intent in passing the national interest waiver provision, it can be assumed that its underlying policy corresponds to a basic jurisprudential principle, which is that the law is intended either to reward desirable behavior or to induce "socially beneficial cooperative behavior" - i.e., to get people to undertake actions they otherwise would not undertake in light of certain rewards for this type of socially desirable behavior.5 In the aftermath of these new provisions, the INS Administrative Appeals Unit sought to provide some guidelines as to factors impacting on national interest wavier standards in the Mississippi Phosphate case.6 Specifically, this case identified seven (7) key factors, which could favorably be considered for national interest waiver purposes, including the improvement in healthcare. In the ensuing period, many medical providers located in medically underserved communities utilized successfully the national interest wavier provisions which, incidentally, became a useful and powerful recruitment tool in order to get foreign physicians to commit to practices in generally underserved practice locations. This policy seemed to receive strong sanction from the INS, which instructed that "the service centers should continue their past practice of favorably adjudicating most national interest waivers for physicians who will be practicing in medically underserved areas of the United States".7 While the general, overall pattern of the INS Regional Service Centers has been to approve national interest waiver requests for physicians working in designated medically underserved areas, it became progressively more clear that there was a growing resistance to this policy, particularly within the California RSC. Starting roughly in the spring 1998, there emerged a growing pattern of denials of national interest waiver cases for physicians, generally based on assertions that a physician's services to a medically underserved community was local rather than national in scope or that the stipulated term of a physician's employment of three years (as required for J-1 wavier purposes) was not of sufficient duration to make a true and lasting impact on the community.8 While the sources of this change in policy remain unclear, it would seem that the primary motivation rested in a perceived pattern of premature physician departure from communities at risk and a growing movement within the American medical establishment for harsher new policies toward foreign physicians.9 In the aftermath of NYSDOT, the Service has at least thus far been nearly uniform in its denial pattern of cases filed under the national interest waiver standards for physicians. Illustrative of this trend is the AAO's statement that "there is no indication in the legislative history, statute, regulations, or binding legal precedent that physicians as a group are exempt from the labor certification requirement."10 The AAO further placed significant reliance on a 1987 study by the Department of Labor indicating a poor pattern of retention of foreign physicians in medically underserved communities.11 III. Policy Analysis Few would question that a physician's activities - particularly as conducted within a medically underserved community - represents anything but a laudable initiative of substantial humanitarian benefit to the community. The issue, though, is whether these activities rise to the level of national interest consideration under the standards appearing in NYSDOT. In order to fully determine this issue, it is necessary to step back and to consider the overall goals and challenges of the medical profession within our society. A. General Flaws/Concerns in the National Healthcare System There has never been a more technologically advanced medical system than in the United States. However, this system is characterized by three (3) major flaws:
These are major issues of profound national concern. At present, roughly 37 million individuals in this country are without medical insurance13 and 64 million people live in communities designated by the federal government as medically underserved - i.e., areas in which medical coverage falls short of minimally acceptable norms for adequate access to healthcare providers.14 Furthermore, this shortage pattern is disproportionately experienced by minorities and by many of the most vulnerable segments of our society.15 In a sense, our national healthcare system is broken into two contradictory components: a technologically advanced, sophisticated system of medical achievement and a deeply rooted, structural inability to uniformly deliver healthcare services within the United States. This basic tension within the healthcare delivery system carries profound consequences to our entire national experience and forms the background for determining the overall importance and the national interest implications of physician relocation to medically underserved communities. 1. National Concern with Physician Maldistribution It is a matter of major ongoing national concern that substantial areas of the United States continue to suffer from a shortage of physicians. In a recently published statement, the Department of Health and Human Services (HHS) confirms that roughly 64 million Americans live in geographic areas designated as medically underserved.16 This is not a recent situation, but rather has been a long-standing problem in which physicians tend to avoid the rigors of medical practice in inner city or rural isolated impoverished communities in favor of more upscale professional practice settings. As stated by the Department in its notice of Proposed Rulemaking: [D]espite increases in the total number of physicians practicing in the United States, including increases in the numbers of primary care physicians, anticipated "diffusion" of these physicians in frontier and other remote rural areas has been limited.17 At one level, a physician working in a medically underserved area involves a simple matter of importance solely to local concern, although it does raise an ethical issue as to why a resident in a medically underserved area should be deprived of acceptable access to a physician in order to address his/her basic most fundamental health care needs. If the physician maldistribution issue were solely a local matter, the solution would also lie at a local level. However, the Congress has undertaken a number of broad initiatives precisely in order to facilitate the relocation of primary care physicians into medically underserved areas. Among the federal initiatives precisely intended to stimulate the relocation of physicians to medically underserved communities are: The National Health Service Corps.19 The Physician Loan Repayment Program, The Target Assistance Grant Program, the Community Rural Healthcare Network,20 the J-1 Waiver Program, and the Stepped-Up Medicare Reimbursement schedules to qualifying rural and inner city clinics. All of these federal initiatives have been undertaken in recognition that the continuing maldistribution of physicians is a matter of serious national concern. On a national level, healthcare planners have stated that the minimally acceptable target physician-to-population ratio is 1:2000.21 Yet, in most communities which have been designated by the federal government as medically underserved, the physician-to-population ratio is in excess of 1:3500. By federal measures, this situation of physician underservice is simply not considered to be a matter of local concern, but rather constitutes a serious issue impacting the national interest. As countless studies have established, the lack of access to physician services directly correlates to substandard healthcare outcomes, particularly among the indigent.22 Quite simply, if a physician is not readily available within a community, the local resident is much less likely to engage in preventive healthcare measures and instead tends to postpone healthcare treatment until the given medical condition has reached an advanced or even crisis stage. This statistically established pattern of medical treatment directly translates not only into substandard healthcare outcomes, but adds both direct and indirect costs in terms of an overall increase in federal expenditures for treatment programs, lost productivity, undermining of the family structure, etc. On a national level, our nation spends over 14% of our Gross National Product on healthcare.23 This is the largest expenditure within any single industrial sector in our country. As a nation, we spend grossly more on healthcare needs than is the case in any other industrialized country. These enormous expenditures present a very real threat to this country with profound implications on our future economic growth and our decency as a society in serving the needs of future generations and of the elderly. In short, there is a direct, documented correlation between a lack of adequate physician coverage and a deterioration in community stability, direct and hidden economic waste, and inferior healthcare outcomes. These are not mere speculations, but rather represents an established pattern documented in the literature which has serious national implications. There is, in fact, a high and growing level of popular acceptance for increased federal government intervention in order to provide enhanced healthcare coverage in this country. In a recent poll, almost 90% of those surveyed support federal legislation intended to improve the quality of healthcare services, lower out-of-pocket costs, and preserve individual choice of physicians.24 In short, the general popular sentiment is that access to healthcare services, which is ultimately the issue here under discussion, should not simply be a matter of parochial local concern or a function of market mechanisms, but rather is a valid issue of national concern. The class of physicians currently under consideration constitute primary care physicians who provide inclusive, basic, comprehensive medical services in a community setting. This is simply not a situation of a high priced, narrowly focused physician with a restrictive set of patients; rather, this article concerns a class of physicians providing comprehensive medical services within a community so as to benefit the widest possible spectrum - especially the indigent and medically underserved, Quite simply, these activities are and should be regarded as fully within the national interest. 2. Benefits of Primary Care Medicine to Areas of National Interest The employment as a primary care physician has certain national interest implications. As such, a primary care physician is defined as "a physician who usually is the first health professional to examine a patient and who recommends secondary care physicians, medical or surgical specialists with expertise in the patient's specific health problem…."25 The primary care disciplines are generally limited to: internal medicine, pediatrics, family practice, Ob/Gyn, and more recently, geriatrics. As noted above, our national healthcare system as emerged as the most technologically advanced system in the world, but one characterized by gross economic waste as treatment programs are devised by medical specialists without regard to the overall healthcare profile of a patient. Also, since medical specialists tend to practice in upscale urban centers rather than to distribute themselves throughout the country, the large numbers of medical specialists tend to reinforce physician's inaccessibility in underserved areas. With the demise of a national healthcare plan, the only comprehensive approach to address our nation's healthcare crisis is the doctrine of managed care which requires a substantially increased number of primary care physicians to provide accessible, cost effective, and comprehensive therapeutic, preventive, and diagnostic services. Under managed care doctrine, the target balance within the physician workforce is a 50-50 split between medical specialists and primary care physicians. At present, our nation has a major shortage of primary care physicians in that roughly 70% of all physicians are specialists.26 This preponderance of medical specialists is generally ascribed to a variety of circumstances chiefly linked to their higher compensation schedules and enhanced prestige within the profession. As a result, as a nation we continue to produce an overabundance of medical specialists at a time when we have a pronounced and still unmet need for primary care physicians. According to the U.S. Department of Health and Human Services, the United States currently has a national shortage of approximately 13,000 primary care physicians in order to meet the optimal target ratio of 1 physician for 2,000 residents. Even in order to meet a far more modest goal of achieving a physician-to-population ratio of 1:3,500, which would at least statistically fill the shortfall in designated medically underserved communities, we have an immediate need of approximately 5,500 additional primary care physicians.27 Therefore, we would think that medical practice in a primary care discipline should be in furtherance of a stated national need of increasing the supply of primary care physicians, which has become a national priority precisely in order to decrease national healthcare expenditures while preserving professional quality standards. Again, primary care physicians working at the community level are not practicing in an esoteric or limited branch of medicine; rather, by definition, they are practicing in an area of medicine precisely intended to provide comprehensive, inclusive medical services. The practice of primary care medicine is consistent with a current national emphasis on an increase in primary care medicine so as to provide expanded healthcare coverage at lowered costs without any deterioration in healthcare outcome. 3. Congruence of National and Public Interest Many physicians working within medical underserved areas are also the beneficiaries of waivers of the home residence requirement as issued by interested government agencies. While national interest eligibility should not be the function of the issuance of a J-1 waiver but should rather reflect substantive contributions to primary medical care coverage in at risk communities, the logical overlap of the public interest wavier of §212(e) with the national interest waiver standards of §203(b)(2)(B) provides an additional justification for the eligibility of physicians in medically underserved communities to national interest wavier entitlement. Essentially, an interested government agency issues a favorable waiver recommendation in light of the perceived importance to federal interests from a physician's relocation to a medically underserved community. In order to receive a waiver of the two year home residence requirement, a physician needs to be endorsed by three (3) governmental agencies: the initial recommending federal agency or the appropriate state department of health under the Conrad State 20 Program,28 the U.S. Information Agency, and the Immigration and Naturalization Service. There are two issues of relevance here: first, that the issuance of a §212(e) waiver by these agencies directly reflects upon the fact that a physician's employment in a medically underserved community is a matter of federal concern; and second that under a clear reading of the statutory language and the legislative history, the granting of a 212(e) waiver rests upon identical principles as those utilized for national interest waiver purposes.29 Quite simply, both the Congress and the federal agencies have generally regarded a §212(e) waiver as strongly suggesting fulfillment of national interest waiver standards in that "both the USIA recommendation and the Attorney General's ultimate public interest determination are, in fact, considerations of national and international interest rather than of individual interest".30 Therefore, we think that the approval of the §212(e) waiver of the home residence requirement should be a highly persuasive - if not outright dispositive - factor in the approval of a national interest waiver. These agencies have specifically acted in order to facilitate a physician's relocation to a designated medically underserved area in furtherance of the national interest. Furthermore, these agencies have a definite commitment to ensuring that the physician integrates as fully as possible into the community with the goal of his/her long-term retention in the community. Again, it would be logically inconsistent to restrict national interest waivers solely to physicians previously in J-1 status who have received §212(e) waivers. Rather, the ultimate justification for the §212(e) waiver presents the same logical basis for approving the national interest waiver for a physician in that both rest upon the core national value of service to a medically underserved community. 4. Growing Statistical Evidence of Foreign Physicians' Services to National Healthcare Priorities Over these past years, the Service has generally been supportive of the approval of national interest waiver requests by physicians.31 Quite frankly, the Immigration and Naturalization Service should be proud of its contributions in rectifying the physician imbalance/maldistribution patterns through facilitating the relocation of physicians to communities in need. In this light, two central points should again be reaffirmed: first, that in passing the national interest/job waiver provisions, the Congress was presumably trying to encourage certain desirable social behavior which otherwise would not take place which, in this instance, is the relocation and retention of physicians into medically underserved communities; and second, that despite the increase in the overall numbers of physicians in practice, there has been relatively little diffusion among the general physician population into medically underserved areas with the result being that 64 million Americans still live in areas without minimally acceptable access to physicians. However, there is now growing statistical evidence which indicates that foreign physicians disproportionately practice medicine in designated medically underserved communities and that they target their services toward minority populations. In contrast to the practice trends within the general physician population, it appears as though foreign physicians to a much larger extent than their domestic counterparts are engaged in a socially desirable pattern of taking up practice opportunities in designated medically underserved areas and in providing various "gap-filling" services which have traditionally not been discharged by domestic physicians.32 In a series of articles written by researchers at the University of Michigan based on extensive statistical analysis from the Master Database File of the American Medical Association, foreign physicians have been found to provide "gap-filling" services within the United States - i.e., they tend to disproportionately serve the needs of at risk population groups in the United States. Specifically, as a general pattern, foreign physicians tend to provide medical services in specific roles which are not adequately being addressed by domestic physicians.33 We assume that this differing medical practice pattern does not result from a greater level of altruism of foreign physicians than their U.S. counterparts; rather, we would submit that this highly desirable course of conduct is in some measure precisely the result of legal measures such as the provisions of §203(b)(2)(B) of the Act which have over the past several years stimulated foreign physicians into taking up practice opportunities in undesirable, medically underserved communities. More specifically, the studies conducted by Dr. Mick and Dr. Lee, as referenced above, indicate that to a disproportionate extent, foreign physicians tend to display the following practice characteristics:
Undoubtedly, there are various reasons why foreign physicians tend to perform these "gap-filling" services which have the effect of channeling physician services into practice settings of maximum national benefit. We would surmise that immigration considerations is among the greatest single factors leading foreign physicians to take up "undesirable" practice opportunities, and this is a factor which should be of considerable pride to the Service in its effectuation of Congressional intent. We would forthrightly submit that the J-1 waiver program and the previous Service adjudication record of according national interest waiver benefits to foreign physicians practicing in medically underserved communities have been important initiatives of national significance. We again assume that foreign physicians are not more altruistic than their U.S. Counterparts; rather, they have availed themselves of various legal initiatives which have substantially facilitated their relocation into medically underserved areas and which, in the aggregate is benefiting U.S. national interests. 5. Intrinsic Merit of Medical Practice in a Designated Medically Underserved Area While recognizing the controlling nature of the NYSDOT case, it is very important to point out that this precedent decision concerned a structural engineer involved in highway engineering. The benefits of his services resulted in cost efficiencies and improved transportation. This is an entirely different set of principles than those pertaining to physician services which, by their nature, deeply touch certain fundamental human values of health and welfare. By its nature, the profession of medicine, if discharged properly, holds major keys to the health and welfare of an individual, his/her circle of family and friends, and the community at large. Conversely, a lack of accessible, professional medical attention carries substantial adverse consequences not only in terms of immediate human suffering, but also in terms of social and community disruption and increased direct and indirect federal and other expenditures. Owing to the intrinsic life-and-death considerations as performed by members of the medical profession, the Service should grant greater recognition to the national interest arising from physicians practicing at a community level. In short, for national interest waiver benefits, we would submit that there should be an inverse correlation between the intrinsic impact of the alien's activities on fundamental issues of health and human welfare and the number of individuals directly benefiting from the activity itself. As an illustration of the above, we would submit that in cases involving cultural enrichment or economic benefit, the petitioner should have a substantially higher burden of showing broad national consequences than should be required for practicing physicians or biomedical researchers. The justification for this proposition lies essentially in the intrinsic importance of medical doctors on human life and welfare. Furthermore, it should also be noted that the federal government is already heavily involved in the field of medicine, running from the funding of medical research initiatives to the training of physicians to their placement in undesirable, medically underserved communities. The national interest waiver approach would be simply one more initiative undertaken by the federal government as a matter of national interest in order to address and rectify the physician maldistribution patterns in this country. Therefore, in contrast to the profession of structural engineering, there are special national interest waiver considerations to the medical profession. We believe that perhaps along with the National Defense, there is no greater obligation of the federal government to its citizenry than to facilitate (although not mandate) adequate health coverage. Quite simply, this is an important national value that rises to the level of the national interest. 6. Special Situation of Medical Practice in Rural Communities Presently, only 9% of all primary care physicians work in rural communities.34 The chief reasons cited for this avoidance of rural medical practice opportunities are: lower compensation schedules; longer working hours; professional isolation; increased opportunities under managed care in more attractive upscale urban practices; and a lack of medical infrastructure/support. The consequences of a lack of adequate physician resources in a rural community are profound and far reaching, including: it decreases patient accessibility to preventive (and cost effective) treatment programs; it increases hospital treatment expenditures because rural patients are required to seek treatment in non local referral centers or urban hospitals; it has substantial negative impact on employment patterns and economic development in rural communities.35 These are not personal speculations or even an exaggerated statement of the consequences of the situation in broad areas of Rural America; rather, it is a straightforward statement of the ripple effects experienced over the years in many rural parts of the United States. Therefore, while physician availability may on first inspection seem like strictly a matter of local concern, the spillover effect of physician inaccessibility has major implications on both rural and inner-city infrastructures and should be regarded as a matter of national concern. 7. Counterproductivity to National Interests of the Labor Certification Application Process NYSDOT also requires that the petitioner seeking the national interest waiver must persuasively demonstrate that the national interest would be adversely affected if a labor certification were to be required. Setting aside for current purposes the legitimacy of this primacy of the labor market test, we would submit that the overall benefits of a physician's services to matters of national importance would indeed be undercut through the labor certification application process. The designation of an area as medically underserved presupposes a physician shortage situation of such long-term dimensions as to undercut the essential welfare of a community. In such cases, the burden of proof in a labor certification application has already been met due to the long term unavailability of sufficient medical practitioners in order to meet legitimate community needs. Quite simply, the very fact that a community has already been designated by the federal government as a medically underserved area implicitly establishes that there is a pervasive, long standing shortage of physicians which undercuts the basic welfare of a community. The designation process involves local, state federal, and community resources and is intended precisely in order to identify areas in which various federal initiatives can be most appropriately utilized in order to rectify an otherwise untenable healthcare coverage situation.36 The utilization of a labor certification application approach is simply not appropriate in this situation for the following reasons. First, the national interest waiver program has been a powerful tool in order to encourage physicians to relocate to medically underserved communities. There are already a number of disincentives to rural medical practice, which tend to encourage physicians to take up practice opportunities in more upscale urban situations. The availability of the national interest waiver approach for qualifying primary care foreign physicians creates a more even playing field for communities in need. Indeed, as noted in the study conducted by researchers at the University of Michigan, foreign physicians over the past several years have disproportionately tended to take up practice opportunities in underserved communities. We believe that the national interest waiver has been an important incentive for foreign physicians to commit long term to communities located in medically underserved areas. Second, from the standpoint of the community itself, the national interest waiver has proven to be a major recruitment tool which has enabled these communities to compete for medical practitioners having a far better professional credentials than would otherwise be available to them. The medical literature contains a great deal of information regarding the substantial difficulties of rural communities in effectively recruiting physicians and unquestionably, the national interest waiver has proven to be a major, highly welcomed initiative which has enabled communities to recruit and retain physicians in medically underserved communities. Furthermore, there has been no empirical data reflecting on a failure to retain physicians in their communities of need. According to a report conducted by the U.S. General Accounting Office (GAO), the level of retention of physicians in medically underserved communities is actually quite high. Specifically, the GAO Report found that 90% of the physicians whose waivers were recommended by the Appalachian Regional Commission (and most of these physicians, we would submit, are also beneficiaries of national interest waivers) fulfilled their required two year term of service; for J-1 physicians receiving waiver recommendations in the 1994-1995 timeframe, the retention as of January 1, 1996, approached 96%.37 In short, there is no question but that the national interest waiver has proven to be a powerful incentive for enabling communities in need to compete for competent, critically needed physician services and based on the data developed thus far, there simply are no widespread abuses of this program. Third, in order to get a J-1 waiver based on a government agency recommendation, the medical facility already has to have recruited for the position. In most instances, this recruitment will not fulfill labor certification application procedures, particularly since the credentialing and licensing requirements in substantiation of a physician's medical competence makes it unfeasible for the recruitment to take place within the allowable six month period of time for reduction in recruitment procedures. Nevertheless, the employer has clearly carried its burden of showing the unavailability of recruiting a U.S. physician based both upon its own previous recruitment/advertising actions as well as the presumption of an unavailability of U.S. physicians as derived from the designation of the area as medically underserved.38 Therefore, we believe that the labor certification application process is simply counterproductive to national interests. One of the principal benefits from a foreign physician's relocation to a community in need is the prospect of gaining permanent residence through a quick and efficient filing procedure. This has been a major catalyst in encouraging foreign physicians to consider practice opportunities in medically underserved areas and has also enabled communities themselves to more effectively recruit physicians to their communities. The appropriate focus of federal policy in designated medically underserved areas is to promote the most efficient utilization of resources in order to recruit and retain physicians, and this is best served through the national interest wavier mechanism. V. Conclusion At present, the long-term effects of NYSDOT remain unknown. In its current formulation, NYSDOT seems to be an open ended invitation to issue blanket denials of national interest wavier cases. Therefore, at present, NYSDOT challenges the practitioner not only by articulating new standards, which may or may not fairly define the standards for national interest, but also by providing the INS Regional Service Centers with unfettered discretion to deny cases. The passage of time as well as aggressive lawyering by members of the bar will determine the extent to which this new era of national interest wavier standards will prevail. This article simply seeks to accept on its face the standards set forth in NYSDOT and to then examine whether a certain professional class of physicians working within designated medically underserved areas still merit national interest waiver benefits. We would suggest that this situation remains national in scope, is a matter of actual intrinsic merit, and in no manner undercuts the labor certification application process. The continuing recognition of this class of physicians for national interest wavier benefits would be consistent with a broad range of other federal initiatives which have consistently recognized that adequate accessible health care is a matter of not only local but of national concern. The general overlap between the public interest standards governing §212(e) waivers and the national interest waiver standards further reinforce the national interest wavier implications and importance of primary care physicians practicing in designated medically underserved areas. The ultimate irony of the current situation is that it appears as though the previous eligibility of foreign physicians to national interest waiver benefits was a highly successful program. In contrast to the continuing failure of the medical establishment to more equitably address the medical needs of underserved communities, there is a growing body of statistical evidence suggesting that foreign physicians disproportionately settle in medically underserved areas and attend to the needs of minority, at risk patient populations. In large measure, this different practice pattern among foreign physicians has been the result of national interest waiver eligibility, which has formed a powerful inducement for physicians to relocate to undesirable practice settings. In this sense, the Service's previous adjudication pattern in granting national interest waiver benefits to physicians has very successfully fulfilled a presumably basic objective of these provisions, which is to channel professional resources into the most socially desirable activities to the national interest. Hopefully, the past record of achievement will be a powerful impetuous to the restoration of national interest waiver eligibility to foreign primary care physicians who agree to assume practice opportunities in medically underserved communities. 1999 by Robert D. Aronson * At the time this article was written, the Immigration and Naturalization Service (INS) served as the main immigration body of the U.S. Government. Since March 2003 immigration processing functions are a part of the Department of Homeland Security, U.S. Citizenship and Immigration Services (USCIS). 1.INA § 203(b)(2)(B) |
Aronson & Associates, P.A. |