Indentured doctors: Foreign-born doctors exploited by U.S. physicians

By Marshall Allen
Las Vegas Sun

This was the birth of an important story.

“Did you know about the foreign doctors working as indentured servants here in Las Vegas?” the doctor asked me.

I leaned forward in my seat. This was a respected physician, but his question sounded like a non sequitur. About 25 percent of physicians in the United States are foreign medical graduates. They’re the best and brightest from their home countries and an essential part of our health care system. They are highly educated, driven and are well paid.

“Indentured doctors?” I asked, incredulous.

The physician told me how foreign-born doctors who are encouraged by the federal government to work in medically underserved areas of the United States are used and abused – exploited for profit – by none other than the U.S. doctors who employ them.

The background to the story was steeped in government bureaucracy – one reason why, it turns out, the abuses were allowed to occur. The notion of doctors taking advantage of other doctors seemed counter-intuitive to me. It turned out that, on this day, I was let in on a dirty little secret in the medical profession.

And my stories already have triggered cries for an investigation by U.S. Senators, state legislators and local doctor groups affiliated with the American Medical Association. Additionally, the state health division has pledged to clean up the program. Reporters across the country should be able to have the same results.

It took me about 10 months to report and write the story, but in the next 10 minutes I can lay out the details for other journalists who want to investigate this story. Let me lay out the road map.

Why are the doctors in the United States?

The foreign doctors originally came here for their residency. In those years each doctor had a J-1 visa, which required him to return home for two years after finishing his training.

In 1994 Congress created the J-1 visa waiver program, also known as Conrad State 30 program, to harness this labor force. The so-called “J-1 doctors” are allowed to stay in the United States as long as they work in blighted urban areas and rural towns where there is a shortage of American doctors. The foreign doctors must work at least 40 hours a week in the underserved areas, for at least three years. When their term is finished, they can become permanent residents.

So the doctors pursue the American dream and medically needy patients get care. What’s the problem?

Often, the J-1 system works fine. But, sadly, many of these doctors in Nevada are running a gauntlet of abuse in their pursuit of the American Dream. They are frequently overworked, cheated financially, and diverted away from the underserved patients they are supposed to serve. Their bosses make more money when the J-1 doctors treat affluent patients in hospitals.

The abuses are possible because each employer sponsors the visas for his J-1 doctors. That means a J-1 doctor who loses his job might have to leave the country. The foreign doctors have worked their entire lives for the chance to become Americans, so they’re unlikely to complain, because it puts their immigration status at risk.

It’s entirely possible the same abuses are happening in other states.

Who’s in charge here? How can these employers get away with this?

Oversight is absent in most cases or passive and based on self-reporting. The J-1 program involves so many bureaucracies that the right hand doesn’t know what the left is doing. State health departments administer the programs, but they receive no funding from the feds. The federal enforcement agencies – the U.S. Citizenship and Immigration Services and Labor Department – also do little to police the program.

The Government Accountability Office, in its November 2006 report, said that no single agency is actively policing the program.

Officials with the state health division and the federal agencies that oversee the program said they only would investigate the program if they received specific complaints, and they acknowledged that complaints would be unlikely because employers sponsor the visas.

Throughout the reporting process, I found that many people in official positions assume there are few employers abusing the J-1 system and exploiting the doctors – but no one has ever verified that this is the case. Right now, the system presumes the employers are following the federal law, even though there’s financial motive for them to break it.

So why should I investigate this program?

Journalists around the country have an opportunity to do collectively what no one has done before: scrutinize the J-1 visa waiver system and provide accountability for employers. With some legwork, it’s possible to verify whether employers are following the federal law or cheating the system. And the timing is right to put the program under the microscope. Congress must reauthorize it by June, and exposing problems may motivate lawmakers to close the loopholes that allow the abuses to go on.

My stories prompted immediate action from the state health department and members of Congress. It’s gratifying to see officials take action, but they need to do much more to correct the problems.

Perhaps the greatest reason for journalists to pursue this story, in my view, is the human rights factor. It’s a vital that we stand up on behalf of the voiceless – in this case, foreign doctors, who have little standing because of their immigration status. Because of my stories, the J-1 employers in Nevada have been put on notice, and many of the abuses that were common in the past decade have ceased. This has been a relief for the doctors.

OK, enough already. You’re making me feel guilty. How can I check out the J-1 program in my state?

To examine the program, I started with the Nevada State Health Division, which, like most states, has its J-1 visa waiver guidelines posted online. States have some leeway in how they run the program – some allow specialists, some do not; some ban non-compete agreements. But in general the programs must follow two major rules:

• J-1 doctors must spend at least 40 hours per week working in an area that’s been designated by the federal government as a Medically Underserved Area (MUA), Medically Underserved Population (MUP) or Health Professional Shortage Area (HPSA).

• J-1 doctors must be paid the “prevailing wage,” which is generally defined as the same salary a similarly skilled American physician would earn. Employers are not allowed to pay based on patient census, force J-1 doctors to take out loans, or come up with other creative schemes to fund them.

Once I knew the state guidelines, I requested the database of current and former J-1 doctors from the health division. This is public information and included the name and address of the clinic where the doctor was assigned, the name of the employer and other information like specialty, date of hire and end date.

With the database in hand, I began verifying whether or not the doctors were working in the medically needy areas, as is required by law. I started by visiting the clinics in the underserved parts of North Las Vegas and Pahrump, a rural town an hour from Las Vegas. Several clinics were nothing but shell operations: no patients, no doctors and receptionists who said the doctors always worked in the hospitals. In such cases, the J-1 doctors are violating the terms of their visa, and the employers may be committing immigration fraud.

On my initial visits to the clinics, I did not volunteer that I’m a reporter – though I would not have lied about it. I just asked the receptionist for a list of the doctors who worked at the site, and their schedule, in case someone wanted to make an appointment. I already knew the J-1 doctors at the site, so I just wrote down their schedules.

I found that some of the foreign doctors were not working the required 40 hours a week in the underserved clinics. Instead, they were being sent to non-underserved hospitals, or other clinics with more affluent patients.

To verify their work sites were in underserved areas, I did an address search on the Census Bureau's American Fact Finder Web site to find which census tract for the particular clinic, and then went to http://hpsafind.hrsa.gov or http://muafind.hrsa.gov to see if they’re in a designated shortage area. (One word of warning: Sometimes these sites have not been updated to reflect all the underserved areas. For clarification, call Andy Jordan, chief of the shortage designation branch for the U.S. Health Resources and Services Administration.)

I made a public information request for all the employment agreements for J-1 doctors in Nevada. This allowed me to compare the stated salaries with the prevailing wage, which can be found at www.flcdatacenter.com. Reporting on the prevailing wage must be done with caution, because in some cases employers can get salaries approved by the Labor Department that are less than the prevailing wage. I pretty much stuck to blatant wage violations – situations where doctors were being unpaid, or were forced to take out a loan on an employer’s behalf.

I also used the state’s J-1 database to search court records for any lawsuits involving J-1 doctors. This resulted in a few hits and some anecdotes for my story. I also called immigration attorneys throughout the country (Caution: They usually represent J-1 doctors and employers, so they’re not always the best source.) and some of them pointed me to other cases that had entered the public record.

Were the foreign doctors willing to talk to you?

The foreign doctors were my key source of information. They know the potential for abuses in the J-1 visa waiver program, and they hear tales of abuses while they’re in residency. While many reported they were happy with their employers, many others said officials only need to speak with them to learn that many employers, at least in Las Vegas, are cheating the system.

To connect with the J-1 doctors I contacted anyone who might know them and looked them up individually if I could do so without their employer’s notice. Those who have finished the program and have their green cards were much more free to talk, but still they were apprehensive. Many J-1 doctors were unwilling to talk to me, which I considered to be a sign that they may be being exploited. If everything was OK, then why not say so?

Discretion was essential. My editors and I determined it was OK to use anonymous sources for these stories. If I could not pledge anonymity to the doctors, almost none would have spoken to me. Only a few were courageous enough to speak out publicly.

Once I earned the trust of one J-1 doctor it was usually possible to get them to pass on cell phone numbers of their colleagues. The physicians know each other – particularly if they’re from the same country.

What was the response to your stories?

My stories received an astounding level of response – in the local medical community, the statehouse and Congress. The Nevada and Clark County physician associations have called on the governor to put an end to the abuses. Nevada legislators pledged to fix the problems and the state health division is now inspecting clinics for violations and holding hearings to discuss necessary changes to the oversight and administration of the program. Sens. Harry Reid of Nevada and Kent Conrad of North Dakota, who created the program, wrote a letter to the Department of Homeland Security, which oversees immigration, calling for a thorough investigation of the J-1 program nationwide, and a full report so Congress can make necessary changes.

Some of the most satisfying response has come from the doctors themselves, who said for the first time someone has listened to their complaints and held employers accountable.

All right, any last words?

All it takes to check out this program is some visits to clinics and a few cups of coffee with foreign doctors. But if you find abuses and exploitation of J-1 doctors in your community, the story is sure to get tongues wagging in the community. In that case there’s great potential for positive change.

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Marshall Allen is a reporter for the Las Vegas Sun. If you have questions about reporting on the J-1 visa waiver program, contact Allen at marshall.allen@lasvegassun.com or 702-259-2330.