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Vara Venkata Ponnada, MD, an immigrant physician from India, has been looking for permanent residency status in the United States, but she doesn’t expect to get it anytime soon.
Now working as a hospitalist in Waterloo, Iowa, Ponnada feels disheartened about her nearly 5-year wait for a green card. Now at age 53, and fighting cancer, she wonders if she will even be alive by the time her green card comes.
Ponnada and several thousand other international medical graduates (IMGs) from India have been waiting for years to get a green card, which provides a path to US citizenship. In 2018, more than 400,000 Indians with advanced degrees and their dependents applied for green cards, but there were fewer than 3000 green cards to be had for people from India with advanced degrees, reports David J. Bier, immigration policy analyst at the Cato Institute Center for Global Liberty and Prosperity. He predicted it would take decades for Indians with advanced degrees, including IMGs, to get through the current backlog.
Ponnada’s H-1B visa stipulates that she has to work at an assigned employer or leave the United States. When she was diagnosed with breast cancer last year and underwent a mastectomy, she was frightened ― and not just because of the disease. “If I got too sick to work, then I would have to leave the country,” she said. Ponnada pays income taxes, and she estimates that she has paid more than $100,000 into Social Security. But she will not be eligible for Social Security until after she gets a green card.
Thankfully, the cancer is in remission, but now her two children are “aging out” of their dependent status on her H-1B visa. At age 21, they have to get their own visas or leave the country. “My kids don’t want to go back to India,” she said. “They are American.”
Without permanent residency status, she doesn’t feel she belongs anywhere. “Legally, I am still Indian, but I don’t feel Indian, for sure,” she said. “And I can’t call myself American. I feel I am nowhere now.”
The Long Road to a Green Card
The US federal government allocates the same 7% of employment-based green cards to immigrants from each country, no matter the country’s size ― even to India, the second most populous country in the world.
Ponnada, who works in an underserved area, thinks she should have an easier time getting a green card because she is providing a service to the nation. According to a 2012 study, IMGs provided up to 25% of medical care in underserved areas.
Last year, she joined the group Physicians for American Healthcare Access (PAHA), which includes other Indian IMGs without green cards. The group is asking that the green card quota be removed for IMGs who work in underserved areas.
PAHA supports a new bill in Congress, the Conrad State 30 & Physician Access Act (Senate Bill 948), that would remove the quota for these physicians after they had worked more than 5 years in an underserved area. The bill was introduced by Senators Amy Klobuchar (D-MN) and Chuck Grassley (R-IA).
In October 2019, Ponnada flew to Washington for the third time to join PAHA physicians to advocate on Capitol Hill for the bill with lawmakers and their staffs. Ponnanda takes the 2-day visits very seriously. “I don’t have much free time,” she said, “but I am happy to spend it on this.”
Taking Political Action in Washington, DC
In addition to expanding the Conrad program, the bill would provide IMGs with green cards that are not subject to the national quotas for green cards if the IMGs worked in underserved areas for 5 years. “The physician could get a green card after a 1- or 2-year wait, just like any physician not from India today,” Ponnada says.
More than 50 other PAHA members visited offices of senators and representatives on Capitol Hill to promote the bill.
The IMGs worked the halls of Capitol Hill for 2 days, rising early in the morning before sunup. Ponnada, still recovering from her mastectomy, had to take elevators instead of the stairs and ride in taxis between congressional office buildings. “I still get tired easily, but I’m glad I came,” she said at the time. “This is important work.”
“The situation for Indian IMGs will come to a breaking point,” said Raghuveer Kura, MD, a nephrologist from Poplar Bluff, Missouri, who helped found PAHA and who also came to the DC event. “Either there will be an easier path to permanent residency or many of them will have to leave the United States.”
Either there will be an easier path to permanent residency or many [Indian IMGs] will have to leave the United States.
In the 2-day event, the PAHA physicians visited 160 offices of senators and representatives on Capitol Hill. Twice as many PAHA members came compared to the last visit in August. They signed up two more cosponsors of the bill, from North Carolina and Oregon. The congressional aides the PAHA docs met with were generally encouraging, although not necessarily familiar with the bill or the Conrad 30 program.
With 20 representatives and nine senators who have signed up so far, the bill still seems to have a long way to go.
But PAHA leaders say they are optimistic that lawmakers will ultimately support the bill. That’s because it would make tangible improvements for their constituencies at no cost to taxpayers. The bill allows more physicians to be placed in underserved areas. Also, the states ― and not the federal government ― maintain control over the process. Conrad 30 positions are chosen by state departments of health.
“There is no security until you get the green card,” Kura added. “As an IMG without permanent residency, I have to be careful not to have any brushes with the law. Anything on my record could put my application for a green card in jeopardy.”
PAHA physicians plan to continue their trips to Washington, which they have been carrying out twice a year since they began in 2018.
Ponnada’s Journey to America
In India, Ponnada graduated in 1992 with a Bachelor of Medicine, Bachelor of Surgery (MBBS) degree, which allowed her to be a general practitioner. She had just married another doctor and had an infant daughter. She worked for several years as an industrial physician in a steel plant and then at a multispecialty hospital.
About a decade later, Ponnada obtained a year-long, unpaid research internship with a cardiologist at the Mayo Clinic and moved to Minnesota. She had to pay all of her own expenses, so she came alone.
Feeling very ambitious, she began think of entering a US residency training program. While in the states, she took and passed parts 1 and 2 of the US Medical Licensing Examination, which is required for becoming a doctor in the United States. “Ultimately, I wanted to be a cardiologist,” she said.
Getting into an internal medine program in the United States is intensely competitive for IMGs. For example, a 10-slot primary care residency program may get thousands of applicants, many of them IMGs, according to another Indian IMG.
Ponnada got into an internal medicine program at an underserved area in Queens, New York. In the first year, she was living in a small apartment without any of her family with her. Her two children joined her in the second year, and then her husband gave up his job in Jamaica and came in the third and final year.
With just Ponnada’s residency stipend to live on, the family lived in a two-bedroom apartment in a crowded neighborhood. “It was a big change for us,” she said. “We were used to living in big houses in Jamaica and India.”
When she graduated, she had to give up plans to continue training in a cardiology fellowship. “I had a family to take care of, and we couldn’t afford to do it,” she said. But the family was thankful to be in America, and Ponnada’s new ambition was to become a US doctor.
The Decision to Stay in America
Ponnada said that when she started her residency program, she did not plan to stay in America, but by the time she graduated, she had changed her mind. “For a doctor, America is the place with the best medicine,” she said.
Ponnada’s extensive US training was a gift from the federal government. The Medicare program spends $120,000 to $129,000 per year to train each resident, including each IMG, according to a 2018 report by the Congressional Research Service.
Her J-1 visa for that training stipulated that she would have to leave the United States on completion of her program. She would, however, be able to stay by enrolling in the Conrad 30 program, which provides IMGs with temporary H1-B visas and assigns them to sponsoring hospitals or practices in underserved areas.
Ponnada got a position at a small critical access hospital in rural Iowa. But the hospital was in financial straits, and shortly after she arrived, it eliminated her position. She was suddenly stranded without a sponsoring employer.
She ultimately became a hospitalist in Waterloo, Iowa, a job she still holds. The program is completely dependent on IMGs. It has eight full-time and two part-time hospitalists, and all of whom are IMGs on H-1B visas, she said.
Living in a small Iowa town has removed her from Indian culture. “At this point, I think I have lost touch with India,” she said. Her mother still lives in India, but years can go by without Ponnada traveling to see her.
Her husband, on the other hand, has much stronger bonds with India. He cannot practice medicine in America because he does not have a license, and as the spouse of an H-1B visa-holder, he is not even allowed to work in the United States unless he gets a special waiver.
For immigrants on visas, life can be very complicated. When Ponnada moved to Waterloo, her husband went back to India, where he taught in a medical school and tended to his aging father, while Ponnada had the kids in Iowa. This year, after a 3-year absence, her husband returned and is now looking into finding a job in public health, where a physician’s license is not needed, she said.
Living in Limbo
Owing to the backup of green card applications, Ponnada is resigned to being in limbo on an H-1B visa for many years to come. Her H-1B status must be renewed every 3 years, which she can do indefinitely.
The terms of her H-1B sponsorship spell out precisely where she can work. For example, “if I wanted to see discharged patients in the nursing home,” she said, “that is not allowed.”
Her H-1B status also makes it very hard to travel out of the country and see her family in India. “I can leave the US with my Indian passport, but the problem is getting back in,” she said. At the border, she must present an up-to-date stamp in her passport denoting her current visa status.
I can leave the US with my Indian passport, but the problem is getting back in.
Another challenge of H1-B status is seeing children age out. Having children who age out is often a problem for Indian IMGs. IMGs from other countries can get their green cards within a year or two, but Indian IMGs have to wait for a decade or even longer, during which time their kids grow up.
Ponnada’s daughter reached age 21 before completing college and had to switch to an F-1 visa, used by foreign students studying in the United States. After graduating, she had to get her own H-1B visa. She got a job at Microsoft, which agreed to be her H-1B sponsor. While she waited for her visa, Microsoft transferred her to an office in Canada, where it is easier for skilled foreign workers to live.
Ponnada’s son is not quite age 21, but he has already faced barriers because of the family’s immigrant status, she said.
Ponnada thinks of her children as Americans. They dress and talk American, and “they don’t eat all the Indian food I cook,” she said. Ponnada tries to speak Telugu, an Indian language, with them. Her daughter speaks it fairly well, but her son knows very little. “He speaks very funny,” she said with a laugh.
Trying to Change the US Immigration Policy
In Washington, the issue of eliminating visa barriers for skilled immigrants with jobs is often overshadowed by the debate over illegal immigrants. The last major immigration reform bill, sponsored by a bipartisan group of senators, was not voted upon by the House of Representatives in 2013.
The immigration bill had a provision to remove the country quota on green cards. Since then, that provision has been introduced as a separate bill, the Fairness for High-Skilled Immigrants Act, which is supported by Indian IMGs who are in a group called Immigration Voice, an organization that tries to improve immigration laws and employment for Indian immigrants.
This means that there are two very different bills that deal with problems of getting a green card in different ways. The fairness bill would help all Indians with H-1B visas, including Indians in high tech, whereas the Conrad 30 bill is a more modest piece of legislation, focusing only on doctors who work in underserved areas.
The fairness bill passed the House earlier this year, and in October, it came up in the Senate in a vote for “unanimous consent” ― that is, every senator needed to support it in order for it to pass and go to President Trump.
The Senate Judiciary Committee received the bill but did not mark it up, ie, pass it on to the floor. But the bill is not dead, even though it did not pass on unanimous consent.
Unlike the fairness bill, the Conrad bill hasn’t yet come up for a vote in Congress. PAHA members are getting more lawmakers to sign on to it, and it may turn out to be the last, best hope for Indian IMGs.
Although Ponnada can’t vote or even contribute money to a campaign, she has become an artful player in Washington politics. She has come a long way, and she also has a long way to go.
Leigh Page is a freelance writer based in Chicago, Illinois.