National Reporting Instrument 2024

The Department of Health and Human Services (HHS) Health Resources Services Administration (HRSA) Bureau of Health Workforce’s (BHW) National Center for Health Workforce Analysis (NCHWA) publishes detailed projections of the future supply of and demand for over 100 healthcare occupations. Projections are updated annually and are available through an intuitive dashboard.

HRSA’s (BHW) has many programs designed to increase and enhance the health workforce. Several of these programs, like the Geriatrics Workforce Expansion Program, are designed to support and train the next generation of the health workforce with an emphasis on the type of care that will be needed in the future.

HRSA’s BHW has many programs designed to increase and enhance the health workforce. Several programs, like the Faculty Loan Repayment Program, are designed to support and grow faculty who provide quality education to the next generation of the health workforce.

HRSA’s BHW has many programs designed to increase and enhance the health workforce. Several of these programs, like the National Health Service Corps, are designed to place providers in areas where the population most needs care.

The Administration for Strategic Preparedness and Response (ASPR) From: https://aspr.hhs.gov/HealthCareReadiness/Pages/default.aspx, “ASPR’s Health Care Readiness Programs help hospitals, health care facilities, and health care systems across the country overcome the complex challenges associated with disaster health care by providing coordinated, life-saving care and broadening the resources available during a disaster or public health emergency.”

U.S. Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS) implements the Graduate Medical Education (GME) Program (Sections 1886(d) and 1886(h) of the Social Security Act). This Medicare program pays teaching hospitals to train residents in approved graduate medical education (GME) programs. Approved GME programs for which Medicare pays consist of residents in allopathic and osteopathic medicine, podiatry, and dentistry. U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Bureau of Health Workforce (BHW) implements programs and activities to train the next generation of diverse health care providers to deliver inter-professional care to underserved populations through its grants to U.S. health professions schools and training programs (Title VII of the Public Health Service Act). Title VII programs support educational institutions in the development, improvement, and operation of educational programs for primary care physicians, physician assistants, dentists and dental hygienists. Other sections also support community-based training and faculty development to teach in primary care specialties training. Programs include the Geriatrics Workforce Enhancement Programs, Oral Health Training Programs, and Primary Care Training and Enhancement Programs. HRSA’s Bureau of Health Workforce (BHW) also implements nursing programs (Title VIII of the Public Health Service Act) with the goal to better prepare nurses to provide care for underserved populations. These programs work to improve U.S. nursing education, practice, retention, diversity and faculty development. Advanced Nursing Education Programs aim to increase the size of the advance nursing workforce trained to practice as primary care clinicians and to provide high-quality team-based care. Nurse Education, Practice, Quality and Retention Programs aim to expand the nursing pipeline, promote career mobility, enhance nursing practice, increase access to care and inter-professional clinical training and practice, and support retention.

HRSA’s BHW has many programs designed to increase and enhance the health workforce. Several of these programs, like the National Health Service Corps Rural Community Loan Repayment Program, are designed to help rural areas recruit and retain providers.

HRSA’s BHW has many programs designed to increase and enhance the health workforce. Several of these programs, like the Scholarships for Disadvantaged Students program, are designed to support scholarships.

HRSA Bureau of Health Workforce implements: • The Centers of Excellence (COE) Program: The COE program provides grants to health professions schools and other public and nonprofit health or educational entities to serve as innovative resource and education centers for the recruitment, training and retention of underrepresented minority (URM) students and faculty. These award recipients also focus on facilitating faculty and student research on health issues particularly affecting URM groups. In FY 2022-2023, the COE Program supported 586 students and 483 faculty who participated in research on minority health-related issues. • The Scholarships for Disadvantaged Students (SDS) Program: Authorized in 1989, SDS provides grants to eligible health professions and nursing schools for use in awarding scholarships to students from disadvantaged backgrounds who have financial need, many of whom are underrepresented minorities (URMs). The program also connects students to retention services and activities that support their progression through the health professions pipeline program. In Academic Year (AY) 2022-2023, the SDS Program provided scholarships to 2,613 health professions students from disadvantaged backgrounds. A total of 1,236 students graduated, including 471 nursing students, 299 behavioral health students, and 239 allied health students. • The Health Careers Opportunity Program (HCOP): The National HCOP Academies provides individuals from economically and educationally disadvantaged backgrounds an opportunity to develop the skills needed to successfully compete for, enter, and graduate from schools of health professions or allied health professions. The National HCOP Academies provide a variety of academic and social supports to individuals from disadvantaged backgrounds through formal academic and research training, programming, and student enhancement or support services that can include tailored academic counseling and highly focused mentoring services, student financial assistance in the form of scholarships and stipends, financial planning resources, and health care careers and training information. In Academic Year 2022-2023, HCOP grantees reached over 4800 disadvantaged trainees across the country through structured programs. and activities to promote interest in the health professions among prospective, disadvantaged students.

The programs listed in response 2.2.3 have a requirement for the beneficiaries to work in shortage areas such as rural areas for a specified period of time. For example, the Nurse Corps Loan Repayment Program requires beneficiaries to work at least two years in either a critical shortage facility located in an area lacking enough health professionals or an eligible nursing school as nurse faculty. Similarly, the National Health Service Corps Loan Repayment Program requires a 2-year commitment of service at an approved health facility.

HRSA Bureau of Health Workforce (BHW)’s National Health Service Corps (NHSC) Scholarship and Loan Repayment Programs provide financial, professional and educational resources to medical, dental, and behavioral health care providers who bring their skills to areas of the United States with limited access to health care. Since 1972, the Corps has helped build healthy communities by connecting these primary health care providers to areas of the country where they are needed most. Today, more than 18,000 NHSC members are providing culturally competent care to almost 19 million people at 20,912 NHSC‐approved health car sites in urban, rural, and frontier areas. In addition, more than 4370 students, residents, and health providers in the Corps pipeline are in training and preparing to enter practice. HRSA’s Bureau of Health Workforce (BHW) also administers the NURSE Corps program to provide nurses nationwide the opportunity to turn their passion for service into a lifelong career through scholarship and loan repayment programs. NURSE Corps helps to build healthier communities in urban, rural and frontier areas by supporting nurses and nursing students committed to working in communities with inadequate access to care. The NURSE Corps Loan Repayment and Scholarship Programs have helped critical shortage facilities meet their urgent need for nurses since 2002. Today, more than 3,600 NURSE Corps nurses are providing care where they are needed most, and an additional 1,199 NURSE Corps scholarship recipients will begin their service once they complete their training.

Many of the grants provided to rural providers are aimed at empowering them to provide more benefits to their work force and improve their well-being. For example, the Nurse Education, Practice, Quality, and Retention Program (NEPQR) Grants strive for retention through continuous professional development programs that promote nurses’ career advancement, enhancing communication and collaboration among nurses and promoting nurses’ involvement in the organizational decision making of the health facilities. Recently, an estimated $103 million in American Rescue Plan Act funding over a three-year period was allocated with the aim of reducing burnout and promoting mental health of the health workforce. The funding helps health care organizations to establish and sustain a culture of wellness among the health and public safety workforce and to support training efforts to build resiliency for those at the beginning of their health careers. These investments, which take into special consideration the needs of rural and medically underserved communities, aim to limit burnout, stress, depression, and suicide, and promote resiliency among the workforce during the COVID-19 pandemic and beyond.

In the United States, there is no federal law regulating placement agencies or employment contracts overall. Rather, public authorities regulate certain aspects of private recruitment and employment contracts, as set forth in the requirements for temporary migrant labor programs.   However, some federal agencies have taken action to regulate certain kinds of contractual provisions that may be coercive. For example, the Department of Labor filed suit against healthcare staffing agency that recruited a foreign nurse and allegedly made employees sign contracts that would force them to work for the company for three years or repay rightfully earned wages, which the Department alleged violated the Fair Labor Standards Act. In April 2024, the Federal Trade Commission (FTC) published a final rule banning new noncompete provisions, which could impact the recruitment and hiring of foreign healthcare workers.

While not focused specifically on recruitment of health personnel, the Department of Labor’s Office of Foreign Labor Certification (OFLC) periodically offers several opportunities for stakeholder consultation in relation to the temporary and permanent labor programs.  OFLC participates and may conduct stakeholder outreach and engagement OFLC conducts quarterly stakeholder meetings, at which stakeholders may raise questions or issues on any of the programs the Office administers.  In addition, when promulgating regulations, proposed rules are submitted for public notice and comment and the agency must respond to public comments received during the notice and comment period when issuing the final rule.  In December 2023, OFLC announced that it is considering revisions to Schedule A of the permanent labor certification process to include occupations in Science, Technology, Engineering and Mathematics (STEM) and other non-STEM occupations and invites employers and other interested parties to comment on this Request for Information (RFI). OFLC developed the RFI and published it for comment so that the public may provide input, including data, statistical metrics or models, studies, and other relevant information, on how the Department may establish a reliable, objective, and transparent methodology for revising Schedule A to include STEM and other non-STEM occupations that are experiencing labor shortages, consistent with requirements of the Immigration and Nationality Act (INA). The comment period closed in May 2024. Information received from the public will help inform decisions regarding whether or how to improve Schedule A and ensure that its purpose in responding to national labor shortages is more effectively met. Additionally, in October 2022, the White House launched the H-2B Worker Protection Taskforce to strengthen protections for workers in the H-2B program. The Taskforce released a report in October 2023 announcing actions to protect H-2 workers and has continued to engage stakeholders in an ongoing manner. In June 2022, the DOL, Department of State, and USAID issued “Guidance on Fair Recruitment Practices for Temporary Migrant Workers” to assist governments of countries of origin, recruiters and employers in achieving fair recruitment for workers bound for employment in the United States under the H-2 programs.

As noted previously, there is no federal law regulating placement agencies or employment contracts overall. However, the regulations for the H-2B program, for the hiring of nonimmigrants to perform nonagricultural labor or services on a temporary basis, requires employers to retain their foreign worker recruitment contracts in their compliance files into the event of a Department of Labor audit or investigation, and those agreements must contain a prohibition against charging the foreign worker recruitment fees. The Department of Labor also maintains a publicly available list of agents and recruiters who are party to such contracts and the locations in which they are operating. For more information, please see: https://www.foreignlaborcert.doleta.gov/Foreign_Labor_Recruiter_List.cfm  

Although the United States does not have a federal law regulating recruitment agencies overall, there are some safeguards in place to help combat fraudulent and unscrupulous recruitment practices. For example, current H2-B regulations generally prohibit the collection of recruitment fees or labor certification expenses and require that employers disclose to workers the terms and conditions of the job and provide the Department of Labor copies of contracts with their recruiters, and the names and locations of all subsidiary recruiters. The Department of Labor maintains a publicly available list of agents and recruiters. Remedies for violations include reimbursement of unlawfully collected fees to workers, civil money penalties, and debarment from these programs where appropriate.   In the permanent labor certification program, current regulations prohibit employers from seeking or receiving payments of any kind for any activity related to obtaining permanent labor certification, whether as an incentive or inducement to filing, or reimbursement for costs incurred in preparing or filing a permanent labor certification application.  The kinds of payments that are prohibited include monetary payments, wage concessions, kickbacks, bribes, or tributes, in-kind payments, and free labor.  Additionally, U.S. labor and employment laws relating to wages, working conditions, and anti-discrimination generally apply to all workers in the U.S. regardless of citizenship status. Enforcing labor and employment laws for all workers can help decrease their vulnerability to various forms of exploitation, including human trafficking. It can also level the playing field for employers who meet their obligations under the law. 

The Department of Labor requires employers who are bringing workers to the United States temporarily on an H-1B visa to provide the workers with a copy of the Labor Condition Application (LCA) no later than when the worker reports to work. The LCA informs the foreign worker of the wage to be paid, the job title, period of intended employment, and place of employment. The LCA also informs the worker of how to file a complaint alleging misrepresentation of material facts or failure to comply with the terms listed on the LCA. The Department of Labor also requires employers who are bringing in H-2B temporary workers to provide the workers with a copy of the job order no later than when the worker applies for the visa, in a language understood by the worker, as necessary or reasonable. The H-2B job order informs the foreign worker of the job duties, period of employment, wage to be paid, any training that will be available, deductions that will be made, and how the employer will provide or pay for the cost of the worker’s transportation, among other things. Additionally, the U.S. State Department has several resources available for certain individuals traveling to the United States as temporary workers or students informing them of their legal rights and protections: https://travel.state.gov/content/travel/en/us-visas/visa-information-resources/rights.html     There are no specific laws or policies for internationally recruited or trained health personnel. The U.S. federal labor and employment laws generally apply to all workers, and agencies across the federal government, such as the Department of Homeland Security, the Equal Employment Opportunity Commission, the Department of Labor, and the National Labor Relations Board frequently work together to coordinate enforcement of federal law. For example, through the conclusion of a Memoranda of Understanding (MOU), which also recognizes the importance of protecting workers who seek to assert their workplace rights from retaliation by employers, recruiters or other parties, the Departments of Homeland Security and Labor undertook coordination efforts to advance the respective missions of each agency. https://www.dol.gov/sites/default/files/documents/MOU-Addendum.pdf. In January 2023, the Department of Homeland Security announced that noncitizen workers who are victims of, or witnesses to, the violation of labor rights, can now access a streamlined and expedited deferred action request process. Deferred action protects noncitizen workers from retaliation and threats of retaliation from exploitative employers and supports the enforcement of labor and employment laws. Workers requesting deferred action through the streamlined process must submit a statement of interest from a labor or employment agency addressed to DHS supporting the request. https://www.dhs.gov/enforcement-labor-and-employment-laws.

The H-1B program requires that employers first file a Labor Condition Application (LCA) with the Secretary of Labor attesting that the wage paid to the foreign worker is the higher of the actual wage rate (the rate the employer pays to all other individuals with similar experience and qualifications who are performing the same job), or the prevailing wage (a wage that is predominantly paid to workers in the same occupational classification in the area of intended employment at the time the application is filed). Similarly, H-1B employers must provide foreign workers working conditions based on the same criteria as those the employer offers to its U.S. workers, such as hours, shifts, vacation periods, and benefits. In addition, the employer must provide to its U.S workers notice of the filing of the LCA.    Employers wishing to bring in foreign health personnel on a permanent basis must usually obtain a labor certification from the Department of Labor determining that there are not sufficient U.S. workers who are able, willing, qualified, and available in the area of intended employment and that the employment of a foreign worker will not adversely affect the wages and working conditions of workers in the U.S. similarly employed. One of the methods utilized by the Department of Labor to ensure that the wages and working conditions are not affected is to require the employer to offer at least the prevailing wage to all U.S. workers during its labor market test and then to the foreign worker upon receipt of his or her permanent residency. An employer is not required to file a labor certification application with the Department of Labor for those foreign workers (including professional nurses and physical therapists) who qualify under the Department’s Schedule A. In those cases, an employer must attach its labor certification application to the immigrant worker petition it files directly with the Department of Homeland Security.     Employers who are interested in employing H-2B temporary workers must obtain a labor certification from the Department of Labor. Among other requirements, they must offer and pay the H-2B worker no less than the highest of the prevailing wage, the applicable Federal minimum wage, the State minimum wage, or local minimum wage during the entire period of the approved H-2B labor certification. 

Foreign workers do not necessarily have the same education and training opportunities as national workers, as some federal funding streams have limitations on the non-U.S. citizen individuals that can access them. However, migrant health personnel may enroll in private educational courses the same as the domestically trained health workforce, and employer-provided training may be provided to domestic and migrant health personnel equally.

As noted previously, although not specific to healthcare workers, DOL, the Department of State, and USAID issued Guidance on Fair Recruitment Practices for Temporary Migrant Workers in 2022. https://www.dol.gov/sites/dolgov/files/OPA/newsreleases/2022/06/ILAB20220565.pdf

The Department of Labor requires employers who are bringing workers to the United States temporarily on an H-1B visa to provide the workers with a copy of the Labor Condition Application (LCA) no later than when the worker reports to work. The LCA informs the foreign worker of the wage to be paid, the job title, period of intended employment, and place of employment. The LCA also informs the worker of how to file a complaint alleging misrepresentation of material facts or failure to comply with the terms listed on the LCA. The Department of Labor also requires employers who are bringing in H-2B temporary workers to provide the workers with a copy of the job order no later than when the worker applies for the visa, in a language understood by the worker, as necessary or reasonable. The H-2B job order informs the foreign worker of the job duties, period of employment, wage to be paid, any training that will be available, deductions that will be made, and how the employer will provide or pay for the cost of the worker’s transportation, among other things. Additionally, the U.S. State Department has several resources available for certain individuals traveling to the United States as temporary workers or students informing them of their legal rights and protections: https://travel.state.gov/content/travel/en/us-visas/visa-information-resources/rights.html     There are no specific laws or policies for internationally recruited or trained health personnel. The U.S. federal labor and employment laws generally apply to all workers, and agencies across the federal government, such as the Department of Homeland Security, the Equal Employment Opportunity Commission, the Department of Labor, and the National Labor Relations Board frequently work together to coordinate enforcement of federal law. For example, through the conclusion of a Memoranda of Understanding (MOU), which also recognizes the importance of protecting workers who seek to assert their workplace rights from retaliation by employers, recruiters or other parties, the Departments of Homeland Security and Labor undertook coordination efforts to advance the respective missions of each agency. https://www.dol.gov/sites/default/files/documents/MOU-Addendum.pdf 

The H-1B program requires that employers first file a Labor Condition Application (LCA) with the Secretary of Labor attesting that the wage paid to the foreign worker is the higher of the actual wage rate (the rate the employer pays to all other individuals with similar experience and qualifications who are performing the same job), or the prevailing wage (a wage that is predominantly paid to workers in the same occupational classification in the area of intended employment at the time the application is filed). Similarly, H-1B employers must provide foreign workers working conditions based on the same criteria as those the employer offers to its U.S. workers, such as hours, shifts, vacation periods, and benefits. . In addition, the employer must provide to its U.S workers notice of the filing of the LCA.    Employers wishing to bring in foreign health personnel on a permanent basis must usually obtain a labor certification from the Department of Labor determining that the EEOC are not sufficient U.S. workers who are able, willing, qualified, and available in the area of intended employment and that the employment of a foreign worker will not adversely affect the wages and working conditions of workers in the U.S. similarly employed. One of the methods utilized by the Department of Labor to ensure that the wages and working conditions are not affected is to require the employer to offer at least the prevailing wage to all U.S. workers during its labor market test and then to the foreign worker upon receipt of his or her permanent residency. An employer is not required to file a labor certification application with the Department of Labor for those foreign workers (including professional nurses and physical therapists) who qualify under the Department’s Schedule A. In those cases, an employer must attach its labor certification application to the immigrant worker petition it files directly with the Department of Homeland Security.     Employers who are interested in employing H-2B temporary workers must obtain a labor certification from the Department of Labor. Among other requirements, they must offer and pay the H-2B worker no less than the highest of the prevailing wage, the applicable Federal minimum wage, the State minimum wage, or local minimum wage during the entire period of the approved H-2B labor certification. 

Foreign workers do not necessarily have the same education and training opportunities as national workers, as some federal funding streams have limitations on the non-U.S. citizen individuals that can access them. However, migrant health personnel may enroll in private educational courses the same as the domestically trained health workforce, and employer-provided training may be provided to domestic and migrant health personnel equally.