This report focuses on those IMGs who are foreign nationals, hereafter referred to as foreign medical graduates (FMGs). Many FMGs first entered the United States to receive graduate medicaleducation and training as cultural exchange visitors through the J-1 cultural exchange program. After that time, they are required to returnhome for at least two years before they can apply to change to another nonimmigrant status or legalpermanent resident (LPR) status. Under current law, a J-1 physician can receive a waiver of thetwo-year home residency requirement in several ways:
the waiver is requested by an interested government agency (IGA);
the FMG's return would cause extreme hardship to a U.S. citizen or LPRspouse or child; or
the FMG fears persecution in the home country based on race, religion, orpolitical opinion. Historically, the Department of Health and Human Services had been veryrestrictive in its sponsorship of J-1 waiver requests. In December 2002, HHS announced that it wouldbegin sponsoring J-1 waiver requests for primary care physicians and psychiatrists in order toincrease access to healthcare services for those in underserved areas. United States Department of Agriculture (USDA). "Conrad 20" Program for States. Under this program, participating states were allowed tosponsor up to 20 waiver applications annually. Recent Developments

HHS Policy Change. Expiration of "Conrad 30" Program. (17) As discussed below, several billshave been introduced in the 108th Congress toaddress the concerns of medically underserved areas that rely on J-1 physicians. Recommendations from the states for the J-1 visa waiver program included the following: 
allow states to determine the appropriate use of the program;
allow states to determine the number of waivers needed based on the needs ofthe states;
allow fees to support the program;
have HHS coordinate ongoing support and technical assistance;and
have the Department of State and USCIS provide information and technicalassistance to the states. When USDA announced it would no longer participate in the J-1 waiver program in February 2002, the Texas Primary Care Office conducted a second survey, on the impact of the agency'swithdrawal on states and their use of "Conrad 20." (23)
When asked to suggest changes to the program, states continued to express an interest in: the re-distribution of unused slots; possibly increasing the number of waivers available to states to 40;making the program permanent; and allowing the state departments of health or programadministrators decide where the physicians would be placed. Legislation in the 108th Congress

Several bills have been introduced to address the May 2004 expiration of the "Conrad 30"program. The amended bill extends the program until June 1, 2006;exempts waiver recipients from the H-1B cap; allows recruiting of primary and speciality carephysicians; and allows placement of up to five physicians in shortage areas designated by the states. On November 17, 2004, S. 2302 was debated and passed by the House. Commonlyreferred to as the "Conrad 20" program after its sponsor Senator Kent Conrad, it was originally slatedto end on June 1, 1996. On December 3, 2004, the "Conrad 30" program was once again extended.
The Educational and Cultural Exchange Visitor program has become a gateway for foreign medical graduates (FMGs) to gain admission to the United States as nonimmigrants for the purposeof graduate medical education and training. The visa most of these physicians enter under is the J-1nonimmigrant visa. Under the J-1 visa program, participants must return to their home country aftercompleting their education or training for a period of at least two years before they can apply foranother nonimmigrant visa or legal permanent resident (LPR) status, unless they are granted a waiverof the requirement.
The J-1 visa waiver program has recently undergone significant change. In February 2002, the United States Department of Agriculture (USDA), which had historically been the largest sponsorof waivers, decided to end its participation as an interested government agency (IGA). Thisdevelopment and the pending expiration of the "Conrad 20" program, which allowed 20 waivers perstate, threatened the continued availability of waivers. These developments raised concerns amongmany in medically underserved areas because it is often difficult for them to find U.S. medicalgraduates willing to practice in these areas. Bills introduced in the 107th Congress proposed changesto the "Conrad 20" program, including expanding the program and making it permanent.
In an effort to ensure the continued availability of medical care in underserved areas, the Department of Health and Human Services (HHS) announced it would assume USDA's role as asponsor of J-1 primary care physicians. This was a policy change for HHS which has historicallybeen very restrictive in its sponsorship of waivers. Prior to this announcement, HHS had limitedsponsorship to research physicians and scientists involved in research of international or nationalsignificance.
On November 2, 2002, the "Conrad 20" program was extended until 2004 and the number of waivers available to states was increased to 30. This program, which is now referred to as the"Conrad 30"or "State 30" program, expired on June 1, 2004.
Several measures, to address the expiration of the "Conrad 30" program were introduced in the108th Congress. On December 3, 2004, S. 2302 became P.L. 108-441 . The new lawextends the program until June 1, 2006; exempts physicians granted waivers from the H-1Bnumerical limits; allows states to hire primary and speciality care physicians; and place up to fivephysicians in shortage areas designated by the state.