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Wednesday, February 11th 2004

The Honorable Tom Ridge
U.S. Department of Homeland Security
Washington, DC 20528

February 11, 2004

Dear Secretary Ridge:

On behalf of the American Hospital Association (AHA), I am writing to urge you to delay implementation of a Department of Homeland Security's (DHS) health care certificate regulation that will severely exacerbate our nation's nursing shortage and disrupt health care services, particularly among hospitals along our northern border that employ Canadian nurses.

The AHA represents nearly 5,000 member hospitals, health systems, networks and other providers of health care.

Last July, the DHS issued a final rule implementing section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996 (P. L. 104-208).  Under section 343, any alien who comes to the United States for the purpose of working as a health care professional (except physicians) is inadmissible unless the alien presents a certificate issued by the Commission on Graduates of Foreign Nursing Schools (CGFNS) or another DHS-approved credentialing body.  The certificate's purpose is to ensure that the alien health care professional's education is equivalent to that of a U.S. program and that the alien has an unencumbered license and is proficient in English.

The regulation applies even if the alien health care professional holds a valid U.S. state license.  It also applies in the case of an alien health care professional who is educated in the U.S.  Under the regulation, Canadian health care professionals, who heretofore have been governed under the North American Free Trade Agreement, must present a health care certificate each time they cross the border.

The AHA commented on the regulation when it was proposed because we believed it would disrupt the delivery of health care services, particularly in hospitals along our northern border that employ Canadian nurses.  Among the changes we requested was an extended phase-in period.  The final regulation provides for a grace period only until July 26, 2004.  The certification process is lengthy and due to a spike in demand as a result of this rule, there are likely to be significant delays to an already time-consuming process.  Currently, there is only one organization - CGFNS - that is authorized to issue the certificate for nurses.

The regulation not only stands to disrupt the delivery of health care services in many hospitals, but also imposes a considerable burden on alien nurses.  Many who have held a valid license in a state, and who have worked in U.S. hospitals for a number of years, will now be required to take the National Council Licensure Examination (NCLEX) at substantial expense.

We strongly urge you to delay the effective date of this rule until July 2005, at the earliest.  In addition, we request that the department exempt those alien health care professionals who already hold a valid license to practice in a U.S. state.  It is appropriate and fair to impose the requirement on future alien health care professionals, not those who currently hold valid, unencumbered U.S. licensure and have been providing care to countless Americans.

Lastly, we urge you to exempt alien health care workers who received their training in the U.S.  The statute and legislative history are silent on this point; however, the regulation extends the certification requirement to this group.  If alien health care professionals have graduated from a U.S. training program, and passed the requisite exams establishing that they have met the minimum standards for safe practice, the requirement for certification is redundant and unnecessary.

Our nation is already experiencing one of the worst shortages of many types of health care professionals, but particularly nurses.  This shortage is dramatically affecting hospitals' ability to provide care.  The regulation will exacerbate this problem.

Once again, we urge you to delay the implementation of the regulation and to institute the changes we have suggested.  We look forward to working with you on this important issue.


Rick Pollack

Executive Vice President


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