Dear Chair Rochefort, Vice Chair Avard, and Members of the Committee:

My name is Jeffrey A. Singer. I am a Senior Fellow in Health Policy Studies at the Cato Institute. I am also a medical doctor specializing in general surgery and have been practicing that specialty in Phoenix, Arizona, for over 40 years. The Cato Institute is a 501(c)(3) non-partisan, non-profit, tax-exempt educational foundation dedicated to the principles of individual liberty, limited government, free markets, and peace. Cato scholars conduct independent research on a wide range of policy issues. To maintain its independence, the Cato Institute accepts no government funding. Cato receives approximately 80 percent of its funding through tax-deductible contributions from individuals. The remainder of its support comes from foundations, corporations, and the sale of books and other publications. The Cato Institute does not take positions on legislation.

Thank you for the opportunity to submit written testimony regarding SB 457.

New Hampshire, like much of the country, faces persistent and growing challenges in ensuring timely access to physician care—particularly in rural and smaller communities and in certain high-demand specialties. Long wait times for appointments and difficulty recruiting and retaining physicians are not abstract policy concerns; they are practical problems that affect patients, families, and providers across the state.

The COVID-19 pandemic brought these workforce pressures into sharper focus. During the emergency, governors across the country adopted temporary measures to expand the workforce by allowing out-of-state and, in some cases, foreign-trained physicians to provide care. New Jersey, for example, permitted physicians trained, licensed, and experienced in other countries to practice under supervision. When the crisis receded, most of these emergency measures expired, and regulatory systems returned to the status quo. But the underlying workforce constraints did not.

Even before the pandemic, the United States ranked behind most developed countries in physicians per capita. States like New Hampshire—smaller, more rural, and competing with larger systems in neighboring states for clinicians—often feel these shortages more acutely.

One persistently underutilized resource is international medical graduates who are fully trained, licensed, and experienced abroad and who are already legally present in the United States. Yet state licensing systems generally treat these physicians as if they were newly graduated medical students.

Since the late 1950s, a credentialing system overseen by the Educational Commission for Foreign Medical Graduates has required graduates of medical schools outside the U.S. and Canada to pass multiple examinations and repeat U.S. residency training—even when they have already completed residency and practiced safely for many years in other countries. The predictable result is that many highly trained physicians in New Hampshire and elsewhere end up working in non-physician roles, underemployed in the health sector, or leaving medicine altogether, even as patients struggle to find timely care.

I examined this specific problem and the case for provisional licensing pathways for experienced international physicians in my 2025 book, Your Body, Your Health Care, which looks broadly at how regulatory barriers in the U.S. health system often limit access to care without improving patient safety.

Other advanced countries take a more pragmatic and incremental approach. Canada, Australia, and most European Union countries use provisional licensing systems that allow experienced foreign-trained physicians to practice under supervision for a defined period. After demonstrating competence and meeting local requirements, these physicians may receive full, unrestricted licenses.

SB 457 adopts this same general framework and adapts it to New Hampshire’s regulatory and institutional context.

Under SB 457, physicians licensed outside the U.S. or Canada who have either completed a residency program or practiced for at least five years abroad would be eligible for a provisional license, subject to substantial documentation requirements, including verification of credentials, good standing, character and fitness, work authorization, and English proficiency. The bill also requires a job offer from a New Hampshire provider that operates an ACGME-accredited residency program.

During the provisional period, practice would be limited to such a sponsoring institution, creating a built-in structure for professional oversight within New Hampshire’s existing medical and hospital systems. After two years of practice in good standing, the physician could transition to a full, unrestricted New Hampshire license, and the site restriction would be lifted.

This structure closely resembles the approach first adopted in Tennessee and subsequently in Florida and Virginia. Texas has now enacted a comprehensive version of this reform, and Wisconsin is moving in the same direction. Taken together, these developments suggest that states with very different health care systems and political cultures are converging on a similar conclusion: rigid, one-size-fits-all licensing rules are an ill fit for experienced physicians trained abroad, and supervised transitional licensing can expand access to care without compromising standards.

For a state like New Hampshire, where recruiting clinicians is often difficult and where access challenges can be especially pronounced outside major population centers, this type of framework directly addresses a practical constraint: it allows the state to make better use of physicians who are already here, already trained, and already experienced.

From a policy perspective, SB 457 represents a careful and mainstream response to a well-documented workforce bottleneck. It preserves credential verification, supervision, and accountability to the medical board while addressing a structural inefficiency that currently prevents qualified physicians from practicing in New Hampshire.

At a time when patients across the state face persistent access barriers, this type of reform reflects a growing recognition that protecting quality and expanding access are not competing goals.

Thank you once again for considering my perspective on this important issue. I am pleased to provide additional information at the Committee’s request.